Phenomenology, delusions and justice

The paper by Stein et al1 offers a clear and magisterial introduction to philosophy of psychiatry, its key advances and its clinical implications. As the authors note, philosophy is often seen as not necessarily having made progress, but the paper shows that this is not the case for philosophy of psychiatry. Philosophy of psychiatry is both a philosophy of science (similarly to philosophy of physics or biology) and a philosophy of practice and ethics. Indeed, many authors have used philosophy to make sense of, or to interrogate, the changes in our discipline: the hope of the neo-Kraepelinians, the advent of functional neuroimaging, the democratization of psychiatric knowledge, and the partnership with those with lived experience of mental ill health. The areas that Stein et al cover in their paper are broadly those linked to the philosophy of science and of psychology/mind, and the tradition of "Anglo-American" philosophy. This tradition – inaugurated by Russell, Frege and Moore – has a focus on the analysis of concepts and the study of logic and language. My own philosophical work has been partly in this tradition, but also in the other dominant Western tradition of philosophy, namely "continental" or "European" philosophy. This tradition grew out of German idealism, neo-Kantianism and phenomenology, and was initially very similar in interests to early analytic philosophy in its study of language, logic and arithmetic. However, through the work of Heidegger, Jaspers and others, it subsequently took the initial phenomenological insights of Husserl, and began using them to understand concrete, historical, lived experience and existential themes. Such themes reached their apogee in the period after the Second World War, with the existentialism of Sartre and De Beauvoir, and the related work of Merleau-Ponty and Fanon. This work impacted on psychiatry in a series of very direct connections: Heidegger's own teaching of psychiatrists with M. Boss, Binswanger's development of Dasein-analysis, and the influence of phenomenological existentialism on the work of Laing. However, in parallel to the dominance of phenomenology on European philosophy in the key decades of the 20th century, there are two other key strands to this tradition: the interaction of philosophy with psychoanalysis and with Marxism. Hence, continental philosophy brings with it an interest in "hidden" forces, whether the unconscious or capitalism, that shape human experience, and a more contextualized and historicized idea of the person. This approach has allowed a more "political" way of thinking about the self and – with post-structuralism, colonial studies, and feminist philosophy – has granted us tools to reflect about issues of intersectionality, oppression, marginalization, and the experience of migration and colonialization, which are relevant to our work as practitioners and researchers2. In our recent Renewing Phenomenological Psychopathology project, we have tried to bring some of the insights from the continental philosophy of the later 20th century back into the phenomenological psychopathology of Jaspers and his successors3. Much of the "classical" phenomenological psychopathology has been written from a third-person perspective, typically by a European male, trying to describe the structures of the experience of mental illness. With our project we are hoping to increase the international scholarship in the area, to develop new areas of intersection between phenomenology and other academic disciplines and, most importantly, to support those with lived experience who want to work in the area of phenomenology to gain skills through co-production partnerships. In parallel to this long-standing interest in the phenomenological tradition, I have been fortunate to have worked also in a more "analytic" mode, with a particular interest in the nature of delusions4. The definition of delusion has been an area of vigorous debate for philosophy of psychiatry. Influenced by Wittgenstein, Davidson, Dennett, McDowell and others, analytic philosophy provides useful tools to think about rationality. Hence, it comes into conversation with Jaspers' idea of the "un-understandable" nature of primary "true" delusions, and the clinical and empirical interest in how psychosis develops and in continuum models. The exploration of the distinction between rationality and irrationality, between delusion and unusual beliefs, links with a wider issue in the philosophy of psychiatry, and one that echoes back to Minkowski's critique of Jaspers – namely, that the symptoms and signs of psychopathology are not discrete and "atomistic", but rather form a meaningful coherent whole that informs all of our experience. An area of potential fertile future research would be to try and chart how much of the way we structure and categorize psychopathology is dependent upon prior historical ideas of faculty psychology, which may now no longer be viable. As an example of this approach, together with Humpston and Broeker5-7, we have challenged the traditional distinction between passivity experiences, such as thought insertion, and auditory verbal hallucinations, and showed that computational psychiatry may provide a means to empirically demonstrate how symptoms cohere experientially. The final theme I would like to cover in my reflection on Stein et al's paper returns to ideas of politics and ethics and of lived experience, namely epistemic injustice. Epistemic injustice is a term coined by the philosopher M. Fricker, which grew out of feminist theory. It refers to the lack of justice experienced by a person when his/her ability as a knower is discounted due to non-epistemic factors (for example, gender, ethnicity, age). This is often referred to as "testimonial injustice", and in the literature is accompanied by the idea of "hermeneutic injustice", whereby people unjustly lack the concepts to describe their experience and share that knowledge. Epistemic injustice provides a rich set of conceptual tools to help us as philosophers of psychiatry and practitioners to understand why the voices of those subject to intersectional marginalization are silenced8, and importantly, ways to ameliorate that, scaffolding people's ability to be active and valued knowers in their interactions and to maximize their agency in clinical consultations9. This area of philosophy is one that we have brought into close proximity with studying real therapeutic encounters, and the experience of young people with mental health problems, and with work covering a range of areas of health care, with important implications for training and education of clinicians. My own view is that philosophy is an essential ally to the study and practice of psychiatry. As we approach the end of the first quarter of the 21st century, we can see that the hopes of a simple biological, "neo-Kraepelinian", psychiatry are unlikely to be realized, and the suffering and distress caused by mental illness remains. Philosophy brings conceptual clarity, a rigorous questioning, and an expansion of theoretical imagination that can help in addressing the complex set of problems which mental ill health brings, which we as a field have progressed with, and which Stein et al detail and, in their paper, further advance our answers to.