The Transience of DSM Categories: Ian Hacking’s Concept of “Interactive Kinds” as a Heuristic...
Transcript of 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.
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“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).
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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.
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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).
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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).
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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).
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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
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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).
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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).
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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.
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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.
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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.
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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.
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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.
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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.
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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).
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
28
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.
29
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.
30
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.
31
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:
32
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.
33
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.
34
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.
35
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
them.
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.
36
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.
37
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.
38
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.
39
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.
40
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
41
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.
42
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.
43
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.
44
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.
45
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.
46
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.
47
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.
48
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.
49
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.
50
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.
51
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).
52
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.
53
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.
54
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.
55
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.
56
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.
57
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.
58
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.
59
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.
60
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.
61
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.
62
“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.
63
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.
64
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.
65
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.
66
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.
67
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
68
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.
69
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