This book is about mental disorders: how to think about them and how well those of us outside can get a feel for what they are like from inside.
Some dispute the boundaries of mental disorder. Is autism a disorder, or should it be seen as “neurodiversity”? Is antisocial personality disorder rightly named, or is it just ruthless amorality? Is addiction mental illness or just moral weakness? Is either medication or psychotherapy appropriate to ease the devastating grief of bereavement, or should we avoid medicalizing this normal human experience?
When and how much do mental disorders impair agency and responsibility? When should acting under the influence of severe depression excuse someone from responsibility for what she does? What do some disorders do to a person’s identity? When someone with schizophrenia shows unprovoked hostility and aggression, does that reflect him, or is it his illness? How should we draw boundaries here? How much is the original person still present in severe dementia?
This book is about the human interpretation of disordered states. Are mental disorders impenetrably alien? The genetics and brain chemistry of some of these states are starting to be understood, but do the inner landscapes of these states defy empathy at the psychological level? The question of human interpretation is important, not only for psychiatrists, psychotherapists, psychoanalysts, and psychiatric nurses. It is important for, above all, people who have these disorders, and for their families and friends, and for others who are simply interested in this area of human experience. This book is written for anyone who hopes it may be possible to interpret and understand disordered states—and for anyone who hopes, despite a disorder, to be interpreted, to be understood.
It may be presumptuous for someone who is neither a psychiatrist nor any other kind of mental health professional to write a book about these questions. Inevitably the limits of my knowledge will sometimes show through, although I hope these limits may be outweighed by the ideas and the reasons behind them. Mental disorder straddles the boundary between the sciences and the humanities. The subject I teach—philosophy—is in the humanities, and this book has a humanities approach. Many mental health professionals are notably open to viewing mental disorder through the lenses of art, philosophy, poetry, novels, and the humanities in general. Some of them may feel the book presumes too much in this regard. Again, I hope there may be justifying benefits.
The book has several different origins.
In Broadmoor, a secure psychiatric hospital, I interviewed a group of men who had been diagnosed as having “antisocial personality disorder.” The aim was to explore the claim sometimes made that they “lack a conscience.” This was part of a larger project carried out with the psychiatrist Dr. Gwen Adshead. The other part of the project, under the stimulus of an invitation from the neurologist Martin Rossor, involved asking similar questions of a group of people diagnosed with frontotemporal dementia.
In 2003 I gave the Tanner Lectures on Human Values at Princeton. I chose the title “Towards Humanism in Psychiatry” and lectured on psychiatric interpretation and on the relations between psychiatric disorder and a person’s identity. The part on identity developed thoughts I had first aired in the 2002 Aubrey Lewis Lecture at the Institute of Psychiatry at King’s College London.
I have a long-standing interest in the intersection of psychiatry and philosophy. My first book, Responsibility, published more than forty years ago, included chapters on the concept of mental illness and on mental illness and responsibility. I was drawn then to the depth and difficulty of the philosophical questions raised by psychiatry. Rereading those chapters after writing this book, I was pleased that, although my ideas have developed since, there was little I wanted to repudiate in that earlier effort. I was less pleased to notice how very little I then knew about psychiatry. I admit, however, to being now a bit envious of the youthful effrontery.
The interest remained. Fifteen years ago, on coming to the Centre of Medical Law and Ethics at King’s College London, I cooperated with colleagues in the Institute of Psychiatry and the Department of Philosophy to set up and teach a master’s course in the philosophy of mental disorder. In the Centre’s master’s course in medical ethics and law, I also set up and taught a module on psychiatric ethics.
This book did not originate purely in intellectual curiosity. Although I have not been hit by psychiatric disorder, its shadow has touched my family. A minor consequence of that has lasted for nearly a quarter of a century. Without their permission, and without their realizing it, I have been watching many psychiatrists and psychiatric teams at work. They have provided stimulus to reflect on their different approaches—their assumptions, their patterns of thought, and their ways of interpreting other people. I have also noticed how important are both the strengths and the limitations of the different kinds and degrees of perceptiveness and sensitivity they bring to their work. They have provided stimulus to reflect on their different approaches, on their assumptions, their patterns of thought, and their ways of interpreting other people. Although this is not on the surface of the book, I hope it has given it an extra dimension.