From “What is disorder?” to Heidegger & Explanatory Pluralism: A Discussion with James Barnes

James Barnes is a psychotherapist, mental health advocate, and writer. He lives in Exeter in the UK. He is on twitter: @psychgeist52

Discussion Background

This discussion started on Twitter in the context of the last blogpost in which Mark Ruffalo and Ron Pies discuss their views on psychiatric diagnoses and on the definition of “disorder”.

James Barnes objected that a non-essentialist, pragmatic definition of disorder misses the entire point of the term “disorder” or “disease”, which for him is to discriminate an empirical object of/in the organism, as it does in the vast majority of cases of unquestioned physical disorders.

I responded by saying it is possible to define disease/disorder is many different ways, that each definition has its internal logic, and each has pros and cons, and different implications. A common goal of most definitions is to try to capture the everyday use of this term in general medicine, but other definitions may not care for this goal. So, I don't find much value in trying to argue for a specific definition since he can define it differently and may value other goals. I stated that it will be far more fruitful and productive to compare competing conceptualizations of disease/disorder with regards to desired goals.

James responded to this by saying that he understands himself (and the PTMF, for example) to be disputing the existence of such things in terms of “disease” or “disorder”.

My response was that if he takes the stance that our psychological lives should not be understood through the notion of disorder, then he already has an implicit notion of disorder that he think excludes the psychological realm, and so, it becomes important to clarify what that implicit notion is, on what principle does it exclude the mental but not the physical, and how well does that notion apply to rest of medicine.

James said this was fair, and at this point we moved our discussion to email to conduct it more efficiently.

Barnes:

The content of the issues described in physical disorders/diseases is focused on, and primarily about, physical states of the organism. The content of the issues described in 'mental disorders,' however, is focused on, and primarily about, self, world and others — i.e. about meaningful, socioculturally dependent phenomena — and in only some cases, and not necessarily, physical states. As this type of meaningful content is not reducible to/locatable in the organism, I reject the terms disorder or disease for issues that have the stuff of this category for their content. I suggest the terms are only appropriate for issues that are focused on, and primarily about, physical states of the organism, i.e. locatable in it.

Aftab:

Here's what I see as the problem.

You haven't elaborated what a disorder is but you've articulated what it cannot be. The argument seems to be something like this:

Assumption 1: Physical disorders are about physical processes.
Assumption 2: Mental problems are not about physical processes, they are about mental processes.
Assumption 3: Disorders can only involve physical processes.
Therefore mental problems are not disorders.

The whole argument relies on assumption #3, but that is precisely the point that is being disputed by relevant parties. I don't accept assumption 3, for instance. The philosophical question would be, what is it about the nature of disorders that they can only be about physical processes?

Another argument seems to be:
Assumption 1: Mental processes are characterized by intentionality and psychological meaning.
Assumption 2: Physical processes and physical disorders lack intentionality and psychological meaning
Assumption 3: Disorders are incompatible with intentionality & psychological meaning.
Therefore mental processes cannot be disordered.

Problems are with assumption #2 and assumption #3. I don't believe disorders are incompatible with intentionality and meaning. Already in instances of well-defined physical disorders and processes we can see the presence of psychological phenomena. For example, personality changes, delusions, hallucinations in dementia. Paranoia secondary to cocaine intoxication. Anger, mood changes, personality changes due to brain tumors. So, assumption #3 is clearly not valid.

Barnes:

1. You have changed the terms here. I am saying the content of disorders is about physical processes; they can and do involve mental content. And, if you are saying that 'disorder' applies to content that is about self, world and other, why then are we required to locate the disorder inside the organism? It would seem that we are free to think that there are/should be disorders of (and in) world/other — e.g. relational disorders, sociopolitical disorders etc. If you permit those by definition, then I would accept that, but that completely changes the nature of the situation. 

2. This is true; the disorders you mention involve ‘intentionality and psychological meaning.’ But, again, 'involving' is not enough — there could be many reasons for this. It's possible, for example, that it is the profoundly disturbing and radically disorienting experiences of, in, and with, self, world and other that follow from such physical events that come to constitute the content you describe. As such, the physical events would only be the cause of contentless physiological change, and the subsequent 'symptoms' you mention result from events/experiences no longer issued from those changes.

Or, so long as we are not substance dualists, it also makes sense that certain gross physical disturbances could mimic 'mental disorders.' You could argue that if that is possible, then what is stopping us from concluding that we have not just found the physical causes yet, as is often argued? I do not accept that as an argument, as it excuses science from being scientific, being that theoretically you can go on looking for something that is not there for an infinite amount of time. Of course, one can make that statement, but you can't then say that psychiatry is treating anything based on science — the science is searching for the thing to do the science on, and until it finds it, it is merely conjecture. Furthermore, the fact remains that such causes have not been found after decades, several quantum leaps in technology, and billions of dollars spent — and there is no reason to suggest they will.

You seem to be arguing against a dualist straw man. 'Physical' and 'mental' — imperfect, dualistic categories in the first place — of course involve each other. The question, though, is what is the appropriate level of explanation and where is the 'location' of the content in question. I argue that physical explanations, located in the organism, are entirely inappropriate for issues whose content is about self, world and others. 

Aftab:

Thank you for the clarification. This certainly helps me understand your view better.

It seems that you see "disorder" as a species of physical explanation. That is, to call X a disorder is to, among other things, explain X in terms of physical processes. In your view disorders are about physical processes, concerned primarily with physical processes, and involve mental content secondarily, but they are not primarily about mental content.

You are right to guess that I do not restrict disorders to physical explanations (and neither does the historical and “official” understanding of disorder in psychiatry). I think that disorders can primarily deal with mental content and mental explanations as well, that disorders can apply to content that is primarily about the self, the world, and the others.

Why are we required to locate the disorder inside the organism? The way this concept is understood in medicine and psychology, disorder is a property of the individual, not necessary inside the individual, but about the individual, or of the individual. That arises from the fact that disorder is applied to phenomena that are primarily individual, i.e. bodily processes or individual psychological processes. That does not however necessitate that the causes of the phenomena are also located inside the individual; they could very well be spread out and extended beyond the organism into the world.

I want to focus a bit on the issues of
A) what in the realm of the mental is about the self, world, and others, and what is not
B) what is the appropriate level of explanation for a phenomena

A) Is everything in the realm of "mental" about the self, world, and others? What is not and why is it excluded?

Consider perception. How would you classify various modalities of perception such as vision, hearing, olfaction? Are abnormalities in vision about the self, world, and others? What sort of abnormalities of vision would be about the self, world, and others, and what sort won't be? How would we know?

What about sexual desire? Pain? Behaviors such as seizures? Language and speech?

B) You say that physical explanations are entirely inappropriate for issues whose content is about self, world and others.

They would very well be inappropriate as the only explanations, yet I do not see why physical explanations cannot be a part of the larger explanation.

We know very well that mental content, including content about the self, world, and others, arises through a combination of many different sorts of phenomena at many different levels of explanations. For example, personality traits are partly genetic. Which means that if we are to scientifically understand personality traits, genetic explanations would be involved in the larger picture. It would be inappropriate to say they are the only explanation, or the primary explanation, but I don't see how we can say that they are not a part of the explanation at all.

Barnes:

So, this is the point of contention, I think. 

You say that disorder is not necessarily in the individual but is a property of the individual. You make this claim on the basis that even though the causes can be external to the individual, the disorder is nevertheless of the individual. This relies on a metaphysical position that we are under no pressure to accept, and I reject. It is a symptom of dualistic, representationalist metaphysics, for which the world (and by extension, others) is effectively contentless (i.e. qualitiless) and it is the individual mind/brain that embellishes or 'fills out' the neutral data of the world internally. If you start from this metaphysical position, then what you say probably follows, but I do not and there is no reason why we must. 

By contrast, when I talk about the content being about self, world and others, I am not referring to any kind of internal representations of self, world and other, 'triggered' by 'stressors' from the outside— a picture I entirely reject. I am referring, following Heidegger for example, to a trans-individual ontological 'location' — the three of them, together, as the site, so to speak, of the issues in question. Following this, I understand this type of content (unlike content that is about physical states/processes) as being 'a property' of world and others in principle equally (i.e. not in terms of world and others qua self). This being so, I am arguing against psychiatry, and any approaches to 'mental disorder' that assume the same metaphysical picture, for limiting their explanation and interventions to the individual in this sense. The appropriate level of explanation, I suggest, is therefore where the issue is considered in principle as an ontological property of all three.

This is why, for example, I put CBT/cognitivist accounts, and classical psychoanalysis for that matter, into the same category, as all of them presume this same starting point, which I reject. Thus, while the "official understanding of disorder in psychiatry" may not limit itself to physical explanation, it is — by its very nature (i.e. there are no other/world disorders in the DSM) — limited to a dualistic, representational metaphysics of the mental and social, which is what I meant by "inside the individual." While socially derived causes (i.e. 'triggers') form part of the explanation in psychiatry they, as inherently contentless (i.e. 'stressors'), are only 'social' in the capacity of triggering an otherwise internally determined process. To me this ends in effectively the same result, i.e. an inappropriate focus on what is going on 'inside the individual' to the relative exclusion of the actual role of others and the world.  

Finally, I don't think I am able to address your examples and would have to defer to how they are understood from the point of view of such a metaphysical starting point.

Aftab:

A Heideggerian worldview is fascinating and from my own limited studies of Heidegger, I am sympathetic to this perspective, and find this very worthwhile.

However, from your discussion, some things are not clear to me that I’d like you to clarify:

How does your understanding of the Heideggerian metaphysics tackle the mental-physical divide? Is there a suggestion that mental phenomena require a different sort of explanation, an explanation couched within a Heideggerian worldview, but physical phenomena require a different sort of explanation, an explanation in terms of science and physical processes? 

That would be an odd distinction to make for a metaphysic that otherwise prides itself on overcoming Cartesian distinctions.

Secondly, how would the Heideggerian worldview explain something like “sexual desire”? What would be the ontological location of sexual desire? How would this metaphysic account for the idea that differences and disturbances in sexual desire can result from a combination of factors which may include changes in levels of various hormones, changes in levels of neurotransmitter, as well as various psychological processes?

Barnes:

Yes, very true. Glad to hear you are sympathetic to the Heideggerian starting point. 

Clearly, the distinction 'mental and 'physical' is itself a dualistic hangover. It has been fashionable, in one way or another, to collapse the mental to the physical. But this ironically remains dualistic — we are then left with distinct physical substances that have dualistic relationships with each other. I have no definitive answer, but my thought is that if we take an essentially non-dualistic stance, as Heidegger does, then we have to think of it in terms of a continuum from physical to mental; or, in other words, from concrete events in the ecology of the body (such as lesions in the anatomy of the body) to the intangible, pervasive and unlocatable events of the domain of self, world, others (such as our cultural disconnection from nature). Monism remains dualistic, whereas non-dualism involves some sort of paradoxical continuum, I think. 

I would say, positively, that there would necessarily be a subjective/indeterminate element as to the level of explanation, but to me this is no non-problem, as it follows from the non-categorical nature of metaphysics. Although, it also follows form this that there can be no science of this order per se (being some version of the German geisteswissenschaft), I would say that even though there is a ideal of objectivity in the sciences of psychiatry as it stands, clearly it is in the same position anyway given the lack of physical markers, etc. by means of which to eliminate the dualism still invoked — something which I suggest will be a permanent issue due to the error of the metaphysics. 

Having said that, aside from some anomalies (i.e. 'conversion disorders'), it seems to me to be fairly clear what is most appropriately explained in the terms of self, world and others and what in terms of the physical body,  i.e. in terms of what the content of the issue is about, as I have said. As such, what I am practically proposing is to invert the basic assumption we have at the moment: those issues whose content is about self, world and others are presumed to be a property, in principle, of all three, and explained as such, whereas those whose content is about the physical body are to be explained in terms of properties of the individual, bodily processes, etc.— until discovered otherwise. 

I don't think taking an abstract case such as 'sexual desire' is helpful, for me at least. If we are talking about a specific issue related to sexual desire then we'd have to look at it in its complexity and make a decision as to what it is about.

Aftab:

I largely agree with you that there is an explanatory continuum from "physical" to the "mental", as you describe "from concrete events in the ecology of the body to the intangible, pervasive and unlocatable events of the domain of self, world, others".

However, I think we have to resist reification of these modes of explanation. Another way to see this continuum is in terms of "local" to "global". Sanneke de Haan describes it very well in a recent article on enactivism. She writes:

"The important, dualism-defeating move here is to resist thinking about causality in linear terms and instead regard both the physiological and the life-world causes as mereological or organizational forms of causality: the one local to global, the other global to local. The causality involved is rather of a mereological, organizational, or constitutional type. That is: within a specific organizational structure the relation between its local and global processes is reciprocally influential, but without the one working on the other as if they were separate."

The local and global processes are reciprocally influential. To the degree to which local and global processes can correspond to physical and mental processes, the physical and mental are reciprocally influential. We can trace causal relations from local-to-global and global-to-local without resorting to dualism.

Secondly, you write "it seems to me to be fairly clear what is most appropriately explained in the terms of self, world and others and what in terms of the physical body"

There are two issues here:

1) It may be fairly clear to you, but it may not be fairly clear to another. Obviously we have clear-cut cases on which there would be large agreement, but the gray zones in the middle are where much of disagreement and conflict lies in psychiatry, and we have to acknowledge that things are not fairly clear to a lot of people.

2) There is nothing in the Heiddeggerian worldview that necessitates that there be only a single appropriate mode of explanation for a given phenomenon. For phenomena that are in the middle of the physical-mental, local-global continuum, they can be viewed through multiple modes of explanation, and each mode of explanation provides a different sort of insight, a different part of the overall picture. Why would we want to restrict ourselves by insisting that there is always only one appropriate mode of explanation?

Here my question about sexual desire becomes pertinent. Sexual desire belongs to the domain of self, world, others; it is characterized by phenomenology, by intentionality, by interaction with others, with affectivity... and yet, any account of sexual desire that ignores and excludes the physiology of sexual desire will fail to attain a complete explanation of the phenomena. Sexual desire is in the middle of the physical-mental continuum, the local-global continuum. You can look at sexual desire from a local-to-global perspective, or you can look at it from global-to-local, and depending on what we are interested in, either or both perspectives may be relevant to us. This indicates that physical-to-mental and mental-to-physical explanations are not mutually exclusive but rather complementary.

Hence, I see no reason to accept the explanatory dualism being proposed, that "those issues whose content is about self, world and others are presumed to be a property, in principle, of all three, and explained as such, whereas those whose content is about the physical body are to be explained in terms of properties of the individual, bodily processes". In fact, this explanatory dualism is inconsistent with your own view of a continuum from physical to mental, as explained above. If there is a continuum, there is a gray zone, and gray zone is what the debate is all about. Instead of explanatory dualism, we need explanatory pluralism.

Barnes:

Great. Love it. I am aware of the article you mention, and so far as I understand it, global, for de Haan, is describing the 'global organism,' i.e. the mental order as a property of the organism. I liked that article, but it is not Heideggerian, in the sense of rejecting the human organism (Dasein)-world divide. Heideggarian 'global,' or at least my 'global,' actually includes, in principle, the world-globe:

“self and world belong together in the single entity, the Dasein. Self and world are not two

beings, like subject and object, or like I and thou, but self and world are the basic determination
of the Dasein itself in the unity of the structure of being-in-the-world.” (Heidegger 1989: 422)

Thus, I would accept the argument, but again on this basis: that we include processes of world/others under the term 'disorders.' Insofar as we do not, then we are only talking about the properties of the individual and not others and the world, which as I am saying is a dualistic hangover. As such, I agree with what you say about the 'middle,' but only when it is the middle of an organism-world continuum and not a continuum of the organism. The difference here is what is meant by 'mental'. Again, mental is taken to be self, world and other qua organism; I am using mental to refer to something like Dasein, which is trans-organism and has the actual world and others 'equiprimordial,' to use Heidegger’s term, with the self 'in' it. 

So, I agree with a pluralism, but a pluralism of explanation of the organism-world entity, something which radically decenters biology, and indeed psychology (of the variety that presumes the dualism mentioned above), and opens the door to ontological importance of the actual content of world and others per se (i.e. not as contentless 'triggers and stressors').

(Just to be clear, I do not agree with De Hann's statement that her position is 'dualism-defeating' at all. It defeats the dualism of mind and body, but not mind and world, which is by far the more important problem with dualism.)

Aftab:

From a Heideggerian perspective, I agree with you that "disorder" would not be a property of an individual or an organism, but rather something that relates to the organism-world entity, the Dasein, and I agree with you that such a perspective radically decenters biology and individualistic psychology, but I would maintain that while it decenters biology and individualistic psychology, it does not render them irrelevant, it does not exclude them from explanations. The Heideggerian perspective opens up richer ways of seeing the local-to-global and global-to-local causal relations with the full realization that doing so does not and cannot reduce Dasein to local explanations.

Barnes:

I agree, yes. It certainly does not render them irrelevant; it reduces the focus from roughly 100% to 30% in principle, if you'll allow the simplification. We would not then subsume the social into the medical in this context, but the medical into the social — or, at least we would have a proper democracy. This might look like referrals to psychiatry, by an institution that was oriented around the psycho-social, if the physical/medical side of the issues was deemed obvious or pressing. Or it would look like a radical revisioning of the institution of psychiatry from biologically focused to psychosocially focused. 

Aftab:

I am less clear about specific practical implications, since adopting a Heideggerian perspective would require a radical revision not just of psychiatry, but medicine, neuroscience, and many other professions and activities of life. How to implement those in a world where many or most may never adopt the Heideggerian perspective poses complex challenges, even if the practical implications of a philosophical theory could be worked out. But I do know that as long as we keep talking about biological vs psychosocial, we would remain under the shadows of old dualisms. I do agree that generally speaking it would require a substantial de-emphasis of biological explanations in favor of more holistic, pluralistic, integrated explanations. Such explanations can’t be given a generic template since each condition is different and we approach conditions with specific goals seeking certain sorts of outcomes. So, explanations in this sense have a pragmatic function as well, and what explanation works best for our purposes will depend on the question asked and would need to be guided by the best available empirical evidence.

Barnes:

Fair enough. I really do respect the kind of pluralism you are pushing for, and appreciate you entertaining my thoughts. I'm actually not sure that we disagree too much at all. I do recognize that the kind of approach I am advocating for is specific or radical or both, but I don't think it is limited to Heidegger. Alfred North Whitehead — that other great early 20th century 'metaphysician' — has a totally different scheme based on the same rejection of the scientific ontology as explaining life, which would also work but in a very different way. I honestly think momentum is and will take us further in that direction. For me, we are on the brink of a shift in paradigm, which the new process philosophy in biology and 4E in cognitive science are signs of. Anyway, good to have this conversation with you. It was helpful for me to clarify it all!

Aftab:

We do admire many of the same philosophers! A.N. Whitehead has left a mark on me as well but primarily from a theological/mystical perspective with process theology ideas that are derived from his process philosophy. I agree with you that the conversations are shifting, we are witnessing a great synchronicity as individuals with very diverse backgrounds are beginning to grapple with the challenges of pluralism and integrative thinking in psychiatry. Biological reductionism, in any case, is dead, and to quote Nietzsche's madman: "This tremendous event is still on its way, still wandering; it has not yet reached the ears of men. Lightning and thunder require time; the light of the stars requires time; deeds, though done, still require time to be seen and heard." This has been a great conversation, thank you.