Table Of ContentBody-Subjects and
Disordered Minds
International Perspectives in Philosophy and Psychiatry
Series editors: Bill (K.W.M.) Fulford, Katherine Morris, John Z Sadler,
Giovanni Stanghellini
Volumes in the series:
Mind,Meaning,and Mental Disorder
Bolton and Hill
Postpsychiatry
Bracken and Thomas
The Philosophical Understanding ofSchizophrenia
Chung,Fulford,and Graham (ed.)
Nature and Narrative: An Introduction to the New Philosophy ofPsychiatry
Fulford,Morris,Sadler,and Stanghellini
The Oxford Textbook ofPhilosophy and Psychiatry
Fulford,Thornton,and Graham
Dementia: Mind,Meaning,and the Person
Hughes,Louw,and Sabat
Body-Subjects and Disordered Minds
Matthews
The Metaphor ofMental Illness
Pickering
Trauma,Truth,and Reconciliation: Healing Damaged Relationships
Potter
The Philosophy ofPsychiatry: A Companion
Radden
Values and Psychiatric Diagnosis
Sadler
Disembodied Spirits and Deanimated Bodies: The Psychopathology of
Common Sense
Stanghellini
Forthcoming volumes in the series:
Rationality and Compulsion: Applying Action Theory to Psychiatry
Nordenfelt
What is Mental Disorder?
Bolton
Empirical Ethics in Psychiatry
Widdershoven,Hope,van der Scheer,and McMillan
Body-Subjects and
Disordered Minds
Eric Matthews
Emeritus Professor of Philosophy and
Honorary Research Professor of Medical and
Pyschiatric Ethics, University of Aberdeen, UK
11
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Body-subjects and disordered minds / Eric Matthews.
(International perspectives in philosophy and psychiatry)
Includes bibliographical references and index.
ISBN-13:978-0-19-856644-1 (pbk.:alk.paper)
ISBN-10:0-19-856644-1 (pbk.:alk.paper)
ISBN-13:978-0-19-856643-4 (hbk.:alk.paper)
ISBN-10:0-19-856643-3 (hbk.:alk.paper)
1. Mental illness--Philosophy. 2. Mental illness--Physiological aspects.
3. Psychiatry--Philosophy. 4. Mind and body. I. Title. II. Series.
[DNLM:1. Mental Disorders--therapy. 2. Mind-Body Relations (Metaphysics)
3. Psychiatry--ethics. WM 400 M438b 2007]
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Preface
I have long been puzzled by the notions of‘mental health’and ‘mental illness’,
and have struggled to resolve my bafflement in a number of papers
(e.g.Matthews 1995;2003;2004;2005a and forthcoming).At first sight,it
might seem strange to be puzzled by these very familiar notions.It seems
obvious,after all,that people’s thoughts,feelings,desires and behaviour can
go wrong,can be ‘disordered’,just as their hearts,lungs,livers and so on can.
When thoughts and so on go wrong,they can create distressing problems for
the person concerned:their life is not as good as when things are going right,
just as life is not so good when the heart is not going right.When the heart or
the liver go wrong,we call in a suitably qualified medical person to try to put
things right;and nowadays we are likely also to call on the help ofa suitably
qualified medical person to deal with at least some of the problems arising
when thoughts,feelings,desires and so on awry.In both cases,a ‘suitably
qualified’medical person is someone who has gone through a standard train-
ing in general medicine,and has then specialized in the relevant field.
We assume that appropriate medical treatment for thought or mood disorders
is ofthe same general kind as for,say,raised blood pressure or liver problems:
medication,nursing care,and,in extreme cases,more radical interventions
such as surgery.These treatments do often seem to work,at least in alleviating
distress ifnot in curing the condition.
So where is the puzzle? The answer to that question becomes obvious
as soon as one begins to reflect on what has just been said.What is meant by
thoughts etc.‘going wrong’,and do they go wrong in the same way that hearts
and livers do? Talk of thoughts,feelings and desires ‘going wrong’seems to
imply a reference to some kind ofevaluative standard:it may be a cognitive
standard,as when someone’s thoughts become incoherent or illogical;or
a moral standard,as when someone’s desires are directed to a disapproved
object;or some more general standard of social acceptability,not exactly
moral but moral-like,as when someone becomes miserly,or over-anxious,
or lacking in self-esteem.None ofthese ways ofgoing wrong seem to be quite
like raised blood pressure or liver failure.The appropriate way to put them
right does not seem to be medical or surgical,but something more like education:
people with incoherent ideas need to be taught to think more clearly,people
with perverse desires to redirect them,people who are over-anxious not to
vi PREFACE
worry so much.Having proper self-esteem,for instance,depends on how one
thinks about oneself,on giving due account to one’s virtues as well as being
critical ofone’s faults,and it does not seem obvious that taking a pill or having
surgery could change one’s thoughts in relevant ways.Putting things right
seems to be more within one’s own control.It becomes easier to see,therefore,
why,in popular thinking at least,failure to put things right comes to be seen as
open to condemnation or stigma.
Similarly,is the distress caused by things going wrong with one’s thoughts,
feelings,and desires of the same kind as that caused by things going wrong
with one’s bodily processes? Headaches,stomach aches,tingling sensations in
the extremities,sharp stabbing pains,a general lassitude and debility and the
like,are typical results ofbodily illness.Some ofthese may also be found in
some forms of mental disorder,but not all:what is more characteristic
ofmental disorder are such things as feelings ofsadness and bewilderment,
difficulties in forming relationships,an inability to hold down a job,a refusal
of food,feelings of panic.But these are also found in people who are not
regarded as mentally ill,and may also be consequences ofbodily illness.Where
do we draw the line between normal human distress and difficulty in living
and that which is the result ofmental disorder – or is it a matter ofdegree?
Is there a sharp distinction between mental disorder and bodily illness? And
is what we mean by ‘mental health’a feeling of contentment,or an ability
to manage one’s own life,or what? No such difficulties seem to attend the
definition ofbodily health.
These problems are not just theoretical:they have a bearing on actual clinical
practice,which cannot proceed satisfactorily without some thought about key
concepts like those ofmental health,mental illness,bodily health and illness,
the way in which we should explain them and treat them,and so on.They also
give rise to special problems in the ethics and law ofmental health,in deciding
on the responsibility of those who are mentally ill for their actions,and on
questions of consent to treatment.To try to solve these practical problems
requires,in my view,some philosophical reflection,and that is why I have
written this book As a philosopher,who has engaged for the past twenty years
or so in fairly constant dialogue with psychiatrists and others in the mental
health field,I have become increasingly convinced that the questions will
remain unanswered ifwe do not do some hard philosophical thinking about
the concepts used in formulating them.Above all,we need to think rigorously
about what is meant by ‘mind’and ‘mental’,and how it relates to what is
meant by ‘body’and ‘bodily’.Traditionally (and especially since the seven-
teenth century),our culture has been in the grip oftwo opposed conceptions
of the mental,which are nevertheless parasitic on each other.On the one
PREFACE vii
hand,we have thought ofthe mind as a unique kind ofthing,made ofdiffer-
ent stufffrom everything else in the created universe and obeying different
laws.This non-material mind is supposed to be found withineach human
individual,discoverable only by that individual,by means ofintrospection.
On the other hand,and more typical of a science-based society,we have
thought ofthe mind as identical with the brain,an ordinary material thing
made ofthe same stuffas everything else in the universe and governed by the
same laws as them.
The opposition between these two views,and the arguments for and against
each of them,are familiar to anyone with even the slightest acquaintance
with modern philosophy.They are also held,as articles of faith,by people
who know little or nothing about the philosophical debate:the non-material
view mainly by those who think it essential to religious belief,the material
view by those who think it is the only one compatible with a truly scientific
outlook.I want to argue,however,that both are inadequate as a basis for
thinking about mental disorder and its treatment.Instead,I want to present
and argue for a third conception – the account given by the French philoso-
pher,Maurice Merleau-Ponty (1908–1961).According to Merleau-Ponty,we
should not think of‘minds’and ‘bodies’,but rather ofhuman beings,seen as
subjects who are essentially embodied.The thoughts,feelings,desires and so
on that we have are not things or processes going on inside us,but ways
in which we,as embodied subjects,relate to the world ofthings,people and
cultural objects and institutions:ways in which we are,as he would put it,
‘in-the-world’.They explain our behaviour not as causes,governed by general
laws,but by providing reasons for doing what we do:since what we do is
defined by the concepts which we,along with others in our culture,apply to it.
To be in the world in the way in which human beings are is on this view essen-
tially to be embodied:we are not just subjects,but ‘body-subjects’,as it is often
expressed.Our subjectivity – our thoughts,feelings,desires,intentions – is
necessarily expressed in,and constrained by,the structures of our bodies.
Understanding the mind,and so mental disorder,then becomes a matter of
understanding the various ways in which our being-in-the-world can be
related to the nature of our embodiment,and in particular to our brain
processes.
One beneficial consequence ofthis way ofthinking,in my opinion,is that it
loosens up our thinking about mental disorder,and the need for such loosen-
ing up is the main conclusion of this book.We do not need,I shall argue,
to treat all the conditions we call mental disorders in the same way,because
‘mind’is not the name of any unified thing,but a way of referring to a set
of human attributes and capacities, loosely related in that they are all
viii PREFACE
intentional – a term which will be explained in the course ofthe book.We do
not need,therefore,to be stuck with simple dichotomies – is the medical
model applicable to mental disorder,or is it not? Is mental disorder an illness
or is it not? Perhaps it is helpful to think in medicalized terms about some
aspects of some mental disorders,but not so helpful about other aspects,
and maybe what is meant by ‘thinking in medicalized terms’may vary from
context to context.Some mental disorders may be illnesses and others not;
and even those which are may have important differences from bodily
illnesses.Another dichotomy which I shall question is that between the
conception ofmental illness as caused by brain disease and as understandable
as a human response to terrible situations.This distinction is founded,I shall
argue,in a confused account ofthe nature ofexplanation.Similarly,the ques-
tion whether mentally ill offenders are ‘mad or bad’is,I shall conclude,posed
in far too simple terms:deciding whether mental illness excuses may be,and
I shall argue is,a matter for complex and subtle thought about the varieties of
mental disorder.In short,it is not the aim of this book to offer clear-cut
answers to such over-simplified questions,but to make clear just how over-
simplified the questions are.I approach the area with trepidation,since I am a
philosopher with no clinical experience:some ofthe examples I give in illus-
tration may indeed seem to practitioners to be lacking in clinical reality.That
need not matter if they make the essential point clear:it is always open to
readers to find better examples.
This book has benefited from the input ofmore people than I can remember
or mention.As I said earlier,I have been discussing these issues over many
years,in the context ofthe Royal College ofPsychiatrists Philosophy Special
Interest Group,and more recently at meetings ofthe International Network
for Philosophy ofPsychiatry,and have gained much from the comments and
criticisms ofpsychiatric and philosophical colleagues at these meetings.Still,if
I am to single out particular individuals,I must mention a number ofpeople
who have been particularly influential and whom I feel privileged to count as
friends: Bill Fulford (above all), Grant Gillett, Gerrit Glas, Giovanni
Stanghellini,John Sadler,Jennifer Radden,Julian Hughes,Man Chung,Alan
Wear,Iain McGilchrist,John Callender,David Findlay and Martin Wylie.
To all of these I am profoundly grateful,as I am to my wife Hellen for her
patience with my preoccupations and the insights which she has contributed
from her own experience.
Aberdeen Eric Matthews
June 2006
Contents
Preface v
1 Introducing the problem 1
2 Illness and disease 23
3 ‘Minds’and ‘bodies’ 47
4 Phenomenology and Merleau-Ponty 71
5 The body-subject and mental disorder 95
6 Mental disorder and choice 119
7 Mental disorder and legal responsibility 143
8 Treatment without consent 163
References 183
Index 187
