The Transience of DSM Categories: Ian Hacking’s Concept of “Interactive Kinds” as a Heuristic...

The Transience of DSM CategoriesIan Hacking’s Concept of “Interactive Kinds” as a Heuristic Solution to the Ontological Problem of Mental DisordersRobert Bridges: Fall 2014

ABSTRACTIn the Philosophy of Mind, the concept of mental disorder and thediversity of minds has been the object of both epistemological and ontological debate. The spectrum of these considerations ranges from the Thomas Szasz’s contention that mental illnesses are social “myths” used to legitimize the political control of undesirables, to George Graham’s assertion that mental illnesses are “real” so long as they exist independent of theory. The divergence of these philosophical positions is born of the apparent incommensurability of their respective metaphysics of mind. These thinkers have unwittingly fallen into a Cartesian trap by assuming either mental “kinds” must exist objectively andindependently of matter, or that what we consider to be the “mind” is ultimately reducible to matter. While some such as Muhammad Ali Khalidi are hesitant to abandon the attempt to

“distinguish real from non-real kinds on metaphysical grounds,” others such as Andrew Davis recognize the implications of this thinking for authority figures that perceive mental phenomena as non-real threats to social institutions, or alternatively as purely neurological kind-entities that exist independent of environmental influence. I have argued that Ian Hacking’s conceptual tool of “interactive kinds” is a pragmatic answer to this dilemma that does not wed the Philosophy of Mind to one or the other view of mental types and frees clinical psychiatry to concentrate on the patient, the object of Hacking’s process of ‘looping.’ I extend this interpretation of Hacking’s concept of interactive kinds to contemporary debates over organizational revisions to the DSM-V’s differential diagnostic system and arguethat the role these mental categories play in people’s lives extends beyond the boundaries of conflicting scientific paradigms.

“When at last the once totally frozen affects begin to emerge, and a much richer human personality to evolve, then convictions about the psychogenic nature of the disturbance become stronger still.”

- Bruno Bettelheim, The Empty Fortress1

“Normal people have an incredible lack of empathy. They have good emotional empathy, but they don't have much empathy for the autistic kid who is screaming at the baseball game because he can't stand the sensory overload. Or the autistic kid having a meltdown in the school cafeteria because there's too much stimulation.”

- Temple Grandin2

After Catherine Consel and her husband read through

their now 20 year old son Thomas’ medical documents from the

Bordeaux hospital that treated him for three years, they

were shocked to discover that their son had been the subject

of ‘experimental’ treatments. In a country where

psychoanalysis is arguably still in its heyday, it is not

uncommon for psychotherapists to use abstract and

potentially traumatic methods to treat autism. Thomas was

one of several patients chosen for the dubious treatment

method known as le packing, which involves wrapping the mostly

naked test subject (in this case a young boy) in cold wet

1 Bruno Bettelheim, The Empty Fortress: Infantile Autism and the Birth of the Self (New York: Free Press, 1972, ©1967), 412.2 John Hamilton and Vikki Valentine, "Q&A: Temple Grandin on Autism & Language," (NPR. NPR, 09 July 2006. Web. 14 Nov. 2014).

towels to ‘reconnect’ their mind with their body.3 Marie

Dominique Amy, president of the French association of

psychotherapists and psychiatrists (CIPPA) has found the

controversial (albeit rare) treatment method can prove

efficacious, given the autistic children’s’ post-treatment

responsiveness and spontaneous creativity and sociability.

Conversely, Tony Charman, Chair of Autism at the Institute

of Education in London, has observed no long-term empirical

evidence this “treatment” is successful at stimulating the

‘socialization’ of autistic children. Likewise, he expressed

shock that “something potentially dangerous and harmful

would be performed on vulnerable children.”4 I share this

anecdote in part because it evokes the spectre of past moral

injustices committed in the name of psychiatric treatment.

On the surface, this case reveals a deep institutional flaw

in the French psychiatric profession. While the actions of

the Bordeaux hospital psychiatrists’ were repugnant and

3 Maria Cheng, “French Autism Treatments: Children in the European Country Mostly Get Psychotherapy.” Huffington Post, May 18th,2012. http://www.huffingtonpost.com/2012/05/18/french-kids-with-autism-psychotherapy_n_1527028.html. (accessed September 21, 2014).4 Ibid.

certainly violated the Hippocratic epithet primum non nocere,

their transgressions are part of a long history of repeat

offenses that has had far more damaging implications for the

legitimacy of the profession. 5

Given the vast intellectual gap between the psychiatric

understanding of autism in France and the United States,

there are some philosophers who argue the question of mental

disorder diagnosis is not only significant to ethics, but to

ontology. The question becomes how psychiatrists and mental-

health practitioners in the United States and other parts of

the world determine the legitimacy of clinical diagnoses and

whether or not our contemporary understanding of mental

disorder categories are accurate real-world depictions or

(most extremely) even scientifically valid? Psychiatrists 5 In France, a doctor is given an inordinate amount of power to determine a child’s chances for future financial aid and educational opportunities. The doctor’s financial influence over the parents, coupled with the ambiguity of consent given by children with severe speech or cognitive impairment makes not only this treatment, but also the doctor-parent-patient relationship paradigm in general ethically unpalatable. – OlivierBousquet and David Heurtevent, “What is “Packing”? A “barbaric” practice for autistic children!” trans. Karen Wilshin, Soutenons Le Mur (website), January 11th, 2012. http://www.supportthewall.org/2012/01/opinions-what-is-packing-a-barbaric-practice-for-autistic-children/ (accessed September 21, 2014).

who ask questions of this sort may be trying to direct blame

toward a specific social or physical causal vector for the

“disease.” After failing to identify some miasma or other as

the culprit, they look to genetics as the ultimate

determinant of their patient’s suffering, tantalizingly

beyond the grasp of treatment and yet sufficiently

explanatory to forego other options. Contemporary

philosophers have weighed in at different sides of the ring

over the ambiguous ontology of mind-dependent categories.

Some claim that the concept of a mental disorder is both

ontologically sound and a useful heuristic for the diagnosis

and treatment of patients in the absence of “a complete

neurology,” while others find the concept has no scientific

validity and is only an oppressive expression of power on

the part of the psychiatrist to quell the patient’s

undesirable behaviors.6

6 David H. Brendel, "Philosophy of Mind in the Clinic: The Relation between Causal and Meaningful Explanation in Psychiatry," (Harvard Review Of Psychiatry (Taylor & Francis Ltd) 8, no. 4, October 2000), 184-5; George Graham, The Disordered Mind: An Introduction to Philosophy of Mind and Mental Illness, (2nd ed. New York City, NY: Routledge, 2013).

This orientation toward a discursive metaphysics is

ultimately detrimental to furthering patient-centered care

in the field of psychiatry and has led the profession toward

a false intellectual dichotomy between those who favor the

language of psychology and those who espouse the primacy of

neurology. In the first two sections of this article, I

contrast Hacking’s theory of “interactive” and “indifferent”

kinds with the divergent theories of George Graham and

Thomas Szsasz and offer a defense of Hacking against

critiques of his theory.7 In my final section, I adjust my

orientation away from the metaphysics of mind toward an

evaluation of the philosophical debates over the Diagnostic

and Statistical Manual of Mental Disorders in order to offer

an epistemological critique of it’s Linnaean structure in

light of Hacking’s work. Through this critical appraisal of

the metaphysics of Ian Hacking’s theory of Kinds, I argue

that a more inclusive epistemological system for the

7 Ian Hacking, The Social Construction of What? (Cambridge, Mass: HarvardUniversity Press, 1999); Thomas Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, rev. ed., Harper Colophon Books (New York: Harper & Row, 1974).

diagnosis of mental disorders is needed, both for scientific

investigation and for legalistic efficiency.

Section 1: Disorder, Myth, or Interactive Kind?

“The real is what resists symbolization absolutely.”

- Jacques Lacan, The Seminar of Jacques Lacan: Freud’s Letters on Technique

“The term "mental illness" refers to the undesirable thoughts, feelings, and behaviorsof persons. Classifying thoughts, feelings, and behaviors as diseases is a logical and semantic error, like classifying the whale as a fish. As the whale is not a fish, mental illness is not a disease. Individuals with brain diseases (bad brains) or kidney diseases (bad kidneys) are literally sick. Individuals with mental diseases (bad behaviors), like societies with economic diseases (bad fiscal policies), are metaphorically sick.”

- Thomas Szasz, Manifesto of the Cybercenter for Liberty and Responsibility

The French psychiatrists who prescribe le packing as

treatment, do so under the theoretical framework of the

early to mid-twentieth century psychoanalytic tradition,

traced to the founder of the French school Jacques Lacan.

These psychiatrists have adopted a discursive view of mental

disorders based on the Freudian theory that one can tap into

a patient’s unconscious mind through their description of

dreams via language and signs. As one of several active

proponents of this Lacanian psychoanalytic view who also

happens to be diagnosed with Asperger’s syndrome (now

formally on the Autistic Spectrum), Henry Bond maintains

that autistic individuals are “spoken by the real, possessed

by language.”8 Ever since Sophie Robert’s film Le Mur (The

Wall) came out in 2012, French psychoanalysts have been

criticized both for the clinical implications of their

theory for autistic patients, and for the failure of

psychoanalysis to stand up to empirical analysis and

scientific rigor. Despite the shortcomings of their theory

to offer a monistic explanation of mind, one cannot deny the

profound effect their understanding of mental categories has

on the ‘autistic’ experience in France. The film Le Mur

follows two patients; one who, like Thomas Consel, was

subject to the French psychoanalytic treatment, while the

other was treated under the American behavioral model. The

film demonstrates the tendency among Lacanian psychoanalysts

to tacitly assume that the mother’s prenatal mental health

is to blame for the autistic child’s disinterestedness with

communication, and that only a “talking cure” will help the

8 “What Autism can teach us about Psychoanalysis,” The Guardian, 16th

April, 2012. http://www.theguardian.com/commentisfree/2012/apr/16/autism-psychoanalysis-lacanian. (accessed September 21, 2014).

child. While this arrangement sounds cruel to us in the

States, some French psychiatrists who acknowledge the

existence of ADHD in France raise their own criticism of

American diagnostic practices and the gross over-

prescription of drugs like Ritalin to underdeveloped

youths.9 As a result of this conservatism among

psychiatrists, the diagnosis of ADHD in France is rare.

This fundamental disagreement among psychiatrists,

whether due to political concerns or to ambiguity in their

respective typologies of mental disorders is by no means

unique to contemporary French society. At the turn of the

century, Jean-Martin Charcot’s categorical diagnostic method

for differentiating hysteria from ‘similar’ mental states

was unique compared to the methods employed by his

international colleagues. His use of hypnotism was subject

to repeated criticism in his waning years, especially when

it was found that several of his patients demonstrated

9 David Jolly and Stephanie Novak “A French Film takes Issue Withthe Psychoanalytic Approach to Autism,” New York Times, January 19th,2012 http://www.nytimes.com/2012/01/20/health/film-about-treatment-of-autism-strongly-criticized-in-france.html?pagewanted=all&_r=0. (accessed September 21, 2014).

fraudulent symptoms. Two of Charcot’s most infamous

students, Sigmund Freud and Josef Breuer began the process

of curing their patients using “differential diagnosis,” in

order to determine appropriate treatment, whether ‘talking

cure’ or dream analysis. Writing in the heyday of

psychoanalysis as a paradigm in the 1970s, Thomas Szasz

criticized the immediate recourse of psychoanalysts to

“mental illness” as the cause of a patient’s complaints. He

argued that the inconsistency of psychiatry’s treatment

success and empirical rigor demonstrated the flawed

presumptuousness of psychiatry as a medical practice.10

Furthermore, any similar “psychotherapeutic situation” to

the ‘talking cures’ of Breuer and Freud in which the

psychiatrist takes on the role of diagnostician is harmful

due to complicating vectors that obscure the doctor –

patient relationship, such as the role that money has in

influencing diagnosis.

Rather pessimistically (and one hopes not self-

reflectively), Szasz accuses members of his own profession

10 Thomas Szasz, The Myth of Mental Illness, 71-4.

of cronyism. He maintains that psychiatrists in private

practices wield false power over their patients by taking on

the role of the “patient’s agent,” confirming the patient’s

complaints are due to mental illness. Moreover, he argues

insured mental health practices are similarly devious since

the psychiatrist essentially becomes “society’s agent”

disagreeing with the patient’s claims to illness, or most

malevolently “his own agent” by maximizing gains from the

patient’s insurance.11 Szasz thus maintains throughout that

the disability of someone who is mentally ill derives not

from neurological origins, but perhaps from some other

reaction to environmental stress. He distinguishes between

“illness-imitative” behavior, and real neurological damage

or impairment as “objects proper,” the former being a

communicative problem, which some psychiatrists confuse with

the latter being a physiological or neurological condition.

Therefore, Szasz claims psychiatry concerns “signs qua

signs” and not “signs qua objects in their own rights,” and

so psychiatrists are necessarily “dealing not with mental

11 See Table 2, Ibid., 58.

illness but with communications.”12 Needless to say, Szasz’s

thesis was just as unpopular among his colleagues in the

1970s, as it seems to us today. In a subsequent article

written years later in 1997, Szasz offers a renewed defense

of his contribution to the philosophy of psychiatry.13 In

both 1970 and in 1997, Szasz claims our understanding of

schizophrenia among other “mental illnesses” is misguided,

because we have no physiological basis to determine whether

the patient’s suffering is caused by anything other than a

somatic condition. Unless we observe clear chemical

imbalances, abrasions or any other form of damage to the

brain, there is no reason to believe the patient is

suffering from anything other than the stresses of living.14

In the thick of his diatribe against the efficacy of

his own profession, Szasz uncovered pertinent truths

regarding the quality of psychoanalysis as a therapeutic

solution to mental illness. The psychiatric consensus since

the 1950s, Szasz maintains, had rooted the illnesses of the 12 Ibid., 47.13 Thomas Szasz, “Mental Illness is Still a Myth,” Review of Existential Psychology and Psychiatry (23, no. 1/2/3 (January 1, 1997): 70-80), 71.14 Ibid., 71-2.

mind to some original disease of the brain and had thus

justified a cure for the brain through the treatment of the

mind.15 Whereas Karl Marx believed religion to be the

“opiate of the people,” Szasz claimed this notion of “mind”

is a similarly fictitious category.16 What follows in his

account is a society obsessed with diagnosis and treatment,

and one that fetishizes the former for the sake of the

latter. Instead of moving “miscreants” through the law

courts and into prisons, we replaced the punitive judge with

the punitive psychiatrist, and the prison with the

therapeutic “constraint and compulsion” solution of the

mental hospital.17 This obsessive compartmentalization of

communicative problems and family mishaps as mental illness

threatens the integrity of moral agents in a democratic

society and places inordinate power in the hands of the

psychiatrists as a new kind of state bureaucracy.18

While Szasz is certainly the most boisterous and

extreme voice among the skeptics of the anti-psychiatry 15 Ibid., 73.16 Ibid., 72.17 Ibid., 78.18 Ibid., 79.

movement, he is not alone in his critique of the mind as a

reduction to matter. Through his theory of ‘eliminative

materialism,’ Paul Churchland argued that neuroscience will

one day become the dominant field in the study of the

psyche, and that psychology will necessarily be eclipsed

once mind is reduced to matter.19 Even early in the

twentieth century, philosophers and theorists of mind were

concerned with the ascendency of this reductionist vision of

science. Karl Jaspers, the epistemological opponent to

eliminative materialist arguments felt the scientific

investigations were more inclined toward studies of physical

anomalies in the brain, at the expense of “everything that

can be called mental.”20 David Brendel argues this

dichotomous thinking in the philosophy of mind has inhibited

creativity and flexibility in the field of clinical

psychiatry in favor of materialistic rigidity. Brendel

delineates this conceptual weakness in philosophy of Paul

19 David H. Brendel, "Philosophy of Mind in the Clinic: The Relation between Causal and Meaningful Explanation in Psychiatry," (Harvard Review Of Psychiatry (Taylor & Francis Ltd) 8, no. 4, October 2000), 184.20 Karl Jasper’s 1913 essay quoted in David H. Brendel, "Philosophy of Mind in the Clinic,” 185.

Churchland, whose theory of eliminative materialism, Brendel

argues, fails to capture the epistemic force of

psychological concepts as mental realities. According to

Brendel, psychiatrists still display this categorical

preference to speak of mental phenomena in neurological as

opposed to psychological vocabulary, and to represent

certain physical pathologies in the words of Michel

Foucault, as a “fall into determinism.”21 In Szasz’s view,

those who suffer from mental illnesses without the necessary

neurological or environmental underpinnings to constitute

“objects proper” fall into manipulation.

Is mental illness purely rooted in the brain, and if

not, is it really a nonissue and just some byproduct of the

anxiety and pressures of our daily existence? To understand

the critique Szasz is leveling against the moral

implications of his profession, consider a student who has

just been diagnosed with ADHD, and is now told he/she could

take as much time on a test as needed. The student has just

been granted a privilege no other student in his/her class 21 Michel Foucault, Madness and Civilization, 1965 quoted in David H. Brendel, "Philosophy of Mind in the Clinic,” 186.

has been granted, and the reason is medical. It appears the

teacher’s authority has been undermined by the psychiatrist

who places unusual power in the student’s hand, and

rightfully so, because this student now has a diagnosed

medical difference from his classmates and requires these

concessions to succeed.22 George Graham synthesizes the

Szaszian skeptics’ position in response to this situation as

follows. First, an individual’s responsibility for his/her

own mental health has been compromised by allowing the

psychiatrist to step in and prescribe concessions as

treatment, rather than allowing the student to develop

coping methods. The student may then be shuffled into a

resource room with other students with similarly diagnosed

mental illnesses and is segregated from the rest of his/her

classmates, a violation of civil liberties. Finally, this

student now diagnosed with ADHD or some variant, may be

stigmatized for the rest of his/her life, and discriminated

against by coworkers or professors or social organizations

in which members claim these medical concessions are 22 George Graham, The Disordered Mind: An Introduction to Philosophy of Mind and Mental Illness, (2nd ed. New York City, NY: Routledge, 2013).

unwarranted and refuse the individual the opportunity to

thrive in society.23

Thus the Szaszian critique of psychiatry is as much

moral as it is ontological. To determine that, because of

the risk of disrespect to the student or someone else with a

diagnosed mental disorder, that there is something indignant

and disrespectful about mental disorder itself is, I

maintain, a step too far in the wrong direction. George

Graham argues that the ontological position of Szaszian

skeptics is too reliant on the normative determinants of

diagnosis.24 Graham reconstructs the theories of disease

posited by the philosopher Christopher Boorse, who argued

“disease” is that which inhibits the adaptive functions of

the body’s machinery.25 What is the body’s correct function

is determined by objective scientific data analysis, by

evolutionary biologists, and neuroscientists. The Modular

Design of our bodies is thus determined by the evolutionary

23 Graham uses similar examples in reference to a fictitious mental disorder GOD or Grade Obsessive Disorder, which most students at Gettysburg College will attest, is a rampant and potentially harmful condition. - Ibid., 94-5.24 Ibid., 97.25 Ibid.

trajectory of the human species, and any deviation of the

design’s functionality is objectively a physiological

disease.26 Graham asks if we can determine what is

biologically adaptive objectively? Since we do not have

access to the wealth of knowledge about our own evolutionary

history, doctors must make judgments regarding somatic

disorders independently of objective criteria.27 Graham

argues a doctor can only ask questions that relate to the

efficacy of treatment such as, “is this person’s condition

painful, does it cause suffering, or is it going to cause

them to die if untreated?”28

In this very different “realist” theory, mental

illnesses must exist “independent of whether we have a

theory about them, think about them as such, or classify

people as subjects of mental illness.”29 His contention

hinges on the assumption that one’s neural pathways can

function normally as observed under a PET scan, and yet

despite the normality of the brain, the person (Alice) can 26 Ibid.27 Ibid., 98.28 Ibid.29 Ibid., 10-2.

be clinically depressed.30 While Graham’s theory seems

plausible from the perspective of biology, it is hard to

assume that neurological affects would not manifest as the

patient’s clinical depression persists.31 To defend his

theory of mental disorder, Graham uses the two examples.

First he cites premature birth as both dangerous for the

species as well as the mother and child, and second he cites

kidney damage, while not necessarily damaging the species as

a whole, is just as dangerous for the patient as premature

birth is for the mother.32 Graham thus subscribes to a broad

theory of disease as that which makes us worse off than we

would be without it.33 Throughout our lives our friends,

families, and environments affect us in ways that can and

often do leave us with debilitating psychological issues,

30 Ibid., 11-12.31 Thomas Jovanovski, Review of “The Disordered Mind: An Introduction to the Philosophy of Mind and Mental Illness,” (Essays in Philosophy, Vol. 15: Iss. 1, Article 20http://commons.pacificu.edu/cgi/viewcontent.cgi?article=1504&context=eip), 232.32 George Graham, The Disordered Mind, 98.33 Ibid., 100.

and whether or not these are somatic or “mental,” it would

be wrong to deny the sufferer healing or appropriate help.34

The weakness of Graham’s theory is its lack of

specificity regarding the metaphysical qualifications for a

mental disorder. While his position is certainly more

sympathetic and oriented toward treatment and patient-care,

rather than critical (like Szasz’s position) of

psychiatrists’ diagnostic practices, however, with regard to

the empirical justification for categorical diagnosis and

the medicalization of mental disorders, his theory is found

wanting. The ambiguity of his hermeneutical justification of

mental disorder categories is apparent in his conclusion

that, “only if attributions of mental disorder are

essentially morally suspect or demeaning should we suppose

that moral skepticism about the category of mental disorder

is justified.”35 His theory therefore refutes Szasz

successfully from a values perspective. Even if we assume,

as Graham does, that values presuppose the diagnosis of

somatic disorders just as they do for the diagnosis of 34 Ibid., 102.35 Ibid., 104.

mental disorders, the Szaszian contention that what we call

mental is constituted of the supervenient properties of the

brain still holds validity.36 His ontological account is

ultimately problematic and fails to refute the reductionist

trap of Szasz’s skepticism. Is the uncertainty associated

with misconstruing someone’s mental state too great to take

the risk of diagnosing mental disorder or mental difference

from a medical standpoint, regardless of any morally

contingent justification? To answer this question, we must

explore an alternative theory of mind, one that includes a

mechanism for addressing our diagnostic uncertainties.

The analytical philosopher Ian Hacking offers an

alternative, more pragmatic theory of mind and the reality

of mental categories in two separate lecture series. In the

first series of lectures titled Mad Travellers (1998), Hacking

discusses the historical development of what he refers to as

“transient mental illnesses,” a concept which in many ways

provides the intellectual basis for his work a year later in

36 Ibid., 162.

The Social Construction of What (1999).37 In the former lectures he

discusses the combination of vectors required, not only for

medical practitioners to recognize and diagnose mental

disorders, but also for those disorders to flourish in a

society. Unlike Szasz, Hacking is sympathetic toward the

historic practitioners of psychiatry like Charcot, who he

felt were warranted in their belief about the reality of

these illnesses. The early twentieth century psychoanalysts

were warranted in their belief in the existence of these

disorders, because a confluence of vectors, namely medical

taxonomy, cultural polarity, observability, and release

allowed these transient mental illnesses to emerge as

distinctive types or “Kinds.”38 His epistemological

distinction between the mental disorders we perceive as real

and those we are hesitant to call real lies in his concept

of an “ecological niche,” which encompasses these vectors.

In the late nineteenth and early twentieth century,

dissociative fugue was such a transient mental illness at 37 Ian Hacking, Mad Travelers: Reflections On the Reality of Transient Mental Illnesses, (Cambridge, Mass.: Harvard University Press, 2002); Ian Hacking, The Social Construction of What?, 101.38 Ian Hacking, Mad Travelers, 81.

the confluence of these factors. A particular socio-economic

class of men (cultural polarity), with access to new modes

of transportation in an urban world with increased police

surveillance (observability), were able to exploit the

ambiguous gap between criminal vagrancy and tourism

(release), because psychiatrists and mental-health

practitioners confirmed their place in the diagnostic

categories that prevailed toward the end of the nineteenth

century, mainly hysteria or epilepsy (medical taxonomy).39

Although some mental illnesses are transient and flourish in

specific times and places, others have certainly remained

with our species much longer. Hacking argues in his second

set of lectures (1999), that the more commonly observed

types of mental conditions such as schizophrenia or mental

retardation are imperfectly understood disorders, not

because we have failed to identify whether they are

“socially constructed” or biologically determined, but due

to our false conceptual dichotomy we draw between that which

is “socially constructed” and that which is “real.”40

39 Ibid., 81-2.40 Ian Hacking, The Social Construction of What? 101.

We tend to overlook how the diagnostic categories and

treatments we employ interact with the patient and the

society in which he/she subsists. The child diagnosed with

ADHD or dyslexia or some other learning difference pulled

from the DSM-V does not simply change his/her behavior when

diagnosed with a particular disorder or difference. There

must also be an institutional response to his/her diagnosis,

both at the micro and macro level of society, which in part

defines the child’s experience with the disorder.41 The

choices children with dyslexia or ADHD or Autism spectrum

differences have are in part shaped by these interactive

institutional elements. Thus the experience of being

autistic in France is qualitatively different from the

experience of being autistic in the United States. The

institutions, whether positive or negative, shape the

quality of these children’s experiences with autism.

The theoretical grounding of this interaction of

institutions and people with the categories that demarcate

them is exemplified in Hacking’s theory of “Interactive”

41 Ibid., 103.

versus “Indifferent” Kinds. For the most part the names

chosen for these two concepts are self-explanatory. A kind

is “interactive,” because the differences or conditions that

make it unique interacts with the individuals demarcated by

it, and as a result of this interaction, the kind changes

the behaviors of the individual. Subsequently, through what

Hacking refers to as a “looping effect,” these new, kind-

dependent behaviors change our collective understanding of

the classification of the disorders as well.42 Thus a mental

disorder category, such as one identified in the DSM-V, is

revised over time in response to the looping effects of the

interactive kinds delineated in its pages. Indifferent or

natural kinds in Hacking’s epistemology are those that do

not act in a specific way because of how we classify them,

and do not act to alter the classification under which we

identify them. Thus, quarks are quarks (tautology aside) and

do not change their behavior because of our classification

of them as such, and plutonium neither interacts with our

concept of plutonium, nor is it aware it is called

42 Ibid., 105.

plutonium.43 Even though these distinctions appear sharp,

Hacking argues there are cases in which both the indifferent

and interactive kinds can be and are present in individuals

diagnosed with certain mental disorders. Children identified

as mentally retarded twenty, fifty, one hundred years ago

might today be classified as children with severe learning

differences. Hacking argues we have not suddenly discovered

these differences. Those who have been categorized under the

label “mentally retarded” have reacted to the “complex

matrix of institutions and practices,” which defined their

experience, and over the years, these individuals have been

reclassified within this matrix, and not as “pure beings-in-

themselves.”44

The experience of being autistic or dyslexic in certain

places and times can change drastically. Ian Hacking’s

thesis helps explain how the experience of autistic children

in France versus in the United States can have lasting

repercussions, both for the individual diagnosed/treated,

and for the society in which he or she lives. The French 43 Ibid.44 Ibid., 112.

psychoanalysts have created a negative feedback looping

effect by pulling these children from the world and

subjecting them to an array of bizarre and morally

questionable treatments, all in an attempt to stymie

undesired behavior (or as they see it a lack thereof). In

the past few decades, philosophers and psychiatrists have

delved into the supposed metaphysical incommensurability of

the realist and social construction positions on mental

disorders. Ian Hacking argues for a different conception of

“realism” that reconciles the two, and maintains that they

are not mutually exclusive positions. The concept of “mental

disorder” is uniquely positioned at the nexus of ontological

realism and social construction, and therefore requires both

a social science and neuroscience definition.45 Still, there

are still philosophers, such as Szasz and the anti-

psychiatry movement, who find the distinction between these

two ontological positions incongruous, and that it is

impossible to set aside the “epistemic, metaphysical, and

45 Dominic Murphy, "Hacking's Reconciliation: Putting the Biological and Sociological Together in the Explanation of MentalIllness," (Philosophy Of The Social Sciences 31, no. 2 (June 1, 2001): 139-162), 140.

political issues” necessarily central to the “dynamics of

classification.”46 Hacking argues that a complete ontology

of mental disorders considers them to be both socially

constructed and “natural kinds,” and that such a

presupposition is expedient for diagnosticians and

researchers seeking a comprehensive interdisciplinary

understanding of mental phenomena.

Section 2: Descartes Ain’t Hacking It

“I can't go back to yesterday because I was a different person then.”

“How puzzling all these changes are! I'm never sure what I'm going to be, from one minute to another.”

- Lewis Carroll, Alice in Wonderland

Critiques of The Social Construction of What (1999) that have

arisen over the years identify similar “flaws” in the basic

tenets of Hacking’s theory of Kinds. These philosophers

criticize Hacking’s theory of “interactive kinds” for its

lack of empirical validity, criticizing it for trying to

resolve the realist’s dilemma of mind-body dualism. Through

46 Ibid., 155.

their reappropriation of the dualism problem of mind and

body, these critics rely on an already problematic

epistemology and misapprehend the promise of Hacking’s

theory. Despite the contention of Hacking’s critics that his

epistemological framework fails to offer a sufficient

account of interactive kinds predicated on mind-body

reductionism, Hacking’s theory of “kinds” should be

understood more as a modification of a Cartesian dualist

perspective, rather than as an epistemological challenge to

ontological “realism.”47 Rather than attempt to

differentiate between “real” and “subjective” interactive

kinds, philosophers should revisit Hacking’s pragmatic

interpretive stance regarding mental illnesses as laid out

in his works The Social Construction of What, and Mad Travelers. I

maintain that Hacking’s theory of “interactive kinds” is

both a tenable and useful framework for evaluating the

medical diagnosis of mental disorders and similarly

categorized mental phenomena or “kinds.”

47 “Realism” refers here more to a reductionist perspective of mental disorder used to undermine rather than support the realismespoused by George Graham in the previous chapter.

Descartes’s theory of mind is today referred to as

“substance dualism” and is differentiated from later

theories of “property dualism,” which are known for their

attenuation of mind to body.48 The concept of “substances”

is best understood as a misappropriation of the language of

logic to functional properties of our physical world, and is

thus no longer consistent with modern psychological

theories.49 Even though the concept of substance is missing

from our modern vocabulary, Hacking argues, Descartes’

lesson on the differentiation of mind and matter (or body)

is illustrative. It is gibberish to talk of a grammatical

distinction between mind and matter, because mind and matter

are two unique ways to perceive and describe our experience

of the world.50 Certainly from a linguistic perspective,

Descartes’ system cannot be used to reduce mind to matter,

however, this fact reveals more of Hacking’s philosophical

thought than he acknowledges outright. Both the mental and

48 George Graham, The Disordered Mind, 77.49 Ian Hacking, “The Cartesian Vision Fulfilled: Analogue Bodies and Digital Minds,” (Interdisciplinary Science Reviews 30, no. 2 (2005): 153–66), 158.50 Ibid.

physical domains define the human experience, and therefore,

both must be discussed, but not necessarily in the same

heuristics structure.

The distinction Hacking draws between mind and matter

is applied more eloquently to his theoretical division

between Interactive and Indifferent Kinds. What is more

efficacious for our understanding of interactive kinds is

not our semantic categories, but the dynamic process by

which those categories are negotiated and renegotiated over

time.51 Interactive kinds, which are of humans and interact

with humans, are distinguishable from indifferent kinds,

which are conceived by man to describe nature. The dynamic

process that transforms interactive kinds is unique, because

humans become conscious of their category and react to it.

Even in the case of biolooping, a successful psychiatrist

who diagnoses a patient as depressed is informing the

patient who consciously accepts or rejects the

classification. The patient reacts by altering his/her

living conditions and if a treatment regimen works, a 51 Ian Hacking,The Social Construction of What? (Cambridge, Mass: HarvardUniversity Press, 1999), 122-3.

chemical alteration occurs in his/her brain to mitigate the

symptoms of depression. In turn, the change in the patient’s

behavior or modification of his/her life styles leads to a

re-appropriation of a disorder and change in its psychiatric

classification.52 Hacking describes himself as one

ambivalent disputant who is critical of social construction,

but is also cautious about casting his lot with those in

favor of a “rigid” program of classification and

diagnosis.53

In Hacking’s framework, the “real v. construction”

debate can be boiled down to a “relatively minor technical

matter.”54 What is needed is the right conception of the

semantic category under which we identify certain people as

autistic, dyslexic, or some other interactive kind. Hacking

uses the theories of reference developed by Kripke (1980)

and Putnam (1975) to illustrate the difference of his

concept of the semantic category “childhood autism.”55 While52 Ibid.53 Ibid., 122.54 Ibid., 123.55 Saul Kripke, Naming and Necessity, (Cambridge, MA: Harvard University Press, 1980); Hilary Putnam, The Meaning of Meaning. In Putnam, Mind, Language, and Reality. Vol. 2 of Philosophical Papers. (Cambridge:

in Putnam and Kripke’s theories, the designation of

“childhood autism,” is used in reference to an underlying

biological pathology P, in Hacking’s system, P is an

indifferent kind, with “Childhood autism” as our linguistic

moniker for P.56 By adding details such as prototypical

descriptions, hypotheses or therapies used with autistic

children to P, Hacking offers a complete definition of

“childhood autism.”57 Thus, the category itself includes not

just a biological type or indifferent kind, but the socially

constructed or interactive elements, which fall under that

category. Hacking also maintains this conceptual unification

satisfies any moral quandaries that anti-psychiatrists like

Thomas Szasz have with categorical designations. The concept

of interactive kinds supports a program of self-

actualization and determination on the part of the

classified group of individuals. The classified group does

not, however, have autonomous determination independent of

Cambridge University Press, 1975).56 Ian Hacking, The Social Construction of What?, 120.57 Ibid., 121.

their initial designation, but understands the interactive

element of the kind attributed to them.

Yet other authors have wrestled with Hacking’s semantic

system and found that it lacks the epistemological

credibility and strong metaphysical grounds necessary for

interactive kinds to guarantee their objective validity.

Both Rachel Cooper and Muhammad Ali Khalidi in particular

believe Hacking’s epistemology fails to distinguish between

kinds that are independently constituted and those that are

mind-dependent. In his essay “Interactive Kinds,” Muhammad

Ali Khalidi argues that the criterion Hacking uses to

identify interactive kinds actually admits non-human kinds

as necessarily interactive.58 For example, dogs, which at

one point in human history were categorized under a

different kind from wolves, are understood to be tame. The

expectation of this tame behavior reinforced our category of

“dog,” and subsequent changes in the behavior and appearance

of dogs caused us to further differentiate the species into

58 Muhammad Ali Khalidi, "Interactive Kinds," (British Journal For The Philosophy Of Science 61, no. 2 (June 1, 2010): 335-360), 336-7.

types or breeds.59 Thus, the interactive elements Hacking

ascribes specifically to humans and identifies as mind-

dependent extends beyond his own narrow set of criteria. For

the sake of clarity, I will reproduce the chain of events

Khalidi associates with the repeated iterations of Hacking’s

dynamic interactive kind-concept feedback loop:

(1) Introduction of concept and semantic label(2) Classification of individual and groups under

label(3) Identification with label by said individual

and group (consciously or not).60

(4) Process of further distinguishing between labeled group and other people, by which the former acquires new properties.

(5) The kind-concept or label acquires the new properties from the group, and is revised by the kind-concept makers.

Khalidi argues Hacking’s framework for a feedback loop

is a challenge to realism, since it assumes humans bring

kinds into being by simply identifying them. Therefore, a

feedback loop process that is not based on an empirically

sound independent ground fails to hold ontological

59 Ibid., 346.60 Khalidi makes this distinction here as well, though it may be possible, in Hacking’s framework, that conscious reaction to the category may be derived from unconscious identification with it. – Ibid., 337.

legitimacy, and begins iterations of a self-fulfilling

prophecy.61 While an individual’s response to an illness is

dependent in part on the semantic category, it is also a

product of human volition and action. Hacking contends that

interactive kinds should be understood as “mind-dependent,”

in so far as they are malleable to human power and

historical development. For Khalidi, however, the nature of

a kind’s existence is paramount to determining its validity.

A kind must be both “real,” independent from the mind, and

not subjective in a sense that it does not exist.62 His

solution to this supposed dilemma is to offer a more

specific definition of kinds, which distinguishes between

genuine “real kinds” and those that are purely mind-

dependent or exist because humans ascribe false validity to

If we concede that kinds must inherently display an

independent “real” aspect, are we really denying the tenets

of Hacking’s thesis? Hacking specifies his lack of

preference between a biological and a constructionist 61 Ibid., 339.62 Ibid., 357.

perspective of mental illness and disorders.63 He makes room

for both views through a dichotomy that separates

“classificatory looping” from “biolooping.”64 Khalidi

confounds these two separate looping processes as parts of a

single process. He justifies this alteration to Hacking’s

framework by making the following argument. First, he

maintains that Hacking fails to show how indifferent kinds

are mind-independent. Since Hacking fails to distinguish

kind interactions from indifferent kinds, we must conclude

that the mind itself must be an indifferent kind. Therefore,

mind is ultimately reducible to the physical. In Hacking’s

framework, however, physical changes may be actualized from

interactions with the mind, but the categorical alterations

form a fundamentally different feedback loop that must be

studied in addition to the physical or biological feedback

loop. In other words, Hacking concedes that mind may be

reducible to matter physically, but it is our experiences

that ultimately define us. He further buttresses his theory

against this type of criticism by separating the different 63 Ian Hacking, The Social Construction of What?, 109.64 Ibid., 110.

aspects that constitute interactive kind P, namely

descriptions, hypotheses, therapies, etc.65 Looping may

occur in interactions with nonhuman kinds, but the

categories we formulate to describe these objects are not

any less real, despite their social construction. Khalidi

succeeds in confirming that kinds have real affects on our

perceptions, but fails to recognize that ontological

legitimacy is as much a product of human subjectivity as it

is of neurological or body processes.

While Hacking’s theory of categorical looping and

biolooping processes is a useful heuristic, is it a

practical one? In her critique of Hacking’s theory of

interactive kinds, Cooper identifies the deficiency in

Hacking’s thesis to develop or expand on typological

criteria for distinguishing between “kinds” that possess

similar properties or looping effects.66 More to the point,

she finds flaws in Hacking’s contention that human kinds

65 Ibid., 121.66 Cooper uses an early version of Hacking’s theory that uses “human” and “natural” as the placeholders for “interactive” and “indifferent kinds” respectively. Rachel Cooper, "Why Hacking Is Wrong about Human Kinds," (British Journal For The Philosophy Of Science 55, no. 1 (March 1, 2004): 73-85), 74, 77.

cannot be natural kinds because of the supposedly unique

type of feedback loop that transforms human kinds. Since

Khalidi and others before him determined feedback loops work

to transform natural kinds as well as human kinds, Hacking’s

interactive kinds must be differentiated from natural kinds

by their awareness of their condition.67 Interactive kinds may

only go through the transformation process in response to

our classifications of those kinds, but to say a kind is not

natural because of what affects it, is an entirely different

claim.68 Human kind-categories interact with humans on a

physical “biolooping” plain at a greater speed than dogs

take to evolve from wolves. As Cooper argues, this may make

inductive inferences more difficult when considering the 67 I refer here to the criticisms raised by James Bogen (1988) andSally Haslanger (1995). The former offers the counter-example of marijuana, which responds to its designation as an illegal kind by growing in a unique way from other marijuana plants that are not being grown in dark attics by drug dealers. This is also an interesting example to use as a comparison to the example of autistic children who grew up in France versus the United States.While the former are raised under a cruel diagnostic and treatment paradigm, the latter medical community classifies autistic children under a different linguistic scheme for better or worse. James Bogen, “Comments on ‘The Sociology of Knowledge about Child Abuse,’” Nous, no. 22, 65-66), 66; Sally Haslanger, “Ontology and Social Construction,” (Philosophical Topics, no. 23, 95-125), 104.68 Rachel Cooper, "Why Hacking Is Wrong about Human Kinds," 79.

interactive process of human kinds, but this does not give

us good reason to conclude humans cannot be natural kinds.

Likewise, idea-dependence is problematic when one considers

how some ideas have objective implications, such as a female

losing weight to mimic an idea of being slim, while others

do not have objectively verifiable results, such as patients

who “develop” Multiple Personality Disorder. In order to use

idea-dependence to prove a kind is not natural, one must

prove definitively that there is something genuine rather

than disingenuous about a kind. The kind must be empirically

verifiable and not caused by what Cooper refers to as

“relational” changes, such as the image of an “attractive

woman,” which is subjectively determined by societal

norms.69

While Hacking has since revised his initial claim that

human kinds are not natural kinds with the publication of

The Social Construction of What? (1999), Cooper’s critique of idea-

dependence is more difficult to endorse. Regardless of

whether or not a change is “relational” or “objective,”

69 Ibid., 80.

there are real implications that arise from the categories

we develop and assign to people diagnosed with mental

disorders or specific learning differences. While Hacking

certainly has his reservations about some mental disorders,

such as his famous example in Mad Travellers (1998) of

“dissociative fugue,” he draws attention to our types of

justification used to explain diagnostic categories to

illustrate the limits of our empirical comprehensibility.

The late nineteenth century psychiatrists who diagnosed

vagabonds in France with dissociative fugue and who tried to

understand it as a product of a hysteria or neurosis were

certainly wrong about the empirical truth of the disorder.

Notwithstanding the incorrectness of their theories, Hacking

argues that given their categorical understanding of the

“interactive kind” of dissociative fugue, they were

warranted in their diagnoses. They were genuinely persuaded

of the empirical truth of the disorder, and in the empirical

validity of hypnosis as a treatment method, but over the

course of their kind-concepts’ “looping effects,” the

patients’ behaviors and the categories assigned to those

behaviors changed. The transience of mental illnesses thus

follows from the interaction of kind-concepts within a

societal niche, through the looping effects of medical

taxonomy, cultural polarity, observability, and release.70

What makes mental disorders as categories empirically

justifiable is our incorporation of degrees of uncertainty

into our kind-concept models.

In the midst of the panoply of mechanisms through which

kinds are transformed, how can we be sure our current kind-

concept is more empirically and ethically justifiable than

previous iterations, or that individuals diagnosed with said

disorder will benefit from our concurrent understanding of

treatment methods? First, we can incorporate meta-analyses

of interactive kinds into our development of psychiatric

reference texts, such as the DSM-V, or lend more attention

to specific details of particular cases of mental disorders.

This last comment is worth addressing in light of Andrew

Davis’ application of Ian Hacking’s theories to learner

70 Ian Hacking, Mad Travelers, 81.

categories.71 Davis offers the example of the genotype-

phenotype relationship that is commonly observable in

nature. He defines a genotype as the physical description

that includes all levels of the biosphere down to the DNA

building blocks. The phenotype on the other hand, is defined

by the same physical characteristics and includes the

behavioral differences of the organism. The DNA makes up the

genes that define the mechanism of neural interface, but the

environment ultimately determines which genes are expressed.

Even though there is no known variation in the genetic make-

up, the expression of genes is niche-specific.72 Davis

maintains that by focusing on the genetic origins of certain

learning disabilities, psychiatrists and social workers

ignore the environmental causes that determine student

success in the classroom, such as the teaching methods

employed by the instructor.73 It is incumbent on researchers

to test for treatments that are specific to certain learner

71 Andrew Davis, "Ian Hacking, Learner Categories and Human Taxonomies," (Journal Of Philosophy Of Education 42, no. 3-4 (August 1, 2008): 441-455), 451.72 Ibid.73 Ibid.

categories such as Dyslexia or ADHD, and in failing to do

so, they must re-evaluate both their definition of the

category, and their a priori assumption of the presence of

“discrete underlying neurological origins corresponding to

each ‘condition.’”74

As the narrative at the beginning of this article

demonstrates, the French psychoanalysts are in need of a

similar re-evaluation of their current psychiatric paradigm.

Hopefully they do so soon, to avoid the same social backlash

that occurred in the United States in the 1970s. Despite the

need for research into the ‘treatment’ options for

individual cases of mental disorder or learner categories,

Khalidi expresses concern that it is not possible to

“anticipate the variety of ways in which interaction and

feedback take place,” given we are uncertain of the

ontological origins of any specific interactive kind.75 If

we introduce alternative concepts, does this mean the

trajectory of the interactive kinds will move toward a

different identity? As Hacking indicates, the very different74 Ibid., 452.75 Muhammad Ali Khalidi, "Interactive Kinds," 339.

concepts we employ for interactive kinds make them “moving

targets,” which social science inquiries do not always

pinpoint.76 Thus, child abuse, or Multiple Personality

Disorder, or some other “interactive kind” is difficult to

study empirically, or on independent grounds. Mental

disorders confound this difficulty even more than other

kind-concepts, given that the interactive kind is

necessarily of our mind and therefore difficult to

“separate” from its natural element i.e. our brain.

Cooper criticizes Hacking for a similar theoretical

ambiguity. She argues Hacking confuses the conditions of an

intentional action with the conditions under which we

observe and interpret an action.77 Hacking maintains that

humans respond to the definitional aspect of categories, and

not just to actions taken by their peers in response to the

classification. In other words, a description of a mental

illness diagnosis is what leads to certain treatment

methods, while for a tumor to be “malignant,” our concept

76 Ian Hacking,The Social Construction of What? (Cambridge, Mass: HarvardUniversity Press, 1999),108.77 Rachel Cooper, "Why Hacking Is Wrong about Human Kinds," 82.

alone does not affect change in the state of the tumor.78

Cooper cannot reconcile the underlying logic of Hacking’s

interactive kinds with her concept of intentional actions.

As we can imagine the Szaszian skeptic would argue, humans

do not require the definitional category to make decisions,

nor do we necessarily require them to observe and explain

the intentions behind human or animal actions.79 Likewise,

we cannot empirically verify or infer intentions of a kind

by observing their interactions, because “we cannot decide

what someone intends merely by looking at their

movements.”80 Cooper maintains that the intentional action

78 Muhammad Ali Khalidi, "Interactive Kinds," 344.79 I do not mean to associate Rachel Cooper with the Szaszian anti-psychiatry perspective, as she states elsewhere somewhat conservatively, “We can conclude that Szasz is wrong to suggest that ‘mental disorder’ is a myth. Sometimes the best explanation of a behavior is sub-personal, and when such behaviours are problematic it may often be reasonable for them to be treated by physicians.” Likewise, instead of discursively arguing that all behavioural problems are problems with living, Cooper maintains that hearing voices for example is a subpersonal problem and that“what matters is the nature of the explanation for norm violation, not the nature of the norm that is violated.” Rachel Cooper, Psychiatry and Philosophy of Science, (Montreal: McGill-Queen, ©2007), 19; Cooper may not be in complete agreement with Hacking’s work, but she is certainly a supporter of his scholarship. Rachel Cooper, "Why Hacking Is Wrong about Human Kinds," 82.80 Ibid., 82.

of an interactive kind is only “contingently dependent” and

not absolutely dependent on the classification.81

The problem of intentionality is pivotal to Hacking’s

theory. It is difficult to identify and discriminate between

the sources of a kind-concepts, and even more difficult to

attribute all human behavior as responses to the description

of a kind. Instead of concentrating our theoretical

understanding of interactive kinds as either non-real or

real, and attempting to distinguish between the two, Hacking

implores us to study how these interactive kinds behave at

the confluence of factors in a specific ecological niche.82

We may not be able to anticipate the way kind-concepts such

as mental disorders interact in different contexts, but this

need for clarity does not force us to search ceaselessly for

a method to distinguish between “real” and “non-real” kinds.

Hacking refers to Hilary Putnam’s contention that we must

examine the ways reality itself is renegotiated as our

linguistic categories evolve.83 Just as Descartes’

81 Ibid., 83.82 Muhammad Ali Khalidi, "Interactive Kinds," 358.83 Ian Hacking, Mad Travelers, 95.

linguistic categories cannot be used to reduce mind to

matter, Hacking’s concept of interactive and indifferent

kinds cannot be used to analyze our neural processes.

Instead of requiring a heuristics structure in which the

mind is reduced to the physical domain, or our neural

pathways can be measured and made comprehensible to us, we

must examine the ways we describe the experience of living

with a mental disorder. We must broaden our concept of

reality, rather than search for “modified criterion for what

makes a kind real.”84

Philosophers of Mind continue to debate the efficacy of

realism and labor under the view that scientific analyses of

mental disorders require a rigid metaphysical grounding. In

response to these hard-nosed theoreticians, Hacking assumes

the pragmatic stance of the American philosopher C.S.

Peirce, who argued in his 1878 essay “How to Make our Ideas

Clear” that what is “true” constitutes “the opinion which is

fated to be ultimately agreed to by all who investigate” and

84 Muhammad Ali Khalidi, "Interactive Kinds," 358.

what is “real” is “the object represented in this

opinion.”85 Instead of concerning ourselves with the

ontology of kinds, philosophers must consider how kinds or

mental disorder categories interact with the people who are

classified, and what our interpretive frameworks do to

improve the lives of those classified by our kind-concepts.

We must redirect our focus from the “real” as observable

neurological process to the individual as family member,

patient, student, co-worker, autistic, dyslexic or some

other combination of categories.

Section 3: Clearing the Forest: The DSM-5 Debate

“Confined in the ship, from which it is impossible to escape, the madman is confined to the thousand branches of the river, the thousand paths of the sea, to this great uncertainty external to everything. He is a prisoner in the midst of the most free, the most open of roads: chained solidly to an infinite crossroads.”

- Michel Foucault, Madness and Civilization

85 C.S. Peirce, “How to Make our Ideas Clear,” (1878) quoted in Ian Hacking, Mad Travelers, 93.

In the first chapter, I began with a narrative example

of a child with autism abused under the pretense of

treatment. The methods of the French psychoanalysts and

medical practitioners are harmful by most ethical standards;

however, philosophers of mind and psychiatry choose to

debate the existence of mental phenomena rather than search

for an appropriate treatment paradigm. The spectrum of these

considerations ranges from the Szasz’s contention that

mental illnesses are social “myths” used to legitimize the

political control of undesirables, to Graham’s assertion

that mental illnesses are “real” so long as they inhibit our

capacity for self-control and responsibility and so long as

they exist “independent of whether we have a theory about

them, think about them as such, or classify people as

subjects of mental illness.”86

The divergence of these philosophical positions is born

of the apparent incommensurability of their respective

metaphysics of mind. These thinkers have unwittingly fallen

into a mind-body dualism trap by assuming either mental 86 Thomas Szasz, The Myth of Mental Illness; George Graham, The Disordered Mind, 10-2.

kinds must exist objectively and independently of matter, or

that what we consider to be the “mind” is ultimately

reducible to matter. As Ian Hacking’s work and subsequent

criticisms of the theory of “interactive” and “indifferent

kinds” demonstrates, this dichotomous reasoning is not only

conceptually incoherent, but difficult to reproduce

empirically. While some such as Muhammad Ali Khalidi are

hesitant to abandon the search for this veritable

philosopher’s stone, others such as Andrew Davis recognize

the implications of this thinking for authority figures that

perceive mental phenomena as threats to social institutions,

and as purely neurological kind-entities that exist

independent of environmental influence.87 I have argued that

Ian Hacking’s conceptual tool of “interactive kinds” is a

pragmatic answer to this dilemma that does not wed

philosophy of mind to one or the other view of mental types

and frees clinical psychiatry to concentrate on the patient,

the object of Hacking’s process of ‘looping.’88

87 Muhammad Ali Khalidi, "Interactive Kinds"; Andrew Davis, "Ian Hacking, Learner Categories and Human Taxonomies," 451.88 Ian Hacking, The Social Construction of What?, 105.

There is perhaps no other ground on which the ‘looping’

of mental categories is more contentious than in conceptual

debates surrounding the various revisions to the Diagnostic

and Statistical Manuel of Mental Disorders.89 Scholars have

called for a reconceptualization of this area of medical

science without recourse to debates over the mind and brain

dichotomy. As Ian Hacking demonstrates, a deterministic

position for human kinds is empirically untenable, given one

cannot quantify the interactivity of kinds in certain social

and ecological niches. The positions held by theorists such

as Thomas Szasz not only suffer from empirical difficulty,

but they also fail to delineate a sound ethical position

against the use of mental diagnosis. If a mental disorder is

causing a patient mental anguish, but there is an absence of

brain abnormalities, that does not exempt a psychiatrist or 89 Hereafter: DSM III, IV, V etc. Diagnostic and Statistical Manual of Mental Disorders: Dsm-5, 5th ed. (Washington, D.C.: American Psychiatric Association, 2013); James Phillips, Allen Frances, and Michael A Cerullo et. al., "The Six Most Essential Questions in Psychiatric Diagnosis: A Pluralogue Part 1: Conceptual and Definitional Issues in Psychiatric Diagnosis," (Philosophy, Ethics, And Humanities In Medicine 7, (January 1, 2012): 1-29); “A Pluralogue Part2: Issues of Conservatism and Pragmatism in Psychiatric Diagnosis," (Philosophy, Ethics, And Humanities In Medicine 7, (January 1, 2012): 1-16); “A Pluralogue Part 4: General Conclusion," (Philosophy, Ethics, And Humanities In Medicine 7, (January 1, 2012): 1-25).

clinician from their duty to help an individual recover

self-control. Karl Jaspers argued something similar in 1913,

writing that the connections that make up the mental life of

persons (Verstehen), also constitute “meaningful connections

emerging in psychotic states, which may at first glance

appear to be quite senseless.”90 Unlike Jaspers, however,

Hacking maintains that psychological states can hold as much

real or ontological “meaning” as those of neurologically

damaged states.91 In Mad Travellers (1998), Ian Hacking argues

that psychiatric diagnoses are warranted, so long as the

conceptual tools employed in a given situation and context

suggest a cure for the patient’s ailment. While our

conceptual tools are imperfect and we do not yet know enough

about certain mental types to distinguish between “real” and

“non-real” kinds, we are not prevented from making justified

medical diagnoses to help patients.

90 Karl Jasper’s 1913 essay quoted in David H. Brendel, "Philosophy of Mind in the Clinic,” 188.91 This is also Brendel’s contention in his critical assessment ofJaspers in response to Paul Churchland’s theory of eliminative materialism. Ibid.

As the very existence and prevalence of the theories of

Thomas Szasz and the anti-psychiatry movement indicates, the

most recent iterations of the DSM display a conservative

approach that incorporate little if any of these conceptual

or ethical issues. In a 2010 article, Paul Healy introduces

some of these ambiguities regarding the ontology of mental

disorder categories as accurate “representations” of real

kinds that appear in field studies.92 The epistemological

underpinning of the DSM is based on a Linnaean-type

hierarchy that originated with the work of Emil Kraepelin

(1899).93 Kraepelin’s was the intellectual originator of the

medical model for psychiatry, which in his construction

emphasized the “convergence of psychopathological symptoms,

aetiology, course, outcome, brain morphology, and

pathophysiology.”94 Since his time, psychiatrists have

primarily emphasized the latter three areas when making

psychiatric diagnoses, and interpreted classification a

92 Paul Healy, "DSM Diagnosis and Beyond: On the Need for a Hermeneutically-Informed Biopsychosocial Framework," (Medicine, Health Care And Philosophy: A European Journal 14, no. 2 (May 1, 2011): 163-175).93 Ibid., 164.94 Footnote 4, Ibid., 165.

purely neurological medical designation.95 While Kraepelin’s

original formulation of psychiatric nosology was flawed in

most respects, the medicalization of psychological

categories as “disease-entities” has continued to be a point

of contention for pro and anti-psychiatry theorists. The

debate over the ontology of mental disorder categories

focuses on the need for a causally descriptive nosology;

however, the DSM model established by Kraepelin does not

offer even the pretense of such an epistemic framework (as

evidenced by its arrangement of psychological kinds into

clusters as opposed to causes).96 Thus, given the

uncertainty of causality and the high rates of comorbidity

in patient diagnoses, some philosophers of clinical

psychiatry have dismissed the DSM as a viable tool for

diagnosis. The suggestion that the DSM should undergo

significant structural revisions was the subject of

extensive debates in the years leading up to the publication

of its most recent revisions.

95 Footnote 4, Ibid.96 Ibid., 166.

In 2010, various commentators began a series of lengthy

blog-posts about the revision process to the DSM that

evolved into a multi-response debate in the Bulletin for the

Association for the Advancement of Philosophy and

Psychiatry, under the editorship of James Phillips.97 Their

debates stemmed from critiques written by Robert Spitzer and

Allen Frances (Chairmen of DSM-III and IV Task Forces

respectively) in the Psychiatric Times, which discussed

transparency and content issues in the new manual.98 Since

the year 2006-7, when the DSM-V Task Force coalesced under

the leadership of Chairman David Kupfer and Vice-Chairman

Darrel Regier, psychiatrists and philosophers have debated

how to interpret the high levels of comorbidity and

treatment resistant issues associated with DSM-III and IV

diagnostic categories.99 Frances argues that the changes the

97 James Phillips, Allen Frances, and Michael A Cerullo et. al., "The Six Most Essential Questions in Psychiatric Diagnosis: A Pluralogue Part 2: Issues of Conservatism and Pragmatism in Psychiatric Diagnosis," (Philosophy, Ethics, And Humanities In Medicine 7, (January 1, 2012): 1-16).98 Ibid., 1.99 James Phillips, Allen Frances, and Michael A Cerullo et. al., "The Six Most Essential Questions in Psychiatric Diagnosis: A Pluralogue Part 1: Conceptual and Definitional Issues in Psychiatric Diagnosis," 2.

Task Force proposed for the new edition of the DSM were

“premature,” since scientific evidence is not available to

legitimize the categories. Instead, Frances maintains the

addition of categories previously believed below the

threshold necessary for a diagnosis would have the

unintended affect of increasing the number of “false-

positive diagnoses,” and the risk of exposing otherwise

healthy individuals to “potent psychotropic medications.”100

Yet the apparent hostility toward debates over these issues

was made evident when in 2008, the Task Force rejected a

proposal for a Conceptual Issues Work Group to debate the

epistemology of the DSM.101

Thus, Phillips’s Bulletin represents the consolidation

of the protracted debate among scholars over conceptual

issues associated not just with the medical diagnostic

categories of the DSM-V, but with the state of psychiatric

nosology.102 As Phillips indicates, psychiatrists and anti-

psychiatrists often become lost in the weeds of the

100 Ibid., 2.101 Ibid.102 Ibid., 4.

different psychological clusters and their concomitant

symptoms. Some argue that these shared symptoms make

differentiation between mental categories more subjective

than objective. Yet ignoring psychological suffering is also

negligent, and requiring an underlying neurological account

for every diagnosis would be unreasonable and

irresponsible.103 What must psychiatrists do, however, if

future breakthroughs in neuroscience contradict the DSM’s

current nosology? Peter Zachar and Steven Lobello of Auburn

University assume a similar position to Hacking in their

section of the debate, arguing that a pragmatic nosology

would aim at the truth, while assuming a degree of epistemic

uncertainty about the representation of a patient’s

suffering in the diagnosis. Unlike the epistemic pragmatist,

who assumes an indirect path toward the truth exists, or

nominalist, who assumes (to an extent) that competent

psychiatrists can identify which mental kinds are real and

which are not, social constructionists tell a historical

narrative of how mental categories came about. As the

103 Ibid.

previous chapter demonstrates, Hacking lies somewhere

between the pragmatist and social constructionist theses,

while philosophers such as Graham and Szasz are preoccupied

with an argument over epistemological realism. In there

segment of the debate, Zachar and Lobello criticize the

Szaszian anti-psychiatry position, viewing it more as a kind

of conscious hostility to rather than a unique argument

against realism, and to sustain such a critique would

necessitate the reconciliation of incommensurable medical

paradigms.104 In order for a strong philosophical defense to

justify the medicalization of the DSM, it must support a

program of scientific investigation, and not just Szasz’s

claim that it is an “utterly indispensable legal-social

tool.”105

Philadelphia psychiatrist Clair Pouncey offers her own

sustained critique of the realism v. construction debate,

claiming that while mental disorders are socially

constructed, this knowledge should only inform our

diagnostic nosology in so far as we recognize the 104 Ibid., 5-6.105 Ibid., 13.

theoretical uncertainty of mental kinds. Yet this position

is discursive and denies the relevance of an epistemological

problem instead of offering a substitute to reconcile the

disparate ontologies. Yes, psychiatrists such as George

Graham attempt to “call them as we see them,” but giving

legitimacy to the claim that disorders are a “heterogeneous

class of abstract entities that have uncertain ontic status

apart from the persons who instantiate them,” only

reinforces the legitimacy of positions that support an

epistemology described by more limited ontic criteria.106

The debate over the ontological status of mental

disorder categories in the DSM is not without its more

hardnosed critics. Nassir Gaemi of the Tufts Dept. of

Psychiatry accuses Phillips of misrepresenting the very

foundations of scientific epistemology by arguing that

objective truths in the world cannot exist. Regardless of

whether this criticism is warranted, Gaemi’s realist

position is of interest because of its critique of the

normative consequences of relativism. After all, how can one

106 Ibid., 7.

reject the reality of psychiatric illness, and prescribe

hard psychotropic drugs under good conscience? As we have

seen with Thomas Szasz, Gaemi’s appeal for moral criteria in

a psychiatric nosology lends his argument more brevity than

it deserves. Associating this moral claim with a need for

realism is logically misguided. As Michael Cerullo aptly

states, “all definitions of disease have normativist and

naturalist elements even in a world described by a

scientific realism.”107 Even though our criteria evolve over

time, we cannot deny the possibility or even the probability

that at some level, there is a physical basis for specific

mental types. How we determine which symptoms express

certain mental types and not others is the hard decision

psychiatrists must make when diagnosing patients. While some

individuals express varying degrees of depression or

anxiety, psychiatrists should avoid identifying the fleeting

expression of psychiatric symptoms as constitutive of a

disorder, unless the symptom is extreme and truly ails the

patient. Yet Cerullo concentrates on the physical

107 Ibid., 9.

determinants of these extremes and ignores the social and

environmental determinants that necessitate our decision to

classify their mental kind as a disorder. Even if, as he

maintains, schizophrenia is ultimately “better defined from

the naturalist perspective along with other physical

diseases like Parkinson’s disease or dementia,” it is folly

to discursively define any of those disease-types as purely

natural.108

Likewise, Ian Hacking does not deny that the use of

high-powered drugs in mental diagnoses must be supported by

neurological research. The affects of these drugs have on

our brains is just as real as the patient’s suffering,

whether or not that suffering is socially constructed or

neurologically based. The psychiatrist must evaluate the

patient’s need, and must exhaust all other treatment options

before attempting to alleviate the patient’s symptoms with

high-powered drugs. Likewise, Gaemi distinguishes between

the moral implications to medical diagnosis of the

epistemological models of the “random walk” and the

108 Ibid., 9.

“epistemic iteration,” borrowed from the philosopher Kenneth

Kendler.109 He argues that if the process of medical

discovery takes a “random walk” toward no foreseeable goal

or essentialist aim, than ethical medicine would be

impossible. The only desirable path is through epistemic

iteration, or a process of discovery with an aim toward the

truth. Yet Kendler’s model could also be appropriated

through a pragmatic perspective, without requiring that we

maintain a Platonic ideal of a mental disorder to reach. It

is possible that the epistemic iterations assume Hacking’s

looping process, and arrive at a more complete definition of

a mental disorder in a specific time and location. Rather

than imagine that the path of epistemic iterations as a

straight line (which Kendler does not as the image

illustrates), the jagged path indicates that both cultural

and environmental conditions select for certain mental types

over others.110

109 Ibid., 7.110 Ibid., 7-8.

Figure 1. Epistemic Iteration Versus Random Walk.

Phillips et al. Philosophy, Ethics, and Humanities in Medicine 2012 7:3 doi:10.1186/1747-5341-7-3.

Of the many voices in the Bulletin debate, Jerome

Wakefield’s prescription for how the DSM diagnostic

categories should be used was perhaps most in line with Ian

Hacking’s philosophy. The fallacy committed by realists and

social constructionists is to confound “ontology in

epistemology into one,” assuming an accurate description of

mental disorder categories either corresponds to an external

reality or to a reality from their own perspective.111 Like

Hacking, Wakefield maintains there is no such false

dichotomy between social construction and realism, but

current DSM categories should be understood as “starting

points for a recursive process aimed at getting at

disorders.”112 It is incumbent on philosophers and

psychiatrists to make judgments to diagnose based on what he

calls factual and value components. The patient’s condition

must be judged harmful to his/herself and must involve the

malfunction of some mental processes, but what those

processes are is difficult to determine and requires

111 Ibid., 10.112 Ibid.

pragmatic decisions on the part of the psychiatrist.

Wakefield’s and by extension Hacking’s weakest suggestion is

to argue that pragmatism should be used to determine what

constitutes an “evolved” psychological dysfunction and what

is a dysfunction in relation to society’s values.113 As Mad

Travellers (1998) reveals, this is a tall order for any

psychiatric paradigm, which is why the DSM should only be

understood as the intellectual starting point for a

research-based diagnostic process.

Conclusion:

I have spent the majority of this paper defending the

theory of interactive kinds as a tenable paradigm for the

philosophy of psychiatry and by extension the DSM. Since

its publication and dissemination to field workers and

academic institutions in 2013, however, Ian Hacking has

produced one of the more critical reviews of the DSM-V. In

this review, titled “Lost in the Forest,” he offers a

scathing critique of the outdated and certainly empirically

113 Ibid., 18.

unjustifiable Linnaean model of the DSM. The segregation of

types into a hierarchical taxonomic structure became

obsolete when genetics regrouped most of the plants

categorized by botanists in the eighteenth century, and it

is reasonable to expect that such an outdated model for

psychiatry could be discarded.114 Hacking’s objection to the

DSM’s internal structure, as he states, is not part of the

same sustained effort theorists like Thomas Szasz and Paul

Churchland have made to persuade colleagues that what we

call the mental will one day be reduced to the physical.115

In line with his claim that nineteenth century hypnotic

medicine was valid, he does not raise objections to the

validity of a diagnostic manual meant to categorize mental

disorders for research and legal purposes. Rather, his

critique is that the DSM does not represent “the nature or

reality of the varieties of mental illness.”116

Therefore, while we should not discard the DSM as a

tool, the tool itself may be in need of an epistemic and 114 Ian Hacking, “Lost in the Forest,” (London Review of Books, Vol. 35, No. 18, August 8th, 2014).115 Ibid.116 Ibid.

organizational overhaul. Rather than debate the actual

internal form of the DSM (a debate I consider to be more

policy and psychiatric science-specific, though certainly

based on strong philosophy), I offer a defense for the

clinical use of such a diagnostic tool. The NIMH said it

would cease using the DSM for its lack of validity, which

Ian Hacking has aptly demonstrated is itself an unwarranted

claim. The content of the DSM has remained conservative over

its past few iterations, with minor changes made here and

there due to fear among psychiatrists that an overhaul to

its content will reflect its epistemological instability.

Yet if we consider mental disorders to be interactive kinds

repeatedly renegotiated over time instead of as purely

natural kinds that are mind-independent, drastic changes to

content and form are both justified and even encouraged in

order for the DSM to be current and reflective of the real

interactive kinds in society. Likewise, the DSM should not

be the be-all-end-all determinant of treatment. The presence

of high levels of comorbidity and a high level of the

patient’s suffering should not make treatment methods more

difficult to identify. Instead, research should be

conducted, and tests redesigned to determine the appropriate

treatment for the individual, rather than the appropriate

treatment for the kind assigned to him/her. Hacking and I

both call for more patient-centered care both as a sustained

critique of the DSM categories and as good medical practice.

Thus, bush whacking through the thick forest of DSM clusters

becomes a process of renegotiating the very categories and

clusters to which we claim epistemological validity. With

that in mind, perhaps we can free the madman from his

chains, and help him/her pick the road with the least amount

of traffic.

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