College 1

History of psychiatry
Pre-classical period (-500 B.C.)
- Madness (alsin being crazy) as fate or punishment (van God)
- Example: Ajax’s suicide
Odysseus en Ajax were kibbeling who could have the armor of Archillus when he
died. Odysseus convinced the council the armor should be given to him. Ajax was
driven mad by anger and jealousy and out of anger en shame (I guess?) murdered the
heard of sheep and threw himself on a sword and died  example of madness which
strikes somebody en do something out of character  punishment by the Gods +
fate.
Classical period (500 B.C. – c. 500 A.D.)
- Euripedes’and Sophocles’ tragedies: the self-conscious hero. Het verschil met de
vorige periode is dat de internal struggle van de hero in the tragedy is made explicit.
Medea is jealous when her husband goes to marry the daughter of the king in
jealousy and rage she poisons her children. Oedipus plucks his own eyes out after he
finds out het killed his father and married his mother  it was his fate (his mother
gave him away om die fate te voorkomen maar isnie gelukt).
- Plato’s psychology (reason, spirit/temper, appetite). Madness komt voor wanneer
reason niet kan rulen over die andere twee, especially the passions. Control by
reason of the other faculties of the mind
- Hippocratic medicine: eerste die dacht dat mental illness rises from the brain. Men
ought to know that from the brain and from the brain only, arise our pleasures joys,
laughters, and jets, as well as our sorrows, pains, griefs and tears.
4 bodily juices that were associated with all kinds of properties (blood, black and
yellow bile etc. This model also explains symptoms we would now classify as mental
illness?) Sanity as balance or harmony between constituents
The clinical gaze: he kinda describes depression/mental illness? (53:00)
Middle ages (c. 500- c. 1500)
- Christianity
o Mental illness understood as: faith, love, sin, divine, devil’s seductions
o Psychomachy of the soul, giving rise to disturbance of the mind
o ‘good madness’ of saints and mystics (ex. Ecstatic revelations, glossolalia)
- Continuations of classical (Hippocratic, Aristotelean tradition in Islamic and Christian
medicine
- Rise of institutional care from 13th to 14th century inspired by Christian duty of
charity.
Renaissance and reformation (c. 1450 – 1700)

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 - Witch persecutions. People who showed symptoms of mental illness were
persecuted as witches.
- Countermovements by physicians:
o Not denying possibility of supernaturally induced madness, but there is no
evidence.
o Some physicians argued that it’s a case of disease en niet supernatural causes.
- New naturalism and rationalism from 17th century onwards
o Cartesian dualism: Res extensa (uitgebreide substantie) vs. res cogitans
(denkende substantie). Madness derives from the body, or from faulty
connections with consciousness (pineal gland). Het kan iig niet aan de res
cogitans liggen volgens Descartes want die is rationeel en madness is
irrationeel.
o Hobbes: Insanity as erroneous thought caused by deficit in body’s machinery
o Locke’s empiricism: Psychological understanding of madness. One could say
that Locke is the first to have a psychological understanding of mental illness.
Mad men put wrong ideas together and reason right from them; but idiots
make very few or no propsitions, but argue and reason scarce at all.
o Thomas Willis: so-called possession is a matter of nerve defects

The rise of the asylum (c. 1750 – 1850) (Bedlam?)

- Downside: the asylums were closed off from the rest of society. Dus ze zaten
helemaal afgesloten vd buitenwereld, was like a small community/village op zichzelf,
vaak in het bos ofzo en later dichtbij train tracks.
- Boost in the development of psychiatry as an art and a science. The birth of
psychiatry as a medical discipline.  dit komt zo doordat veel mensen met dezelfde
problemen dus naar asylums werden gestuurd en daar moest (bv in Engeland volgens
de wet) een arts bij zijn die dan dus die mensen ging behandelen i guess.
- ‘Moral treatment’: banning physical restraint, bloodletting, purges and vomits,
buoyed up by enlightenment optimism, the claim became that the well-designed,
well-managed asylum was the means to restore the insane to health. Dus als je een
goed asylum had dan kon je de gekkies genezen. Restoring health by moral
treatment. Example fancis willis?
- Pinel liberating women patients from their chains.
- Madness is considered a breakdown of rational discipline of the sufferer. Rekindling
of moral and psychological faculties, reanimating reason and conscience. (The ideal)
asylum as a closed environment for education, development and growth. Basically
people were re-raised in een asylum so that they could regain their health.
- Foucault: institutionalization (dat gekkies in afgelegen asylums gingen) was presented
as medical treatment but was in fact an socio-political (exclusion) strategy of the
state. It was a debasement of madness itself. Madness did not have meaning in itself
anymore (debasement of madness): a negation/absence of humanity. Madness as a
A negation of what defines us as humans. En drm moest het dus eradicated worden
van society
(Moral treatment as political strategy)

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 - Portor: deze hele periode van asylums is better understood as side effects of
commerical and professional society’s ‘trade in lunacy (waanzin)’. View it more as a
rise of negotions of wants, rights and responsibilities in a mixed consumer economy
o Many asylums were private institutions, in all shapes and sized, varying
considerably in quality. Private asylums ook beter dan state asylums ??
o Foucault generalizes hoe het in france was over the rest of europe maar thats
bs. Alleen in France it was tradition to institutionalize people. In rest van
Europa asylums as private institutions (zie hierboven). + In England was het
heel anders dan in france : state licenses (1774) and medical superintendent
(1820) required, state led mandatory confinement in county asylums not until
1845
- The asylum as panacea (wondermiddel) or as a problem?
o The asylum got more problematic around 19th early 20th century: skyrocketing
of number and scale of mental hospitals.
o Disappointing results of moral treatment. Lack of differentiation and proper
selection (was wel te verwachten, er was a lack of differentiation in people
who were emitted: bv. Mensen met dementia, antisocial behaviour etc.)
o Disappointment in treatments + rise of neurology as a discipline = Rise of
degenerationist model of mental illness: first biological phase.
The first biological phase (c. 1850 – 1910)
‘Mental illness is cerebral (hersen) illness’ (neurological discovery)
- Inspired by 17-18th century naturalism/mechanism (by studying anatomy we can
understand the mechanisms of the brain.) Something abt understanding mental
illness as degeneration of the brain ?? In part they were right:
- Neurological discoveries: alzheimers description of brain changes and histology in
senility: it’s differentiation from general paralysis of the insane (GP)
- GP patients tested positive for syphilis (1906) and discovery of treponema pallidium
in brain tissue op GP patients (1913)
- Dus these people believed we should study the brain to find out the causes and get
explanations. Ze geloven dat mental illness is the result of degenerating neurological
disorder en treatment is heel difficult.
- Classificatins of psychiatric conditions
o Late 19th century: Proliferation (snelle toename) of classifications
o Neuroscientists Focus on brain tissue (neuro-anatomy and defects in brain
structure as the basis for classifications of diseases)
- Kraepelin
o Focus on clinical research: meticulous (nauwkeurig) recording of
symptomatology and clinical course. Started classifying patients according to
symptoms but also clinical course (how they emerge and evolve through time,
this was new)

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 o Met zijn systeem kwam hij tot classifcation tussen dementio praecox
(schizofrenia) and manic-depressive illnes. Deze distinctie wordt nogsteeds
gebruikt (DSM is kraepelinian in essence)
Competing paradigms (c. 1920 - 1980)
- Neurological vs. Psychological understanding/models of medical illness
- Jean martin charcot: hypnosis as a diagnostic device
- Rise of psychological models
o Psychoanalysis and the modeling of the dynamic unconscious. Modelling
mental illness as conflict between unconscious processes (en unconscious
met conscious en superego??)
o Learning theory, behavioral psychology, cognitive psychology
- Alongside the biological paradigm: invoking seizures as treatment, lobotomy, ECT etc.
The second biological phase (c. 1980 -2010)
- Discovery and development of pharmacological agents. It stimulated the idea we
should not look at structures of the brain but workings of neurotransmitters as the
key to understanding mental illness
- Focus shifted from neuro-anatomy to neurochemistry as likely locus (meetkundige
plek) of abnormality: neurotransmitter hypothesis. It supported? the idea we should
not look at structures of the brain but workings of neurotransmitters as the key to
understanding mental illness
- Developments (and promises) in brain imaging techniques and genetics.
Present (2010-)
•‘Classical’ genetic and neurobiological models fail to deliver
•Shift from ‘isolationism’ and reductionism (zovan is brain disorder or mental construct
of…. ? gorl idek) (biological or psychological) towards interdisciplinary and ‘interlevel’
explanations
•Rise of complexity science
•re-appreciation of ecological validity, use of big data and revival of n=1 studies
•Rise of (neuro)diversity movements, the empowerment of patients,
•Redrawing the boundaries between psychiatry and society?
•Implications for our understanding of psychopathology  girl luister dit miss terug want
wtf idek
Main themesof this course
•Throughout its history, psychiatry has been haunted by conceptual
tensions/challenges:Making sense of and handling madness...1.What is this thing called
‘mental illness’? (ontological)2.How can we understand and explain it?

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(epistemological)3.How should we treat people suffering from it? (ethical)4.What is the
place of psychiatry in society (political)
In eke periode andere antwoorden op deze vragen
Main themes of thiscourse
•What we have seen in this brief historical overview:
•Natural vs supernatural
•Internal vs external
•Biological vs psychological vs social
•Explaining vs understanding
•Mad vs bad
•Inclusion vs exclusion
•Pathological vs different
•Scientific progression vs recurrent struggle
•Treatment vs control and law enforcement
College 2
Medicalization
- Ivan Illich: Medical Nemesis (1975)
- Iatrogenesis (the harm done by doctors to their patients)
o Clinical (iets verkeerd doen tijdens surgery, misdiagnosis)
o Social (door social-political dynamics meer dependent worden on health care
ex. Voor pharmaceutical company is profit beter als zo veel mogelijk mensen
medicijnen nemen)
o Structural (rise in medicine (might change) by how people think about the
good life, might make people less autonomous)
Medicalization (is a neutral term, can be good or bad)
- Wikipedia (13-9-2021):
o The process by which human conditions and problems come to be defined
and treated as medical conditions, and thus become the subject of medical
study, diagnosis, prevention, or treatment.
o Medicalization can be driven by new evidence or hypotheses about
conditions; by changing social attitudes or economic considerations; or by the
development of new medications or treatments.
o Medicalization is studied from a sociological perspective in terms of the role
and power of professionals, patients,
andcorporationsandalsoforitsimplicationsforordinarypeoplewhoseself-

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 identityandlife decisions may depend on the prevailing concepts of health and
illness.
o Since medicalization is the social process through which a condition becomes
a medical disease in need of treatment, medicalization may be viewed as a
benefit to human society.
Medicalization effects
- Reducing suffering and increasing quality of life vs. pathologizing and debasing
human life (it’s a form of pathologizing normal human conditions + debasing
(verlagen/vernederen/vervalesen?): it flattens our ways of thinking about ourselves
bv. About How we relate to death ?? )
- Entitlement to health care (seems good) vs. responsibility for self (but it might reduce
our responsibility, dingen waar mensen responsibility voor zouden moeten nemen
zijn nou referred to health care: I can’t help that my life is troublesome it’s because
of my depression)
- Fair distribution of health care services
- Proportional growth of health care services, at the expense of other goods?
- Enhancing vs. Undermining freedom and autonomy (door health care hebben
mensen hun autonomy regained maar also reduced cuz it stigmatizes.+ iemand kan
admitted worden against his will aka doei freedom)
- Effects on personal identity
- Touching upon complex issues regarding human identity and the good life (what do
we think the good life is)
Demarcating mental disorder
- Defining madness?
- Defining disorder
- Disorder, disease, illness... verschil: disorder: comprising a list of symptoms?
Definition of condition without knowing the cause?  hier gaat vooral om bij
psychiatry
Disease: you know the cause
Illness: concept from the perspective of the person suffering: ‘I feel ill’
- What’s the central issue in demarcating (The demarcation problem in psychiatry is
the question when something is a mental disorder and when it is not; where do you
draw the line?  van maaikes toets) mental disorder?
o Facts versus values ookwel:
o ‘Values in’ or ‘values out’

Can we define mental disorder Value free: scientific natural facts or not, why is this
important?:
Ghosts from the (recent) past
- Drapetomania(illness of black slaves running away from their owners: irrational
behaviour)

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 - ‘Sluggish’ schizophrenia (idk)
- Childhood masturbation disorder
- Homosexuality (tot laat nog this was considered a disorder)
- Hysteria (cuz of inner tentions cuz sexual desires in women not satisfied ofzo, althans
that’s what they made of it lmao)
- Dissociative identities
- The depression epidemic (our criteria for depression has loosened)
- An ADHD-hype (idem)
Anti-psychiatry
Why is this then a problem? In the 60’s the anti-psychiatric movement. Psychiatry is human
rights abuse. Oppressive power justified by calling normal behaviours (although statistically
abnormal) diseases. Dus we need to find out what mental disorder then is cuz there’s a
movement who called psychiatry an illegal practice. So they needed to defend themselves
en gingen zich afvragen oke what ís the basis of our practice then
Defining disorder
- Wakefield zegt: “The concept of disorder is not the same as a theory of disorder.
Physiological, behavioral, psychoanalytic, and other theories attempt to explain the
causes and specify the underlying mechanisms of mental disorder, whereas the
concept of disorder is the criterion used to identify the domain that all these theories
are trying to explain.”
- Wakefield gives a Conceptual analysis. Hij is niet geinteresseerd in theories that try to
explain the causes of disorders. He’s interested in the concept of disorder. The
criterium used to identify the domain that all these theories are trying to explain. Dat
kan je niet doen met empirical research, dat geeft je geen definitions; daarvoor
conceptual analysis nodig
Wakefield:
The naturalist Wakefield makes more of an hybrid notion of ‘disorder’, while staying
naturalistic. He thinks that there IS a part of the demarcation of disorders that implies value,
but that there also is a value-free, objective part. Wakefield states a condition is a disorder if
and only if:
- 1: It is HARMFUL: this implies cultural/personal values. The condition causes harm to
the person.
- 2: It is a DYSFUNCTION: this is value-free. A dysfunction is the inability to perform
natural function.
‘Natural function’ is seen from an evolutionary point of view, namely that natural function is
an effect that is part of the evolutionary explanation of it’s existence. It is a backward-
looking account: the function of something is seen as naturally selected by evolution, this
happened in the past and thus it is backward-looking. Natural function exist now because

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they were naturally selected by evolution. When this natural function is not able to perform
it’s natural function AND this is harmful to the person, then this condition is a disorder.
Both harmful (1) and dysfunction (2) are needed. Describing a disorder only as harmful (1), is
not enough, because then every condition that is harmful can become a disorder and that is
problematic. Naturalism notes that we can, and have been, wrong about what disorder is
(homosexuality was in the past seen as a disorder, for example). We thus need an objective
criteria to demarcate what disorder is and what not.
Only dysfunction (2), however, is also not enough. It is possible to be born with a
dysfunction, but have the dysfunction not be harmful. For example; having three kidneys can
be classified as a dysfunction, but if it is not harmful, it does not need to be treated.
 Van maaike
The myth of mental illness
- Thomas Szasz (he denies mental illness) (1920-2012)
“The concept of illness, whether bodily or mental, implies deviation from some clearly
defined norm. In the case of physical illness, the norm is the structural and functional
integrity of the human body. Thus, although the desirability of physical health, as such, is
an ethical value, what health is can be stated in anatomical and physiological terms.”
(naturalistic and reductionistic conception of physical illness. Physical illness: some
imbalance in structural or functional integrity in the body? )
“What is the norm, deviation form which is regarded as mental illness? This question can
not be easily answered. But whatever this norm maybe, we can be certain of only one
thing: namely, that it must be stated in terms of psychological, ethical, and legal
concepts.” (we cannot state what mental illness is in terms of the physiological going ons
in the brain ???
“When one speaks of mental illness, the norm from which deviation is measured is a
psychosocial and ethical standard. Yet the remedy is sought in terms of medical
measures that–it is hoped and assumed–are free from wide differences in ethical value.”
(somehow or remedy is supposed to be medical maar dat is absurd want mental illness is
abt afwijking v. psychological and ethical standard  conceptueel absurd to justify this)
“Since medical interventions are designed to remedy only medical problems, it is logically
absurd to expect that they will help solve problems whose very existence have been
defined and established on non-medical grounds”
Thomas Szasz(1920-2012)“While I maintain that mental illnesses do not exist, I obviously
do not imply or mean that the social and psychological occurrences to which the label is
attached also do not exist. Like the personal and social troubles that people had in the
Middle Ages, contemporary human problems are real enough. It is the label we give
them that concerns me, and, having labelled them, what we do about them.”
- Hij ontkent niet dat mensen met “Problems of living (dit is wat hij mental problems
noemt)” sufferen. These ppl need help but not medical help

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 - The argument: Pl. what constitutes disorder is a dysfunction or lesion at a structural,
cellular, or molecular level. (naturalist premise)P2. "mental disorders" present
without such a physical lesion. (empirical premise) (it turns out to be true, we haven’t
discovered the cause of the brain for certain disorders) C. mental disorders do not
exist.
- Naturalist conception of disorder (P1)
o Naturalists who defend reality of mental illness mainly attack P1; volgens hen
mental disorder is a notion of biological dysfunction (daarvoor hoef je niet
mental disorder in the brain te zien)
Some accounts of disorder and why they fail (wakefield also talks about this)
- Disorder as whatever professionals treat
o Does not even address, let alone solve, the problem; because it does not
answer the question how to delineate (afbakenen) disorder from non-
disorder
- Disorder as statistical deviance
o What about excellence?
o Statistical normality in deplorable contexts (in middeleeuwen there is a
plague in the village but what is statistically normal is niet per se healthy??)
- Disorder as causing distress and disability
o Not all causes of distress and disability are disorders (bv. Poverty).

Naturalism/naturalistic… is een reactie op:

- In reaction to the concerns of antipsychiatry (dat is bij wakefield iig en hij zegt het
volgende). Naturalism wil laten zien dat: mental disorder has a value-free necessary
condition. There cannot be a form of disorder without there being a value-free
demarcation of the concept. Ofzo.
- In reaction to Szasz’s notion of function as structural lesion (schade/Nadeel): the
notion of biological (dys)function
Wakefield(1992): ‘There are many reasons why mental health professionals should care
about the correct analysis of the concept of disorder. Concerns about the distinction
between disorder and non disorder are omnipresent in the mental health field and range
from the sublime (how can one tell the difference between noble self-sacrifice and
pathological masochism?) to the ridiculous(is snoring a disorder the treatment of which
therefore warrants medical insurance reimbursement?) and on to the tragic (if a person
diagnosed with acquired immunodeficiency syndrome expresses suicidal thoughts, is he or
she suffering from an adjustment disorder or reacting normally to a life threatening
illness?).’
2 dominant naturalist theories: Boorse and Wakefield
The biostatistical account (Boorse)

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 - Health is normal function: the statistically typical contribution to survival and
reproduction of a part or process (bv. je hart of je ogen)within members of a
reference class.
- Disorder is dysfunction, an adverse departure from normal function of that part or
process. Disease is a type of internal state that is either an impairment of normal
functional ability, i.e,m a reduction of one or more functional abilities below typical
efficiency, or a limitation on functional ability caused by environmental agents
- The reference class is a natural class of organisms of uniform functional design;
specifically, an age group or a sex or a species.
- A disease is a type of internal state that is either an impairment of normal functional
ability, i.e., a reduction of one or more functional abilities below typical efficiency, or
a limitation on functional ability caused by environmental agents.
The biostatistical account (Boorse)
- Health is normal function: the statistically typical contribution to survival and
reproduction of a part or process within members of a reference class. (bv. Van hart
of ogen)
Objections I guess:
- Why ‘individual survival and reproduction’ (dus niet survival and reproduction van
een groep en geen mention van evolutionary theory zoals wakefield) -> what about
harmful conditions that do not reduce individual survival and reproduction? (like
pain, heeft niet per se invloed op survival of reproduction)
- Why ‘statistically typical contribution’? -> Where to draw the line? + what about
harmful environments in which diseases are the statistically normal result
- What ‘reference class’? -> How to determine reference classes? Why only age, sex
(for certain purposes) and ethnicity?
Biological dysfunction
- Forward-looking accounts: defines function of a trait as its contribution to individual
survival and reproduction in the present (e.g., Boorse)
- Backward-looking, etiological accounts: define function by reference to the
evolutionary history of a trait. The function of a trait is the effect for which it was
selected by natural selection. (e.g., Wakefield)
- Example: the flippers of sea turtles (they were originally selected to swim maar nu
gebruiken ze ze ook om hun nestjes mee te maken. The trait might gain a different
function in a different context, not what it was selected for. Dus What the function is
might change based on welke account/theory you use
The harmful dysfunction account (Wakefield)
- Hybrid analysis: a)Harmful: implies personal/cultural values b)Dysfunction: value-free
- Dysfunction: failure to perform natural function (voor mental disorder there has to
be a biological dyfunction, this Is not sufficient by itself tho?)
- Example: what is the heart’s natural function?

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 - Natural function: ‘an effect of the organ or mechanism that enters into an
explanation of the existence, structure, or activity of the organ or mechanism.’ 
How do you explain the existence, structure, activity van the heart dit doe je door te
refereren naar wat het doet/de functie ??
- The explanation is provided by evolution theory (natural selection). Alsin why did it
come to existence in the first place.
The harmful dysfunction account (Wakefield)
- Hybrid analysis:
- A condition is a disorder if and only if a)the condition causes some harm or
deprivation of benefit to the person as judged by the standards of the person's
culture (the value criterion), b) the condition results from the inability of some
internal mechanism to perform its natural function, wherein a natural function is an
effect that is part of the evolutionary explanation of the existence and structure of
the mechanism(the explanatory criterion)
- Hoe zit het dan met Mental disorder?
- We should Not try to find mental disorder with reference to the effects of
dysfunction(symptoms). Example: pain
- But with reference to the dysfunction of mental mechanism
- A condition is a mental disorder if and only if a)the condition causes some harm or
deprivation of benefit to the person as judged by the standards of the person's
culture (the value criterion), b)the condition results from the inability of some
internal mental mechanism to perform its natural function, wherein a natural
function is an effect that is part of the evolutionary explanation of the existence and
structure of the mental mechanism(the explanatory criterion) (vgm is dit dus het
objectieve/naturalistische)
The harmful dysfunction account (Wakefield)
- Hybrid analysis:
- Why is ‘harmful’ not enough?
o Examples: social deviance (meeste slaven rennen niet weg van hun owner
maar een slaaf die dat wel doet heeft geen mental illness, mental illness heeft
daar niets mee te maken), ‘normal’ suffering (grief of a loved one is not a
disorder), conflating the undesirable with the pathological (homo zijn was
vroeger undesirable, however that does not make it an illness (idk illness or
disorder))
o In general: we need on objective condition in order to save the intuition that
our beliefs about health and disease can be (and have been!) false
- Why is ‘dysfunction’ not enough (not every dysfunction needs treatment?)
o Harm condition is a practical condition that fits our intuitive concept “The
mental health theoretician is interested in the functions that people care
about and need within the current social environment, not those that are
interesting merely on evolutionary theoretical grounds.”
o Harm cannot be derived from evolutionary theory

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  Change in contexts: dysfunction in evolutionary context without
negative consequences today (colorblindness in the past might be
harmful but not harmful these days)
 Small decreases in reproductive fitness can be important on the
evolutionary time scale, but in the absence of any other negative
effects they are not necessarily harmful in the practical sense relevant
to disorder. (small decrease of fertility)
The harmful dysfunction account (Wakefield)
- Conceptual versus empirical work (he does not do empirical work, just conceptual)
- “The value criterion implies that any successful theory of disorder must link up in the
right way with the common sense concept of harm. The explanatory criterion implies
that any successful theory must offer an account (een verklaring bieden) specifically
of dysfunctions.”
1.“Accounts of disorder in terms of genetic etiology (leer van ziekteoorzaken)
obviously fit well with the approach to disorder I propose.” (genetic abnormality past
goed bij zijn aanpak)
2.“The harmful dysfunction approach equally fits more psychological theories of
disorder. A good example is Freud's repression account (repressin of desires en
onderbewuste enzo) of neurotic disorder.” Depresion als natural function: miss was t
revolutionary beneficial to repress traumatic experiences, maar tegenwoordig kan
dat miss voor problemen zorgen. Dus dan is er een dysfunction of something that
was naturally selected
o Research agenda: ‘Conceptual validity’ of psychiatric nosological
classifications?
Heel de discussie overgeslagen
College 3
The biostatistical account (Boorse): Objections
Kingma:
How to determine reference class?
Presumably Boorse wants to maintain that the BST provides the correct analysis of function
and health, and that alternative concepts generated by alternative reference classes do not.
If so, he needs to provide a non-circular justification for why the reference classes he
proposes are admissible, and alternative reference classes are ruled out.”
So why age, sex and ethnicity. Why not people with a certain social-economic status or
individuals diagnosed with adhd, individuals with a certain religious background.
“In other words, Boorse needs to justify, without prior reference to health and disorder, why
out of all possible ways of groupings humans, only age, sex, and perhaps race are the
groupings that underpin an account of health and disorder. And since Boorse is committed
to arguing that the BST is valuefree—i.e., that a preference for the BST over alternatives

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represents a valuefree choice or objective representation of reality and not a value-laden
preference—this justification for admitting certain reference classes only should be value-
free too.” It can not give us a valuefree answer as to why his reference classes should be
preferred instead of others
Kingma: Determining reference classes presupposes implicit notions of health and illness. 
dus hij kan van andere reference classes ook niet zeggen van nee die zijn niet goed want…..
“as the example of the XST demonstrates, account stated in value-free terms can still
embody deeply held social values.”
“instead they are likely to reflect prior, and possibly value-laden assumptions about which
groups are normal and healthy- assumptions that are deeply embedded in this account of
disorder.”
Als een theory die wel value-laden is you cannot make a good distinction between illness
and health
- The naturalist’s burden of justificiation
[...] given that we are interested in certain conditions that are disabling, painful, and so on,
naturalists have to provide a value-free justification for favoring one possible naturalist
extension of these conditions over another. In other words, given that pneumonia, cancer,
and arthritis are disorders, naturalists have to justify why the category "disorder" that they
belong to is described by—say—the BST rather than the it XST. It is this justification that
Boorse cannot provide. Without it, accounts of disorder in value-free terms cannot on their
own deflect the worry that the concept "disorder" might reflect underlying evaluative
categorical judgments. Naturalists have considerable extra work to do.” ??????
Kingma’s objections to Wakefield’s account:
- Selected disorders (e.g. Anti-social or attention-seeking, dependent behavior, dingen
miss vroeger benificial, maar nu niet meer. Dingen die we nu disorders vinden miss
dus toch eigenlijk niet volgens Wakefields account  bv. We used to think fever was
a disorder).
- Non-selected effect
o Linked traits: the presence of a trait is explained by the effects of a different
trait to which it is (genetically, pleiotropically, developmentally) linked (e.g.
blue eyes and lighter skin). A gene was selected for trait X but in combination
with other genes realizes also other traits.
o Such traits do not have a function on Wakefields account (function is defined
in terms of evolutionary theory a.k.a. the function of a trait is defined in terms
of why the trait exists, evolutionair gezien. Als een trait gelinkt is aan een
andere kan je dat dus niet echt goed doen).
o Example: reading en dyslexia. Reading cannot have been selected for
evolutionary history because in prehistoric times people didn’t read. Maar
dyslexia is now considered a ‘disorder’. Maar reading is not a function on

13
 Wakefields account, dus dan kan dyslexia geen dysfunction en dus disorder
zijn.
o Modularity of the mind (every function is a module in the mind, selected by
natural selection anders kan het geen function zijn on wakefields account.
Dus his theory requires a massive modularity of mind): (kingma):
“...many mental capacities will be like reading in this respect. Wakefield’s
account assumes that ‘every single mental module or capacity must have
been “visible to natural selection” via its own effect rather than through
any...developmental or genetic linkage.... Wakefield’s account, it turns out, is
very strongly revisionist.
What he needs for his theory to work is very controversial and very revisionist
 If Wakefield assuming adaptive explanations for traits we like, as opposed
to traits we don’t like? That would make his account circular of
course. ???? idk
Problem with backwards looking theories: we weren’t there so we don’t
know, post-hoc reference to evolutionary theory. It’s an inference.
Circularity can come in easily als je assumed: there must be an adaptive
explanation for this trait: cuz we value it. Dan ga je bedenken van ja
psychosis must be a dysfunction, it probably wasn’t adapted in prehistoric
times, maar dat weet je niet sommige dingen (zoals psychosis) kon
vroeger miss wel helpful zijn, maar nu niet meer

The harmful dysfunction account: objections Bolton; kritiek op wakefields understanding of

evolutionary theory
Bolton (2013): “recent developments and new paradigms in genetics question the crucial
assumption that social functions can be identified as a separate class contrasted with natural
functions, understood in this context as what are evolved and genetically transmitted.”
1. Human evolution in social context (social context can
have influence on genetic makeup of their offspring)
2. Gene-(social/individual) environment interaction
So can we really make a distinction between natural selection
and the social context where it occurred, where bv. in prehistoric
times certain values already existed. ????
So should we really exclude values from evolutionary theories ???idk
It’s impossible to teach out the different contributions to evolutionary natural selection (aka
genetic inheritance), of all kinds of socialization processes and individual choices  These
are Influences on psychological and behavioral phenotypes
Bolton 2013: “It follows then that a mental state or behavioral response can be said to be
dysfunctional—to deviate from design norms—in one or more of threeways:
1.It fails to operate in the way selected for in evolution.

14
2.It fails to operate in the way taught and sanctioned by the culture.
3.It fails to work in the way the person intends, according to his needs and values as he sees
them. These three kinds of dysfunction are not clearly separated, and they interact.”
A philosophical diagnosis: Fulford
- In much of the discussion between eliminativists and realists about mental disorders,
mental disorders stand out as problematic. Physical disorders are assumed to be
value-free.
- Fulford argues that this assumption is false. Without it, much of the problem
dissolves
- He applies an ordinary-language philosophy to value theory (analysis of our daily use
of value terms. Conceptual confusions (confusions in how we use concepts in our
ordinary language) leiden tot philosophical problems/debates) in order to reveal a
misunderstanding about our use of illness concepts.
- R.M. Hare’s treatment on the logical properties of value terms
- Value judgments expressed by value terms are made on the basis of descriptive
criteria.
o Example: this is a good strawberry
o Criteria: sweet, red, juicy…
- While these criteria are widely agreed upon, it is these descriptive criteria that may
come to dominate the use of the value term (good) in question.
o The term ‘good’ comes to be associated with red, juicy and this descriptive
meaning becomes dominant.
- Contrast with things we don’t agree upon like music taste ‘good music’
We might start use these descriptive terms as if they are valuefree, which they are obv not
Value terms by which shared values are expressed may come, by a process of simple
association, to look like descriptive(factual) terms, whereas value terms expressing values
not agreed upon, remain overtly value-laden in use.
This equally applies to medical language. Both physical illness terms and mental illness terms
are value-laden. (judgements on what is healthy vs unhealthy etc.)
- We tend to agree on the values underlying the diagnosis and treatment of physical
illness, hence descriptive criteria dominate the use of related terms. HIerdoor lijken
de termen valuefree when they are really not.
- Psychiatry is concerned with areas of human experience and behavior (beliefs,
desires, emotions, volitions, the self, etc.) where people’s values strongly diverge.
Hence mental illness terms remain explicitly value laden in use.
- Fulford: The reason that there is more controversy about psychiatry than other
somatic medical disciplins, is not that psychiatry is scientifically deficinient
(gebrekkig) (developed?), but rather that it is evaluatively more complex.
Normativism regarding mental disorder

15
Health and disease concepts are primarily and essentially evaluative
- Negative account: naturalism is wrong
- Positive account: substantive normative model of mental disorder, lets try to find
valueladen definition of mental health and illness
- Naturalist Rachel cooper
by ‘disease’ we aim to pick out a variety of conditions that though being painful, disfiguring
or disabling are of interest to us as people. No biological account of disease can be provided
because this class of conditions is by its nature anthropocentric and corresponds to no
natural class of conditions in the world” (Cooper 2002: 271
ze zegt basically die dingen die ons pijn doen boeien ons obviously (in practical zin want het
is disabling en painful) dus gaan we zoeken naar wat voor condition?/natural process
daarmee correspondeert maar dat is helemaal niet mogelijk, because this class of conditions
is by nature anthropocentric???
Value laden definition of disease that she gives: a condition is a disease if and only if
1 the condition is bad for the sufferer
2 The condition is abnormal or unlucky
3 The condition is potentially medically treatable (deemed by society as the kind of thing
that medicine treats)
Examples, unwanted pregnancy, broken leg etc.
- Normative accounts of disorder
Nordenfeldt(e.g. 2006)
- ‘holistic’ theories of health: refer to norms relating to ‘quality of life’ (rather than
merely natural norms: survival and reproduction)
- ‘Reverse theory of disease and health’: derive concept of disease from concept of
illness dus zoals de persoon het zelf ervaart, zie college 1 of 2 vgm), rather than vice
versa (as in naturalist theories)  dit is evaluative want hoe mensen hun illness
ervaren is natuurlijk filled with values.
Hij laat zien wat hij hiermee bedoeld door:
- Two ‘geneological’ stories
o 1.In history of medicine this I usually how it goes: Illness recognition and
communication-> search for the causes of illness-> disease recognition. Illness
concept is valueladen???
o 2.Person approaches health care service with problem-> doctor diagnoses
problem and treats patient-> patient is healthy again if she has got rid of the
problem. Volgens hem is dit de betere manier ofzo vgm omdat dit in praktijk
is hoe het gaat

16
Disease= defined as bodily or mental process which is such that it tends to cause an
illness(understood as a state of suffering and/or disability experienced by the subject). Voor
naturalists kan dit natuurlijk niet, zij willen valuefree definition of disease??
Suffering/well-being neither seems sufficient nor necessary for illness/health. Still may be
crucial to subjective aspect of it. Er zijn bv voorbeelden where someone is not yet suffering
or will never suffer.
Nordenfelt’s(dis)ability approach
−A is completely healthy if, and only if, A has the ability, given standard circumstances, to
reach all his or her vital goals
−A has a disease if, and only if, A has at least one organ which is involved in such a state or
process as tends to reduce the health of A. The disease is identical with the state or process
itself.
−Vital goals? ‘Necessary and jointly sufficient for minimal long term happiness.’ ‘This
includes more than mere survival. It includes life without disabling pain.; it includes the
realization of the most important projects of the person
Coming to the decision to attend the clinic can be, though is not always, complex, difficult,
contested, and protracted, within the person himself, and within the family, as different
points of view are taken through time or across time. The brief review indicates the
processes and constructions that lie beneath the conceptualization of something as a
problem of the sort to be taken to the mental health clinic, being recognized as such by the
health care professional, and either being or perhaps on its way to becoming a "mental
disorder" in the DSM and ICD
Illness is excusing/exempting(illness discourse)•“There is no objective hard and fast
diagnostic threshold available here. What counts as intolerable distress, and what counts as
serious impairment, what counts as disability(as being unable to do) all depend not only on
individualpsychologicaldifferencesandindividuallife-circumstancesbut those in interaction
with cultural expectations
DSM-5 definition of mental disorder: “A mental disorder is a syndrome characterized by
clinically significant disturbance in an individual’s cognition, emotion regulation, or
behaviour that reflects a dysfunction in the psychological, biological, or developmental
processes underlying mental functioning. Mental disorders are usually associated with
significant distress or disability in social, occupational or other important activities. An
expectable or culturally approved response to a common stressor or loss, such as the death
of a loved one, is not a mental disorder. Socially deviant behaviour (e.g., political, religious,
or sexual) and conflicts that are primarily between the individual and society are not mental
disorders, unless the deviance or conflict results from a dysfunction in the individual, as
described above.” (APA 2013)
Kritiek bv: what exactly ís socially deviant. (zoals dat vb. van middeleeuwen)
Discussie overgeslagen

17
College 4
Historical overview DSM (wordt gegeven door First vgm)
18th century: insanity appeared in formal medical nosologies (medical science dealing with
the classification of diseases) achieving professional authority
- Modern enlightenment ideals
- Rise of the asylums
18th-19th century: A profusion of proposed psychiatric nosologies. Everybody had different
ways to carving up mental health issues: example of Pinel freeing women from the chains.
- Individual cases were considered representative for a large group without looking
at/studying a large group  that is sometimes called the first transition (see below)
- Top down, essentialist approaches ??? he didn’t really explain this
First transition: Kraepelin’s empiricism
- Commitment to longitudinal empirical study: cause, course and outcome. He
followed patients throughout the year to discover certain patterns.
- Move away from unitary conception of insanity to specific disease entities (alsin niet
insanity zien als gewoon een ding zovan y’all insane, over een kam scherend, maar
naar verschillende soorten van insanity kijken ???): it was more empirical, in de zin
van more bottom-up en descriptive: informed by empirical data ipv je eigen
aannames je taxonomies (classifications) laten leiden.
- More ‘bottom up’ descriptive approach (combined with essentialist, ‘top down’
ontological assumptions
Inaugural (openings) lecture
- Psychiatry needs a profound and deep union with general medicine
- The clinical study of disorders should proceed through ‘the empirical determination’
of individuals forms of illness according to their cause, course and outcome by
applying ‘impartional observation and tireless pursuit of individual psychiatric cases.’
- ‘As long as it is impossible to relate a simple and unequivocal pathoanatomic
observation to a simple and unequivocal psychopathological observation’ scientific
psychiatry will not have reached the goals it should be capable of reaching. (ultimate
goal psychiatry: have some kind of neuro-anatomic substrate for every specific
condition)
- The ‘strictly empirical research methods’ of experiencing psychology ‘hold out most
promise’ of ‘validity and scientific utility’. (heeft hij niet uitgelegd)
Second transition: the call for a single national classification system, cuz everybody
(professors etc.) used to have their own classification system and different terminologies etc.
That classification system was motivated in the USA by the mental hygiene movement
- Statistics as a methodological instrument for the mental hygiene movement late
19th, early 20thcentury:

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 - there are social-political reforms necessary to promote mental health: that would be
preventative measure for developing mental health issues. Focus on relation insanity
and social factors, demographic variables for policy setting aimed at prevention
(given overcrowded asylums)
- tools for asylum management. Statistical analysis obv de gegevens was ook een
manier to manage the asylums. De asylums zaten vol met mensen met allerlei
conditions (sommige gingen nooit meer weg) dus ze wilden inzicht in what kind of
condtions do we have in these asylums en what is the trajacory for these people.
- promise for the medical profession of widening its scope beyond the asylum,
increasing professional legitimacy. Psychiatry kon een rol krijgen buiten the asylums
Third transition: the psychosocial turn
- growing influence of psychoanalysis. Psychosocial models of mental illness derived
from ideas of e.g. Freud’s psychoanalysis and Meyer’s ‘psychobiology’: het thought
that the medical psychiatric conditions influenced by biological /sociological factors.
Medical psychiatric symptoms als psychobiological reactions to certain factors zien.
- WW II: current nosology ill-suited to deal problems encountered in the field. Former
Nosologies that there were couldn’t deal with these problems (PTSD etc.). die waren
meer gericht op de shit in de asylums dus schizofrenie enzo. Maar deze soldiers
leefden wel gewoon in society dus they needed a new way of classifying mental
illness.
- Armed forces nomenclature and veterans administration: expansion of neurotic
syndroms, based on psychodynamic theory, to incorporate outpatient
representations of servicemen and veterans:
- Result: departure from kraepelian descriptive, categorical approach. Overgang naar:
- Met psychosocial turn zie je meer psychological models: dimensional, holistic
approach based on psychosocial psychoanalytic views
- More theory-laden and etiology(oorzakenleer)-driven, general description a.o.t.
descriptions of specific symptoms. Not descriptions of symptoms and the
development through time. But in the description of these symptoms was already
the idea that they were reactions to certain conflicts, which means they already
presupposed certain ideas about their etiology, about the way they came into
existence; what caused them.
DSM I ( taxonomy van american psychiatric association )(1952) Justification DSM I:
- 1920’s: ‘each large teaching center employed a system of its own origination’
resulting in ‘a polyglot of diagnostic labels and systems, effectively blocking
communication and the collection of medical statistics.
- 1984: ‘at least three nomenclatures were in general use’ : hoe moet je dan effectief
communiceren en effectief science uitoefenen als iedereen eigen andere
classification systems gebruikt 
- ‘the situation in psychiatric nomenclature had deteriorated almost to the point of
confusion which existed throughout medical nomenclature (terminologie) in the

19
 twenties’ dit leidde tot verwarring. Mensen wisten niet van elkaar wat ze bedoelden.
 drm kwam APA met eigen classification system)
Voorbeeld theoryladennes in DSM I (en II)
- Schizophrenic reactions
‘This term is synonymous with the formerly used term dementia praecox. It
represents a group of psychotic reactions characterized by fundamental disturbances
in reality relationships and concept formations, with affective, behavioral and
intellectual disturbances in varying degrees and mixtures.’
By labeling it as a psychotic reaction it already presupposes some kind of
pathogenesis (the manner of development of a disease) its some kind of unconscious
reaction to something else, which Is a theory about how its caused.
- Psychotic reaction
‘may be defined as one in which the personality, in its struggle for adjustment to
internal and external stresses, utilizes severe affective disturbance, profound autism
and withdrawal from reality, and/or formation of delusions or hallucinations.
Hierin zie je duidelijk de invloed van psychoanalysis, consciousness is trying to deal
with severe stressors by delusions, autism etc. Dus de symptomen worden gezien als
caused by a reaction. Dus er zit een theorie in the way that it is classified informing
our classification system. De theory that was used: psychoanalysis mostly.
DSM II
Die strugglede Hiermee dus veranderde notion schizophrenic reaction to schizophrenia.
‘even if the commity could not establish agreement on what the disorder is; it could only
agree on what to call it. Anders kan je niet met elkaar communiceren en research comparen.
Fourth transition: DSM-III
Due to influence psycho-analysis psychiatry was influential beyond the asylums. People with
normal lives were also getting treated aka:
- Societal expansion of psychoanalystic and psychosocial models outside the asylums
and hospitals (community medicine, education, child reading practices etc.)
- Criticism: Lack of scientific progress psychosocial models
- Social criticism: the anti-psychiatry movement (basically ineens wordt normal gedrag
Koekkoek genoemd)
- So Alan stone (president APA) said: social psychiatry and social activism “carrying
psychiatrists on a mission to change the world, had brought the profession to the
edge of extinction. What started out as a promise for psychiatry to increase their
legitimacy by expanding beyond asylum walls, was actually a death trap according to
stone. This had to change ….. (niet per se acc to stone denk ik, gewoon in general)
Dus ging de groep die de DSM III maakte terug naar Kraeplin: a ‘neo-kraepelinian’ approach -
Klerman (1978) (biological psychiatry):
1. Psychiatry is a branch of medicine

20
2. Psychiatry should utilize modern scientific methodologies and base its practice on
scientific knowlegde
3. Psychiatry treats people who are sick and require treatment
4. There is a boundary between the normal and the sick
5. There are discrete mental illnesses. They are not myths, and there are many of them.
6. The focus of psychiatric physicians should be on the biological aspects of illness.
7. There should be an explicit and intentional concern with diagnosis and classification
.
8. Diagnostic criteria should be codified, and a legitimate and valued area of
research should validate them.
9. Statistical techniques should be used to improve reliability and validity
Carl hempal (logic-positivist): developing an idea of what science should look like: first agree
on what to call things/how to label things a.k.a. have clear terminology. Based on that you
can build scientific system. Then try to understand and study empirical relation between
different factors.
It is said he influenced the ppl who developed dsm III. Because they said DSM I & II, besides
their intentions fail to deliver, because it’s theory-laden and etiology(oorzakenleer)-driven
(the calssifications presuppose a certain way in which the symptoms are caused) + because
everybody had a different theory (termen betekenden bij iedereen iets anders) there was a
low reliability en low validity (because how do we even know that these theories are true?).
- Dus DSM III commity zegt (inspired by Carl Hempal wss) first reliability
(intersubjectively accessible criteria for making a diagnosis ?? Basically als 2
psychiatrists iemand diagnoses met schizofrenie doen ze dat op basis van dezelfde
criteria) Dan study/science naar what mechanisms behind *insert mental illness* are,
then validity (does your classification system represent what is going on in reality)
Kendler Validators (might establish the validity of a certain concept?): idk luister maar
terug
Dus when would a certain type op depression
become more valid: if we see that in certain
configuration of symptoms it aggregates in certain
families or see that it is associated with certain
environmental risk factors or we see that all these
ppl have similar psychiatric histories (antecedent
validators),
People with neuropsychological problems when
tested have certain cognitive deficits or personality

21
traits, or biological markers (MRI findings, something in the blood) (concurrent validators)
of als je deze en deze symptoms hebt then they have the same prognosis/all those people
would all react the same to treatments (predictive validators)
These validators might indicate we are dealing with a causal substrate. If we can
differentiate these reliable categories using empirical validators, then we might specify
disease according to their underlying causal structure (als je depression type x hebt which is
caused in a very specific way dan probably were dealing with a different type of entity en
moeten we hem dus classifien als een andere type of depression). So we need validators
that are referring to things prior to the illness and current and that might predict the
outcome of the illness and using those validators we can: Met validators kan je system zowel
reliable als valid maken? Wdkk idk (this was the promise of the DSM III. In dsm 4&5 no major
changes. Idee blijft hetzelfde : we have imperfect classification systems maar we kunnen als
we de science doen ofzo dus wel valid maken).
If we do the science we can make taxonomies (classification) into subtypes that actually
mimic what is going on in the brain (making it valid I guess???). then we have the holy grail
of nosology (classification of diseases) because then we can classify acc to the underlying
causal structure (dat is wat makers van DSM 3 4 en 5 wilden)
Fifth transition: DSM in doubt. Wat ze wilden gebeurde niet. Het was niet zo dat we could
clearly specify certain subgroups of people who were classified with depression acc to
certain validators for example. (het was bv. niet zo dat mensen met certain depression types
running in their families hetzelfde reageerden op certain drugs + there is no biological
marker?)
- Dus transition from reliability to validity turned out to be problematic
- En er was critique of the consensus model in expert groups and lack of transparency.
Er moest besloten worden door experts welke symptoms should be left out or left in,
it was just a consensus decision (denk aan the voting about homosexuality, vgm ging
het er dan over of die dus wel of niet in the DSM hoorde)
- Reification (making it into a thing) of DSM syndromes: DSM became an ‘epistemic
prison’ (acc to Hyman). Depression is just a description of symptoms but it becomes a
thing. Mensen (scientists) zeggen bv my depression is causing my low mood, maar
nee depression is defined in terms of low mood dus how can it be a cause of low
mood. Slowly but surely the descriptions were reified into essences into the things
that were causing the symptoms, rather than that they were defined in terms of the
symptoms. And because of this Reification it was also these imperfect categories,
everybody knew they were imperfect but they were actually informing our research.
In order to find neurobiology behind the syndromes we actually used imperfect
categories in order to think up research questions.  that didn’t work. But if you
have a heterogeneous (group?, aka group with diversity) have low mood that we
call depression. We (reliably??? Of juist niet???) call it depression. If we look at the
neurobiology of these people we will see all kinds of different things, so then its
only to be expected dat je nooit een unequivocal neurobiological substrate vindt,
cuz it’s a heterogeneous group but if you then let those categories then determine

22
 our esearch questions/how we group patients in order to do research dan kom je
niet ver. This is the main critique that motivated the rdoc (research domain
criteria).

Dus epistemic prison:

Scientists attempting to discover genetic or neural underpinnings of disease have all
too often reified the disorders listed in DSM-IV-TR as ‘natural kinds’ (Hyman2003)
“DSM-IV created an unintended epistemic prison that was palpably impeding
scientific progress. Outside of their ongoing research projects, most investigators
understood that DSM-IV was a heuristic, pending the advance of science. In practice,
however, DSM-IV diagnoses controlled the research questions they could ask, and
perhaps, even imagine
The strength of each of the editions of DSM has been “reliability” –each edition has ensured
that clinicians use the same terms in the same ways. The weakness is its lack of validity.
Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are
based on a consensus about clusters of clinical symptoms, not any objective laboratory
measure. In the rest of medicine, this would be equivalent to creating diagnostic systems
based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis,
once common in other areas of medicine, has been largely replaced in the past half century
as we have understood that symptoms alone rarely indicate the best choice of treatment.
Patients with mental disorders deserve better.” (Thomas Insel) (miss terugluisteren)
Kendler’s thought experiment: contingent happenings, like scientists moving to the other
part of the world etc. what if we let history the last 100 years or so and we have a lot of
possible worlds en we just let it go and everytime it happens in a little different way, would
we then after 400 years (?) come up with the same taxonomy (would we have the same
illness constructs, voor normal en ook voor psychiatric illness) as today. Or is it totally
contingent on the historical facts (miss ook nog andere vragen terugluisteren)  the
outcome of the experiment lies in the thinker’s presupposed view of the legitimacy of the
categories and disorders mentioned.
Kendler(2009): “A defining feature of the mature sciences is their cumulative nature.
Knowledge progresses with research programs building on what has gone before. Should
psychiatric nosology (classification of diseases) strive toward such a goal? For critics of
psychiatric diagnoses who view them as social constructions, this is an incoherent project If
there is no truth out there, we cannot expect to get closer to it For those who adopt either
realist or pragmatist perspectives on psychiatric nosology (classificatie van ziekten) that
there are things or interrelated sets of things out there in the real world that correspond to
individual psychiatric illnesses it is a more rational and, I would argue, vital task
 There has to be ‘psychiatric illnesses’ out there in the real world anders its
impossible to come closer to them. Anders kan je process of epistemic
iteration ( google zegt: a process by which scientific knowledge claims
are progressively altered and refined via self-correction or enrichment)
hebben (that’s what social constructivism would say? Als je mental illness

23
 ziet al seen social construct zie je proces of epistemic iteration niet als
something worth wanting)
Epistemic iteration (in beginning we might change direction maar wordt op een gegeven
moment meer precise) vs. Random walk (no sense of direction if there is nothing we are
aiming towards)
Three key assumptions are required for iteration to work:
1. To be something out there – a solution with a roughly stable place in the world –
toward which the iteration is aiming (zie ook dat Plaatje, x: is solution. A: is aim)
 What kind of thing is mental disorder?
o Is it a natural kind? Is it a thing in nature?
Cooper 2013: “[N]atural kinds are kinds picked out by the sciences. Identifying
natural kinds is worthwhile because such kinds can ground explanations and
predictions and enable us to gain control over a domain.”
“The important thing about natural kinds is that members of a natural kind
are all objectively similar to each other. The basic idea is that the causal
structure of the world is such that certain entities are to a large extent
interchangeable, in the sense that their similar properties mean that they can
be expected to behave in much the same fashion...”  when we hit upon
natural kinds we are discovering basic causal structure of the world. Because
its predictable we know we have hit some kind of basic causal structure

Example natural kinds: chemical elements, een hydrogen atom is

interchangable with another hydrogen atom because they behave the same
way ofzo, its predictable and because its predictable we know we have hit
some kind of basic causal structure. Is een mental disorder een natural kind in
the way that they can ground our explanations and predictions so that it gives
us control over the psychiatric domain? Can we hit upon a notion of
depression suptype ‘z’ such that if we know it is caused by abc, it has certain
features and we know a lot abt its prognosis and what treatment works and
what doensn’t (denk aan die validators). Als dat is dan its reasonable to
assume we have hit upon some kind of a causal structure/brain
structure/brain process that gives us explanatory ….? And gives us control.
Als psychiatric illness geen natural kind is then the whole notion of epistemic
iteration makes no sense.
o Metal illness as a a socially constructed kind? (zie ook Plaatje, x is moving cuz
its contstructed by us, it changes in meaning en because its moving our aim is
changing. We are dealing with moving targets)
Anti-psychiatry
Ian Hacking notion of ‘human kinds’
“Responses of people to attempts to be understood or altered are different
from the responses of things. This trite fact is at the core of one difference
between natural and human sciences... There is a looping or feedback effect

24
 involving the introduction to classifications of people. New sorting and
theorizing induces changes in self-conception and in the behaviour of the
people classified... Kinds are modified, revised classifications are formed, and
the classified change again, loop upon loop.” (1995)  classified individual,
this alters self-concept and behavior. Being aware of being classified alters
your self-concept which also means youre gonna behave differently, which
changes the scientific classifications: aka were in a loop. In die zin is het dus
ook een moving target, Hacking wil niet zeggen dat bv. Autism is een
invention maar dat being diagnosed alters the person that’s diagnosed so in
that sense it’s also a moving target.
Kinds of people: moving targets, ‘making up people’: new scientific
classification may bring into being a new kind of person, conceived of and
experienced as a way to be a person.  People get classified with new
diagnosis, has big impact on their life, people respond to you differently etc.
People start to identify with their diagnosis, bv. Toen aspergers uit de dsm
ging waren mensen boos. ‘i a man aspergers’ self concept is dus ook altered
enzo. (die loop van daarnet)
o Practical kinds: pragmatism says that our classifications are always dependent
on our practical goals, we don’t make taxonomy for fun but to reach certain
goals. So our taxonomies have a relational nature (to the goals that we
have??). they are not nature as it is.
Essentialism (idea we can carve out nature at its causal joints and find out the
essence of what the world are really like) vs pragmatism (there are no
essences in nature because essences are our own concepts, constructs of our
own mind, but that should not lead to relativism.)
Although we may have discovered that everything we call hydrogen has one
proton in its nucleus, we decided that having one proton is the essence of
hydrogen. As the preceding examples suggest, scientists might just as well
decide to nominate an isotope number to be the essence of hydrogen.
Essences are philosophical concepts.
How we carve up things is restricted by how the world is, its not just
coincidence that we came up with periodic table. But the fact that we did that
is relative to goals that we have. It doesn’t mean that its all relative it means
our classification system should always be relative to our goals.
(als je dan kijkt naar plaatje: de a en x are always relational, the process of
aimnig is dependent on x and x is dependent on the process of aiming. We
cant think of x independently)
Bij practical/natural kinds epistemic iteration might work
2. The process of iteration needs to have some stability over time. Even if x is in a stable
position but our aim is going all over then probably we wont get pretty far. Suppose
we are stressing different validators in different periods of time, then we would come
up with a different taxonomy if we focus on one validator instead of the other.
Choice of validator influences the direction of your aim. Welke validator je op
focused ligt aan values, field of work etc.

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 3. Are we looking in the right place? Iterative process getting stuck in a local minimum
were dealing with a paradigm that is unsuccessful. How to get out through epistemic
iteration? Everytime you try to make progress you get pulled back into the minimum.
(But We dont know if we have the right paradigm???)
Cooper abt this problem:
Cooper: [C]lassifications like the DSM can be thought of as forming part of the
infrastructure of science, and have much in common with material infrastructure. In
particular, as with material technologies, it is possible for "path dependent"
development to cause a sub-optimal classification to become "locked in" and hard
tore place.” Idk man I guess zovan miss is DSM uberhaupt niet the right paradigm?
Dsm could be undermining our epistemic iteration process………….. idk. Infrastructure
for new knowledge is based on dsm caterogries maar om dus over the local minimum
te komen we might need new categories
Kendlers paper is helpful here because makes clear what the future of psychiatric nosology
depends upon: field work of scientists ?? The way we set up sciences is informed by
decisions regarding these 3 assumptions. Idk i still dont know <3
College 5 (het hele 2e deel van het college over De Haan ontbreekt)
‘Soft’ (the model raised by the dsm, classify mental disorders in terms of syndromes) versus
‘hard’ medical model (kendler)
DSM: Soft medical models:
- Syndromes with shared symptoms and signs, and a similar disease course and
respond to treatment
- Validated by scientific evidence
Failure of soft medical model:
- No converging validators for DSM-syndromes. If you look at all these validators and
you try to map them onto the dsm syndromes there is no confirmation of the validity
of the DSM syndromes (denk aan dat stuk over epistemic prison?). Er is niet certain
genetic makers for shiczophrenia en certain genetic markers for bipolar disorder en
certain genetic markers for autism. De idea dat met further validation we could
classify synyndromes en dan focus on causal mechanisms enzo lukt niet, because all
these things (what things? Validators maybe?) correlated with all the syndroms
- Putting the cart before the horse: DSM-classifications determine research
- Reification of DSM syndromes: an epistemic prison
Something about stating research questions in terms of the dsm syndromes, we
would select patients with a dsm diagnosis of ex. Bipolar disorder, maar dit is eigk
bunch of ppl grouped together with different forms of neurobiological underpinnings
because it was a very heterogeneous group. So obviously we didn’t find one single
correlate you find bazillions of correlates. There is no one single defining
neurobiological marker for autistic spectrum disorder. (dit heeft te maken met wat

26
 ook in een vorig college is uitgelgd over validators and local minimum ofzo, miss daar
even kijken voor verduidelijking)
That might be because the syndrome we now call autism is not valid (critique dsm)
Hard medical model
- Defining mental disorder in terms of its root (biological?) causes (instead of
symtomps)
- (This presumes a )Privileged levels of causal explanation providing critical information
about etiology, predicted symptoms, course of illness, response to treatment, etc.
- Carving mental illness as its natural joints: mental disorders as natural kinds
Research domain criteria (RDoC) (is van insel)
“RDoC classification rests on three assumptions.
1.First, the RDoCframework conceptualizes mental illnesses as brain disorders. In contrast to
neurological disorders with identifiable lesions, mental disorders can be addressed as
disorders of brain circuits.
2.Second, RDoC classification assumes that the dysfunction in neural circuits can be
identified with the tools of clinical neuroscience, including electrophysiology, functional
neuroimaging, and new methods for quantifying connections in vivo.”
3.Third, the RDoC framework assumes that data from genetics and clinical neuroscience will
yield biosignatures that will augment clinical symptoms and signs for clinical management.”
(Inselet al. 2010)
•The primary focus for RDoC is on neural circuitry, with levels of analysis progressing in one
of two directions: upwards from measures of circuitry function to clinically relevant
variation, or downwards to the genetic and molecular/cellular factors that ultimately
influences such function. (Inselet al. 2010)
we see units of analysis en domains
relating to positive effect, negative
effect etc. Die dingen die daaronder
zegmaar staan zijn psychological
functions, that are often not
functioning properly in case of mental
illness. En de primary level of analysis
(van die domains of function) is
neuralcircuitry and we can get tot the
essence of mental disorder by
approaching from 2 directions (idk wat die 2 directions zijn maaroke)
RDoC critique on DSm, the ppl we now diagnose with schizophrenia are a heterogeneous
group of ppl ( group with diversity) with different kinds of real disorders, correlating with
different kinds of neurobiological mechanism. Dus wat we nu schizophrenia noemen are in
fact three biotypes. Due to our current classification system we cannot separate the one

27
from the other. That’s why we get such poor results. We should stop using dsm
classifications. We should just use the general term for for example psychosis and then we
should do the research and then we’ll see there’s actually 3 groups. Now we haven’t
classified the groups in terms of signs and symptoms but we have grouped the patients in
terms of their neurobiological circuitries/biotypes. This wil give us a homogeneous group of
ppl that helps us get more control over predictions etc.
Why rdoc more valid classification of mental disorder, because als je naar die validators van
vorig college kijkt, in de nieuwe groepen die gevormd worden met de rdoc method dan heb
je very strong validators in terms of biological markers/genetic factors en dan geeft dat ons
diagnostic stablility en can better predict course of illness and what kind of treatment people
need. (that is the promise of rdoc)
What we should do is not select patients based on dsm diagnosis but all ppl with psychiatric
problems who have a similar problem with working memory (een van de domains). Then you
get homogeneous group en dan kan je betere resultaten krijgen en specific biotypes linken,
the one to one mapping that we want.
the promise: ‘Diagnosis in psychiatry, in contrast to most of medicine, remains restricted to
subjective symptoms and observable signs. Clinicians rightly pride themselves on their
empathic listening and well-honed observational skills. But recently psychiatry has
undergone a tectonic shift as the intellectual foundation of the discipline begins to
incorporate the concepts of modern biology, especially contemporary cognitive, affective,
and social neuroscience. As these rapidly evolving sciences yield new insights into the neural
basis of normal and abnormal behavior, syndromes once considered exclusively as “mental”
are being reconsidered as “brain” disorders—or, to be more precise, as syndromes of
disrupted neural, cognitive, and behavioral systems.’ (Inseland Cuthbert 2015)
The promise: “As new diagnostics will likely be redefining “mental disorders” as “brain circuit
disorders,” new therapeutics will likely focus on tuning these circuits. What is the best way
to tune a negative valence or social processing circuit? Medications might be useful, but
recent attention has focused on devices that invasively (deep brain stimulation) or
noninvasively(transcranial magnetic stimulation) alter braincircuit activity. Paradoxically, one
of the most powerful and precise interventions to alter such activity may be targeted
psychotherapy...” (InselandCuthbert2015)  whatever works will work because it influences
the brain circuits
Assumptions:
1. Psychiatric signs and symptoms are realized by brain states (neural circuits)
2. Final common cause of all etiological factors at neurobiological level(s). dus wat
causal factor in de background there are in the end it all converges to the final
common causal pathway at the level of the brain ????  wat voor symptoms je ook
hebt, they are realized by brain circuits
Rdoc shares research diagnostic criteria with dsm III? They have the same motivation to
change classification system

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De DSM III wilde objective, descriptive, a-theoretical classification? But apart from that the
motivation was the same (als RDoC?). But now its not a-theoretical anymore, its explicitly
theoretical (RDoC says mental illness as brain disorders?) ??
Kendler: failure of hard medical model
- Inevitable etiological heterogeneity (i.e.“multi-factor” and “multi-level” etiology):
Neurochemistry, molecular genetics, molecular neuroscience, system neuroscience
(‘circuits’), cognitive (neuro)science, intra-psychic mechanisms, temperament,
interpersonal dynamics, environmental stressors, socio-cultural factors,...
All mental illnesses are multi-factoral disorders, which means that there are all kinds
of different levels of explanations from the physiological to the social. All kinds of
different factors that impact on the severely and prevalence etc of mental discipline.
Its naïve to think this is all going to cluster into certain identifiable root causes in
terms of which we should define our mental disorders
- “The current status of our science, and, most probably, the nature of psychiatric
disorders themselves, does not yield up unambiguous choices for the best level at
which to define psychiatric illness etiologically/causally.”
It’s not only because the current status of our science, it’s not ‘if only we use rdoc/we
do research we will find the essences of mental disorders’. Kendler says its also the
nature of psychiatric disorders themselves that we cannot find the best way to
explain mental disorders ????
- “Nature does not appear to have provided us one critical level of explanation for
psychiatric illness that stands out from the background... For psychiatric disorders,
explanatory power is dispersed and diffuse.
Brain circuitry als primary …? Of analysis is not backed up by science acc to kendler

Alternatives to reductionism
The bio-psycho-social model
- BPS-Model: (mental) illness explained in term of intra-and inter-level dynamics of
hierarchically organized complex systems (engel, 1980). Shouldn’t be focused on only
one dimension.
o Critique: too vague, leading to eclecticism
o Offers too little guidance for clinical action
- Mere heuristic or genuine (causal) explanation: miss moeten we BPS-model slechts
zien als een practical tool, ook rekening houden met social factors enzo
Idk
The network model
- Foundation of the network approach is simple: instead of interpreting symptoms as a
function of a set of underlying/latent disorders, the network approach conceptualizes
symptoms as mutually interacting, often reciprocally reinforcing, elements of a
complex network.
- Voorbeeld depression: the illness depression causes all kinds of symptoms, suicidal
thoughts, weight loss etc. RDoC zou zeggen: find the neurobiological correlates of

29
 this entity which causes all the symptoms. Network model says that’s not how we
should look at psychopathology at all. There is no thing underlying the symptoms, the
thing ís the configuration (?, wat hij zegt klinkt als contriburation tho) of symptoms
and the causal relation between the symptoms. This is why the network models
practice is also very intuitive. Depressed mood  concentration problems 
sleeping problems  increase concentration problems  guilty u cant do work 
more depressed. Symptoms are reinforcing eachother. So we should look at patterns
in a network. ( it is A blob of causally interacting factors ipv a thing that gives certain
symptoms )
- Explaining symptoms by modeling them as nodes in a dynamical causal network
- Psychopathology a patterns emerging in network dynamics.
- The dynamics of symptom networks.
How do nodes influence eachother ofzo?
Resilient network vs vulnerable network. Bij de ene veroorzaakt de node stress
sleeping problems en dat veroorzaakt weer concentration problems etc. maar
wanneer de stress weer weg is gaan die andere ook weg. Bij de ander echter niet en
daar lijdt het uiteindelijk bv ook tot depression en weightloss
Critique De Haan
- Network model is merely a mathematical tool, it provides no account of what
variables are and are not relevant
- Cannot tell us anything about the nature of the nodes (causal, constitutive)
- It presupposes rather than provides a theory that answers these questions.
- Borsboom et al. start from DSM-symptoms (for lack of anything better…). What
about genetic, neurobiological, personal, social etc. variables?
Inactivism does give account of how to understand which nodes, dimensions are
relevant. Ofzo.
 I still don’t get this
 Anw de haan claims inactivism does give us an account of which nodes are
relevant. You need to say more than just having a network; what are the
relations between the nodes? We first nieed a philosophical theory to
inform network moddeling otherwise it will be presupposed.
Enactivism (De Haan 2020)
• Psychiatric disorders enormously
complex: Bio-Psycho-Social-
Existential dimensions
• “A helpful model should
• 1) take into account these four
dimensions
• 2) show how they relate.
• Kind of explanatory models:
• One-sided
• Dualist

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• Integrative
−BPS-model
−Network model
−Enactivism
Enactivism (De Haan 2020)
• Living organisms are autonomous
• Autonomy or self-organization implies dependency on
environment
• Sense-making: organism’s evaluative interaction with the
environment
• Life-mind continuity thesis: living requires sense-making
• Once matter is organized in such a way as to be living
matter, it will engage in sense-making
• sense-making is neither passive reception nor active
projection, it is a relational activity.
• Basic and existential sense making
Psychiatric disorders as disorders in sense-making:
patterns of disorderd sense-making that exhibit
• Inappropriateness of experiences or interactions
• Inflexibility in interacting with the world
• Inflexibility in one’s existential stance taking
• Personal suffering
“These four criteria for disordered sense-making do
not tell us where to draw the lines [...] On an
enactive account then there are no clear, generally
valid cut-off points between normality and
pathology.”
“By characterizing psychiatric disorders as
disorders of sense-making, and sense-making as
a fundamentally embodied and embedded
activity, an enactive account implies that the
proper unit of analysis of psychiatric disorders
will be persons in their worlds.”
•Insel et al (2010): The primary focus for RDoC is on
neural circuitry, with levels of analysis progressing in one
of two directions: upwards from measures of circuitry
function to clinically relevant variation, or downwards to
the genetic and molecular/cellular factors that ultimately
influence such function.
• Integrative?
• Four dimensions, one dynamical system

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• “The concept of sense-making already integrates them. That is, we can understand
persons and their sense-making only if we take into account their bodily nature and
their fundamental embeddedness in their social world. The four dimensions refer to
different excerpts of this one complex person-world system, at different levels of
zooming in.” (De Haan 2020)
• “What is the relation between my feeling annoyed
and the amygdala activity? Am I annoyed because my
amygdala activity has increased? Or has my
annoyance caused my amygdala activity to go up?
From an enactive perspective these are misconceived
questions: both my annoyance and my amygdala
activity are only understandable from the larger
perspective of being a person in a world; having a
certain history of reading and thinking about
philosophy and psychiatry, and reasons to care about
these matters. The amygdala activity is part of my
being annoyed: it is what you get when you zoom in
on what is happening in my brain while I (a person in
her world) am in a state of annoyance.”
(De Haan 2020)
45
• “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.”
(De Haan 2020)
• “Physiological causes (e.g., anxiety as a side effect of
medication) are local to global causes, like the amount of
sugar changing the taste of the cake. Life-world causes
(e.g., anxiety as a result of fear of rejection) on the other
hand, are global to local causes, like the effect of the
temperature of the oven on the overall state of the cake,
including its ingredients.”
(De Haan 2020)
• “The difference between neurological and psychiatric
disorders is that in psychiatric disorders the brain is indeed
implicated, but in a mereological way; as part of the
problems taking place at a more global level of the person-
world system. It is the global problem of sense-making
that affects the more local brain processes in an
organisationally causal, cake-like way. In neurological

32
disorders it is the other way around: a local disturbance at
the level of the brain processes can have global effects on
sense-making amongst other things...”
College 6
The epistemic problem
Kramer: listening to Prozac
I was struck by the sudden change in my experience of his anxiety. One moment, the anxiety
was a collection of meaningless physical symptoms, of interest only because they had to be
suppressed, by other biological means (Prozac for example), in order for the treatment to
continue. At the next, the anxiety was rich in overtones. Hearing that the anxiety was not a
medication side effect, I had an instantaneous sense of how I appeared to the student -
demanding, judgmental, punitive, powerful in the face of his weakness —and how it must
feel for him to go through life surrounded by similar figures. ... The two anxieties were
utterly different: the one a simple outpouring of brain chemicals, calling for a scientific
response, however diplomatically communicated; the other worthy of empathic exploration
of the most delicate sort.” (p. xii) there is 2 ways of looking at the same phenomenon
(anxiety) one through biomedical lens and the other through the lens of (empathic)
understanding: try to find meaning in the students anxiety: what are the reasons, what is the
context of his being anxious. The question is how do these two perspectives relate? Which
perspective should we take when. Should understanding play a role in science?
- How do these various epistemic perspectives relate?
- Ralston (2019): the philosophy of psychiatrists (he interviewed psychiatrists and
found different ways of reasoning)
o Descriptive/actuarial, meaningful (meer understanding), medical (meer
explaining), collaborative modes of reasoning (making inventory of systems
and how they relate through time en which came first and which caused
which, aka its very descriptive. Vs. trying to find the reasons and the motives
(similar to Kramers description in die quote ) and the emotions and beliefs
that ppl have and try to understand it from their point of view.) vs. medical
ish idk(similar to die andere van Kramer in die quote), vs. trying to cocreate a
story abt what happened with the patient, together constructing the story.
Trying to make sense of it, find out how it came to be that patient has these
experiences). Psychiaters switchten voortduren van ways of reasoning
o Biological (severe depressions with psychotic symptoms) versus neurotic
(more mild depression, psychological problems that were clarifiekd by
psychoanalysis) depression
Biological forms of depression ask for more explanatory and medical
approach, neurotic for meaningful/collaborative approach.
Interviewed psychiatrist: “It’s the feeling that it elicits in me. A depression that prompts me
to feel ’I don’t understand this,’ almost analogous to the precox feeling, there is a lowering
of mood but I have no foothold at all to understand where it has originated, from a

33
psychological or social perspective. If I can walk along a little and it resonates, so to speak,
with my emotional life, then I think it is more neurotic.”  precox feeling ofzo??? If there is
no way of asking why/how this happened dan is het biological depression, maar als je een
beetje mee kan lopen en it resonates with your own emotional life dan is het meer neurotic.
Interviewer: “Where are the differences [between ‘neurotic’ and ‘biological’ depression]?
Psychiatrist: “Well, in the influence of the environmental context. Like this patient who is
clearly depressed due to contextual factors and not like suddenly–boom! –everything was
fine and suddenly she becomes depressed. So clearly material.” --? When theres an
understandable connection with environmental factors or sth that happened it looks more
like mild psychological depression, if it pops up out of nowhere biological depression
- Ralston (2019): ‘Participating psychiatrists generally held dualist perspectives on
causation: the more a phenomenon is seen as being materially caused, the less it is
seen as being psychosocially caused, and vice versa.’
- Ralston (2019): “If, after careful exploration of the social and psychosocial domains,
the psychiatrist could not develop a to her satisfactory(meaningful) understanding of
the development of the phenomenon in question, then the phenomenon would be
perceived as psychosocially ‘unexplained’. Causal dualism then leads the psychiatrist
to be more inclined to view the phenomenon as biologically caused.”  pragmatisch
gezien it kinda makes sense. Talking therapy voor iemand met severe depression bv.
Isnt really gonna help, medicatie bv. Wel.
- Cf. De Haan(2020) “whereas in somatic disorders patients’ sense-making can be
secondarily affected, psychiatric disorders are primarily problems of sensemaking....
Another way to describe this difference is that in case of Parkinson’s disease or brain
tumors the sense-making problems have a (somatic) cause, whereas psychiatric
disorders have a reason...”
- De Haan: psychiatric disorders are problems of/consist in sense-making, whereas
somatic disorders are problems posed to sense-making
- ???
- Explaining vs. understanding: reasons vs causes
- What Is the extension of (how far can we go in trying to understand/explain things?)
and the relation between the two
- What does this mean for the science and practice of psychiatry (when should we do
what, explain or understand or both at same time?)
- What does this tell us about the nature of mental disorders

Karl Jaspers (1913) on explaining and understanding in psychiatry•(the limits of) empathic
understanding informs us about some essential features of (what) psychopathology (is)
Karl Jaspers
- Methodenstreit:

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 - How should we see the relation between natural sciences and humanities. Psychiatry
requires both. (psychiatrists should be experienced in arts? Life experience improves
empathic skills)
- What is the proper place and role for erklären and verstehen in the clinical encounter
(with the patient)?
- Japsers: focus on the limits of common sense and rationality (a.o.t. ‘interpretivism’)
idk
- Various forms of ‘understanding’ (as opposed to explaining)
Explanation versus understanding: Causal versus meaningful connections
- Natural sciences: finding generalizable, lawful, causal connections(no mothetic
method)
- Psychology: is also about finding meaningful connections(idiographic method) (not
abt trying to understand how one event came from another??)
“1. We sink ourselves into the psychic (ander word voor mental) situation and understand
genetically (Hiermee wordt bedoeld that one thing evolves from another, has nothing to do
with genes) by empathy how one psychic event emerges from another. finding meangful
connections. Example, the psychic event: seeing sth happen to a loved one, the second is
that u are terribly worried. We can understand this by using our empathic skills, then we are
not trying to make generalisations abt how seeing sth happening to a loved one causes
worrying. We do it by using our empathic skills. (these are 2 ways of making sense of reality
that we should extinguish)
2. We find by repeated experience that a number of phenomena are regularly linked
together, and on this basis we explain causally.” (GP, p. 301)
“In the natural sciences we find causal connections only but in psychology our bent for
knowledge is satisfied with the comprehension of quite a different sort of connection.” (GP,
p. 302)
- The concrete reality and self-evidence of understanding: in zon situatie als net
beschreven is waarbij er iets gebeurt we are trying to make a meaningful connection
between seeing the event: sth bad happening and the expression of worry via
empathy. Het is niet dat we het begrijpen omdat we het al velen malen eerder
hebben zien gebeuren, zelfs als je het nog nooit hebt zien gebeuren begrijp je ow the
one event emerges from the other, maar dus niet via inductie (zoals by natural
sciences) maar empathy.
The evidence for genetic understanding is something ultimate.[...]It strikes us as something
self-evident which cannot be broken down any further. The psychology of meaningful
phenomena is built up entirely on this sort of convincing experience [...] it is not acquired
inductively through repetition of experience. It carries its own power of conviction and it is a
precondition of the psychology of meaningful phenomena that we accept this kind of
evidence just as acceptance of the reality of perception and of causality is the precondition
of the natural sciences”. (GP, p. 303)  the way we understand and find the evidence for

35
our empathic understanding is completely different from the way we understand/find
evidence for in terms of using scientific methods??? Idk but both are equally valid??? Idk
“Because we note the frequency of a meaningful connection this does not mean that the
meaningful connection becomes a rule. This would be a real mistake. Frequency in no way
enlarges the evidence for the connection. Induction only establishes the frequency, not
thereality of the connection itself.” (304)  zelfs in situaties waar je nog nooit in bent
geweest, the reality of the connection then that you see in trying to understand how a
patient for example certain worries have led to depressed mood, this might not be based on
induction itself. Even if it’s the case that when the days are shortening its often the case ppl
get depressed, this does not mean that in a individual case that the shortening days have
evolved in depressed mood?????????????? Oke wdkk
difference between genuine
understanding (finding the real
reason that motivated the person
in this concrete situation) and
interpretation (giving á possible
reason for why someone does sth)
Understanding and interpretation
The self-evidence of a meaningful connection does not prove that in a particular case that
connection is really there nor even that it occurs in reality at all. (there are all kinsd of
possible ways in which ppl can b motivated amaar als we genuine understanding willen van
why someone did sth you try to find all kinds of collateral? Evidence ???? idk) [...] We
understand only so far as such understanding is suggested to us by the objective data of the
individual case, that is, by the patients' expressive movements, acts, speech and self-
description, etc. It is true that we can find immediate meaning in a psychic connection quite
detached from concrete reality, but we can only assume the reality of such a connection to
the extent that the objective data will allow. The fewer these are, the less forcefully do they
compel our understanding; we interpret more and understand less. (GP, p. 303) 
somebody who has a real high developed skill of empathy wil probably be more
intentive/sensitive to all kinds of cues, they will listen and ask questions in order to
understand whats going on from the perspective of the other. Someone who is less
empathically skolled will based on fewer data have his own interpretation of why something
happened. Dit is t vreschil in interpretation and understanding
“...a crucial aspect of Jaspers’ construal of understanding is that understanding, when it is
achieved, is factive: it does not just amount to a useful tool; it captures an objective fact of
the matter about the patient’s mental life. [...] it deals specifically with connections between
elements of a person’s conscious life.” (Hoerl2013)
Empathic/subjective understanding vs. rational/objective understanding
“Genetic understanding has many modes and certain essential distinctions need to be
preserved. For instance, thoughts may be understandable because they emerge from each

36
other according to the rules of logic and here the connections are understood rationally
(that is, we understand what is said).”
“But where we understand how certain thoughts rise from moods, wishes or fears, we are
understanding the connections in the true psychological sense, that is by empathy (we
understand the speaker). Rational understanding always leads to a statement that the
psychic content was simply a rational connection, understandable without the help of any
psychology. Empathic understanding, on the other hand, always leads directly into the
psychic connection itself. Rational understanding is merely an aid to psychology, empathic
understanding brings us to psychology itself.”(GP, p. 301)  not only understanding what is
said but understanding the speaker, leads to psychic (mental) connection
Objective and subjective symptoms
Objective symptoms can all be directly and convincingly demonstrated to anyone capable of
sense-perception and logical thought (for example reading a text); but subjective symptoms,
if they are to be understood, must be referred to some process which, in contrast to sense
perception and logical thought, is usually described by the same term `subjective: Subjective
symptoms cannot be perceived by the sense-organs, but have to be grasped by transferring
oneself, so to say, into the other individual's psyche; that is, by empathy. They can only
become an inner reality for the observer by his participating in the other person's
experiences, not by any intellectual effort. (Jaspers (1912) 1968: 1313)...a purely objective
psychology leads `quite systematically to the elimination of everything that can be called
mental or psychic’ (Jaspers (1912) 1968: 1313
Static (phenomenological) vs genetic understanding
“The former (genetic) grasps particular psychic qualities and states as individually
experienced (phenomenology); the latter grasps the emergence of one psychic event from
another, the whole moving psychic context of motive, contrasting effect and dialectical
opposite (the psychology of meaningful phenomena).” (GP, p. 307)  Static is a snapchot
view: at particular moment how a person felt vs. genetic: trying tu understand how certain
mental events follow eachother
“Thus, the relationship between static and genetic understanding is like this. The former
articulates and vividly presents what it is like, for example, to have a sudden realization or
what it is like to be in a state of happiness. [...] Genetic understanding adds to this the
connection of how one state arises—ideally and typically—from the other. Such connections
are shared empathically by psychological subjects including psychiatrists and their
patients.”(Thornton 2007)
By trying to understand in a genetic way you empathize with someone, try to undrstadn
what it feels like to live life as that person, and to understand how one mental event is
followed by another and how that leads to ?behaviour?  highest standard of
understanding in clinical setting? Als je het op deze manier doet beginnen dingen ineens
understandable te worden

37
De vraag is dan how does that relate to explanation, because explanation is also interested
in trying to understand how one thing causes another thing, maar bij understanding praten
we niet over causes maar we zijn wel geinteresseerd in how one mental phenomenon is
followed understandably, meaningfully by another.
Hoerls paper is trying to make sense of these questions
1. Empathic understanding as a form of causal inquiry?
“In the natural sciences we find causal connections only but in psychology our bent for
knowledge is satisfied with the comprehension of quite a different sort of connection.
Psychic events ‘emerge’ out of each other in a way which we understand.” (GP, p. 302)
- Genetic understanding not concerned with causal connections? But what does
‘emerge out of’ mean? Doesn’t this imply causality?
- Doesn’t this entail causality? How could understanding otherwise be concerned with
real psychic connections? (a.o.t. ‘mere interpretation’).
- Cf. Reasons as causes? àDavidson (1963) “If [...] causal explanations are ‘wholly
irrelevant to the understanding we seek’ of human action then we are without an
analysis of the ‘because’ in ‘He did it because...’, where we go on to name a reason.”
- Distinction between singular and general causal claims
o David’sdrinking10 g&t’slast nightcausedhimtohave a headache
o Drinking10 g&t’scauseheadaches

Singular causation?
"[C]ausality consists in the derivativeness of an effect from its causes. This is the core, the
common feature, of causality in its various kinds. Effects derive from, arise out of, come of,
their causes... [A]nalysis in terms of necessity or universality does not tell us of this
derivednessof the effect; rather, it forgets about that.”(Anscombe, 1981, p. 136
- Hoerl(2013, 2019) on Jaspers: understanding furnishes us with knowledge of
instances of singular causation in the psychological domain.
“It is this kind of causal knowledge that we gain when we are able to “sink ourselves into the
psychic situation” of the other. Explaining, by contrast, as Jaspers thinks of it,
seemstobeconcernedwithestablishinggeneralcausallaws–itmaybesuccesfulin identifying
repeated patterns, but, in doing so, it deals with causal connections only “from without”
insofar as it delivers no insight into what the relevant causal connection actually consists in.”
(Hoerl2019)
Empathic understanding as a form of causal inquiry?
- Empathic understanding uncovers singular causes of mental and behavioral events.
- Psychological explanation reveals patterns of/in these singular causes?
- But empathic understanding has limits...

2. The limits of understanding

38
 - Jaspers’ distinction between primary and secondary delusions
- Jaspers thought that primary delusions are (genetically) un-understandable (bv.
Ineens denken dat je een alien puppet bent). To far removed from our own way of
experiencing the world, that we cant find a way how these delusions are
meaningfully connected with something that preceded. (vb. Auditory hallucionations
make you believe that someone planted a chip in your brain  dit valt nog te
begrijpen, dus is secondary, heft nog meaning?)
“We can distinguish two large groups of delusion according to their origin: one group
emerges understandably from preceding affects, from shattering, mortifying, guilt-provoking
or other such experiences, from false perception or from the experience of derealization in
states of altered consciousness etc. The other group is for us psychologically irreducible;
phenomenologically it is something final. We give the term ‘delusion-like ideas' to the first
group; the latter we term `delusions proper’.” (Jaspers1997: 96)
“The experiences of primary delusion are analogous to ... seeing of meaning.... There is an
immediate, intrusive knowledge of the meaning and it is this which is itself the delusional
experience. ...Significance appears unaccountably, suddenly intruding into the psychic life.”
(Jaspers, 1963, pp. 99, 103)
“[W]hen we consider the middleaged schizophrenic spinster who believes that men unlock
the door of her flat, anaesthetize her and interfere with her sexually, we find an experience
that is ultimately not understandable. We can understand, on obtaining more details of the
history, how her disturbance centres on sexual experience; why she should be distrustful of
men; her doubts about her femininity; and her feelings of social isolation. However, the
delusion, her absolute conviction that these things are happening to her, that they are true,
is not understandable. The best we can do is to try and understand externally, without really
being able to feel ourselves into her position(genetic empathy), what she is thinking and how
she experiences it.” (Sims1988: 85)  limits of ability to empathize and understand from
within
Bij primary delusions there is no room for doubt, you don’t believe that there is a possibility
you could be wrong
- Thornton 2007: onderscheid in un-understandable delusions
o Breakdowns of connections between contingent beliefs(e.g., ‘I have a nuclear
power station in me.’  its physically impossible, these kinds of beliefs can
not hold together, they start to contradict eachother)
o Breakdowns exemplified in impossible beliefs(e.g., ‘I am dead’)
o Breakdowns between beliefs and the actions they normally rationalize (e.g.,
double bookkeeping, someone who is convinced the food is poisoned while
eating it)
So empathic understanding has limits (cf. ‘primary delusions’)
What about explanation beyond the limits of explanation, e.g. neurobiology? (sommige
dingen is men niet bewust van, die zijn dan ook niet echt te begrijpen, doesnt really make

39
sense to empathize with them ??). miss moeten we bij primary delusions dus try to figure
out whats going on by means of explanation en niet understanding
Kendler en campbell: is there a possibility of extending our limits of understanding through
explanation?
Expanding the domain of the understandable
- Explanation-aided understanding (KendlerandCampbell 2013): “Neuroscience, in
general, and the functional analysis of the brain through neuropsychology, in
particular, can allow us to understand empathically aspectsof human experience
previously beyond our grasp.”  sciences expand our empathic abilities?
- KendlerandCampbell (2013): “What Jaspers called the ‘immediacy’ of understanding
should not be interpreted as to exclude the relevance of empirical research to
understanding. Empathic understanding of another may require insight into a whole
host of factors, including, for example, historical processes, economic context, social
hierarchies, and so on. The present point is that neuropsychology provides another
such dimension for the grounding of understanding.”

- Dopamine hypothesis of schizophrenia

- Cf. Kapur(2003): ‘the mesolimbic dopamine system is seen as a critical component in
the ‘attribution of salience, ’ a process whereby events and thoughts come to grab
attention, drive action, and influence goal-directed behavior because of their
association with reward or punishment.  things get an immediate relevance in your
environment, dus when there’s a boost of dopamine things suddenly seem relevant
for you right now right here. Het idee is dat anti-psychotic drugs reduce the over
attribution of salience ofzo. Bij psychosis zijn dingen die normaal niet relevant voor je
zijn zijn nu ineens wel, iemand die random langs loopt is bv. Een conspiracy-theorist
trying to kill you, maar ook dingen die op tv of de radio hoort. Als deze theorie klopt
is de vraag can this aid our empathic abilities?
- KendlerandCampbell (2013): What would it be like if your DA salience system was
chronically in overdrive? Everything around you, even the most mundane, would be
drenched in new meaning.
“ ...patient X is watching the nightly news. His DA salience neurons misfire. He has
the sense of some immediate meaning and importance in the commentator’s
comments. He seeks to ‘discover the meaning’ of the event and realizes that the
commentator really is looking at him, and notices that his newscast may contain
hidden messages to him. It takes little imagination to realize how easily a delusion of
reference (alsin je denkt dat de nieuws/tv is directed at you specifically) might
emerge from this primary experience.”
Does this theory help us understand the delusion of reference?
- KendlerandCampbell (2013): Assume we were at some time in the future when it has
been well established that the DA salience system is dysfunctional in
schizophrenia. ... Given our expanded knowledge of neuroscience, we can convert

40
 these experiences of the intrusion of meaning into consciousness from the un-
understandable to the understandable. ??? idk
KendlerandCampbell (2013): The boundaries of explanation-enhanced understanding.
1.itwillnotworkwhenthereis no underlying mental state with which to identify.  idk
luister terug
2.Second, the experience has to be within our intuitive grasp. It relies on the fact that
neuropsychology provides hypotheses about the functional and physiological correlates
of familiar subjective experiences, and thus puts us in a position to understand the
significance of disturbances in those underlying structures.  in order to help us with
empathic skills it should be close enough to experiences that we cán empathize with
This does not require solving the mind-body problem
- A role for neurophenomenology? (Contra Jaspers...), we can use it to enhance
neuroscience and vice verca?
- How far can we go
College 7
The limits of understanding: introduction
• Central question: How to understand, truly make sense, of ‘bizarre’ delusions?
(cf. Thornton)
• Berrios 1991: delusions as empty speech acts, strictly speaking empty of
content?
• ‘Bottom-up’ (cognitivist) approaches: dysfunction of information processing
systems at subpersonal level
ØBut to what extent is this an instance of empathic understanding??
• ’Top-down’ approaches
ØInterpretivism? Premised on assumption of rationality...
ØPhenomenology?

Explaining delusions?
• Attempts to explain ‘monothematic’ delusions (e.g., Cotard, Capgras)
1. Delusion as rational response to abnormal experience (e.g., Maher 1999)
• Delusional beliefs, like normal beliefs, are attempts to explain experience.
• Defective reasoning is not the primary contributor to the formation of delusional
beliefs.
2. Two-factor account (e.g., Davies et al. 2002)
• a neuropsychological anomaly with some manifestation in the experience of the
subject
• Additional factor(s) concerning subject’s failure to reject the bizarre nature of the
delusional content.

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  thornton (2007): but does this yield delusions understandable? Dilemma:
a. Either the experience is bizarre and the response is understandable. But
then we
still cannot grasp the experience (problem of static understanding)
b. Or the experience is continuous with normal experience but the
transition to the
belief is not. But then we still do not understand (problem of genetic
understanding)
Phenomenological critique

•But should delusions be understood as ‘beliefs’ in the first place?

However, what is presupposed in the “poor reality-testing” criterion is that, while the
content of the delusional beliefs is false or erroneous, the overall form of the patient’s world
and the way he experiences it are essentially unchanged and normal (Henriksen 2013)
...the experience of belonging to the world is not a matter of having a belief-like intentional
state with the content “the world exists”. Rather, it involves—amongst other things—having
a sense of reality, by which I mean a grasp of the distinction between “real”, “present” and
other possibilities, without which one could not encounter anything as “there” or, more
generally, as “real”. We generally take for granted that others share this same modal space
with us and that they are able to encounter things in the same ways we do. (Ratcliffe 2012)
According to Husserl, the “natural attitude” of believing in the existence of the world is not
simply a deeply engrained belief of the form “I believe that p”, like the belief that the Eiffel
Tower is in Paris. Rather, it is something we presuppose when we adopt such beliefs.
(Ratcliffe 2012)
1. Framework propositions (cf. Wittgenstein 1972):
−“If we want the door to turn, the hinges must stay put”

“...beliefs expressed by a heterogeneous group of propositions such as “there are lot of

objects in the world,” “the world has existed for quite a long time,” and “this is one hand and
this is another.” These latter “beliefs” are not typical beliefs that can be proven right
or wrong. On the contrary, they form the background or framework within which all
testing of hypotheses can take place (Wittgenstein 1972, §105), and they are immune to
doubt (Wittgenstein 1972, §§341, 359, 494). Framework propositions make any kind of
inquiry and justification possible; they are not justified by other beliefs nor do they
require justification. (Henriksen 2013)
•But should delusions be understood as ‘beliefs’ in the first place?
1. Framework propositions (cf. Wittgenstein 1972):
−“If we want the door to turn, the hinges must stay put”
−“Certainties, expressed by our actions” (Thornton 2008)

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“... assumptions or guidelines for acting and interacting that are manifested in our actions
and behavior. In other words, acting reflects an implicit knowing, an assumption or a
guideline for acting which is not propositional in nature.” (Henriksen 2013)
• Delusions as framework propositions
−Might explain incorrigibility
−But: does it truly render them comprehensible?
16
“for the proposal to work—for it to enable us to have some understanding of delusions as a
whole by thinking of them as abnormal framework propositions—we need to be able to
understand the idea of a genuinely different framework proposition. It is not clear that
we can.” (Thornton 2008)
2. Delusions as expressions of Quasi solipsism (Sass 1994)
• Making sense of “double bookkeeping” and incorribibility
“Kings and Emperors, Popes, and Redeemers engage, for the most part, in quite banal work,
provided they still have any energy at all for activity. This is true not only of patients in
institutions, but also of those who are completely free. None of our generals has ever
attempted to act in accordance with his imaginary rank and station.” (Bleuler 1950, 129)
1. Framework propositions (cf. Wittgenstein 1972)
2. Delusions as expressions of Quasi solipsism (Sass 1994)
• Making sense of “double bookkeeping” and incorribibility
• Solipsism: “a vision of reality as a dream, but with awareness of the
fact that one is dreaming” (Sass 1994, 34)
• Wittgenstein diagnoses solipsism as a philosophical disease arising
from abstraction and passivity
Ø‘quasi-solipsism’: an attitude of passivity and hyper-concentration
involving a ‘subjectivization of reality’ (Sass 1994)
Acting in a solipsistic world may, as he puts it, “feel either unnecessary or
impossible” (1994, 42); not only does it not make sense to act in an absolutely
mental world, but real acting might even disrupt this world insofar as it depends on
inactivity (1994, 42). And with regard to the “specific schizophrenic incorrigibility,” it
seems only logical from a quasi-solipsistic perspective that delusional beliefs
formed within a solipsistic world cannot be proven wrong or false in a public
domain (Henriksen 2013)
But again: is this truly understandable? -> Critique Thornton
The novel suggestion [...] a middle ground between construing schizophrenic experience
as genuinely beyond understanding and as embodying a set of merely false beliefs.
Philosophical theory might serve as a compromise, which can be both empathically
grasped, whilst at the same time remaining intellectually alien, but whilst Wittgenstein,
especially in his later work, attempted to understand the source of philosophical
confusions, he did not articulate either his own or opposing philosophical ideas as
coherent theses. Thus, it seems that the model cannot work. (Thornton 2007)

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The limits of understanding and ‘the paradox of madness’
• Paradox: empathic understanding essential for not ‘losing the object of inquiry’, yet
it’s limited success appears equally essential in this respect

[...] psychiatric disorders both seem to call for understanding at the same time as defying
understanding. They call for understanding insofar as they call for treating the patient as one
capable of engaging in understandable practices. However, insofar as it is precisely that
capacity that goes awry in psychic illness, they also, at the same time, defy understanding: to
think that the patient could be understood “without remainder”, as it were, would
constitute a failure to see psychic illness for what it is. (Hoerl 2019)
Consider the difference between psychosis and neurological disorders (e.g., dementia)
ØIn case of severe dementia (or other neurological problems), empathic understanding of
the disorder (not necessarily of the person) seems ill-targeted. To understand an essential
feature of what alzheimers is seems to be off-target. We kunnen miss wel beter de
fears/problems van die persoon ofzo bregrijpen through using our capacity for empathic
understanding
Wat is dan het verschil met psychosis? Youre trying to understand what’s going on:
ØThere seems to be a particular kind of constraint to/failure of empathic
understanding that is essential for grasping psychosis. This is not the case with severe
dementia
Oftewel: It seems that people with psychosis are acting for reasons, but the kind of
reasoning (or the experience its drawing from?) seems to elude our common sense terwijl bij
dementia thre is a general breakdown of mental capacities so the disorder itself does not call
for a form of understanding whereas in a mental illness it calls for explanation and
understanding.
ØJaspers’ ’objective mind’:
“The general or objective mind is currently present in social habits, ideas and communal
norms, in language and in the achievements of science, poetry and art. . . . This objective
mind is substantially valid and cannot fall sick. But the individual can fall sick in the
way in which he partakes in it and reproduces it...” (Jaspers 1997)
“The idea, more specifically, would be that psychic illness can only be recognized
for what it is by recognizing the patient as someone in possession of a capacity to
partake in practices that are understandable, and, in this sense, sharing in the
general mind. For what psychic illness consists in is precisely a situation in which
this capacity malfunctions.” (Hoerl 2019)
“[...] another reason for thinking that understanding has an essential role to play in
psychiatry is that it is essential to a grasp of the very nature of psychic illness – that
is, of the particular way of being unwell that having a psychiatric disorder,
distinctively, consists in.” (Hoerl 2019) there seems to be a particular way of being unwell
that psychiatric disorder distinctively consists i; that which constitutes our objective mind
aka common sense ways of doing/reasoning. psychiatric problems seems to be derivatives of

44
this common practice but not fall totally outside of that scope whereas someone with
epileptic seizure that phenomenon does not take place within the realm of reasons or
agency. Zegmaar dat gebeurt gewoon automatisch, ze doen dat niet met een bepaalde
reden ofzo terwijl mensen met psychosis wel maar toch hebben we moeite met die te
begrijpen
It seems to be derived or evolved from our common practice but then in a private way we no
longer follow or think through. (idk who said this tho, maar vgm hoerl)
Empathic understanding is essential to the behaviour/the phenomenon in question seems to
invite empathic understanding as opposed to epileptic seizure, at the same time its limited in
its success because we seem to reach certain limits where we simple cannot follow what
another person is trying to say, think or do
This is where jaspers objective mind comes in again, the objective mind is our common
sense, our shared world which we take for granted and in virtue of which we are able to talk
to eachother abt all sorts or things etc.
Nu gaan we kijken naar de phenomenological approaches ofzo. Zij zouden antwoorden op
deze paradox: Empathic understanding is essential but its also defied by psychopathology
because understanding and its shortcomings that we encounter in (making sense of)
psychopatholy. It informs us about certain pre-conditions, certain common ground we take
for granted and how these preconditions/common ground (structure of ordinary experience)
is radically altered in cases of psychopathology due to certain changes in structure of
experiences of self and others and the world? (this is the claim by Ratcliffe) that are at least
partly accessible and understandable by using phenomenological methods.
So here the idea is we should not merely start from the public domain and then see that we
cannot get further in our ordinary way of understanding/empathy/making sense of people
but we should use insights from phenomenology to study the basic structures or
preconditions of ordinary experiences, if we then understand psychopathology as radical
alterations in life worlds, in the structure of how u experience time, space, relations to
others then it might become more accessible to our understanding.
Understanding and its specific shortcomings in psychopathology informs us about:
• certain preconditions of engaging in common (understandable) practices
• how these preconditions are altered in cases of mental illness
ØDue to changes in experiences of self, others and the world
ØThat are at least partly accessible through phenomenology??
What notion of understanding?
•But should delusions be understood as ‘beliefs’ in the first place?
1. Framework propositions (cf. Wittgenstein 1972)
2. Delusions as expressions of Quasi solipsism (Sass 1994)
−Making sense of “double bookkeeping” and incorribibility
• But is this truly understandable? -> Critique Thornton
27

45
•Henriksen:
• Thornton uses a notion of (empathic) understanding (making sense) that is too
narrow, against the background of the Davidsonian project of rational interpretation 
thornton uses a notion of making sense by which alternative frameworks (such as quasi
solipsism) are not really things we can make sense of
• Jaspers uses a rather commonsensical notion of empathy (to sink or transfer oneself “into
the other’s psyche”)
Hendriksen: psychological vs. philosophical understanding:
This form of understanding, which I here term philosophical understanding, seeks to
grasp and conceptualize the schizophrenic world in which patients experience
themselves as ontologically displaced, i.e., they are deprived the ontological security
that grounds our normal existence and thus bereft of what Blankenburg called
“common sense.” (Henriksen 2013)  hendriksen gives an understanding of understanding
where you do not take for granted our shared world like psychological understanding does.
 Lijkt een beetje op Ratcliffe men mundane and radical empathy?
The phenomenological method: a very brief introduction (studying the way the world
appears to us)
• Introspection vs phenomenological reduction
• Husserl’s epoche: ‘bracketing’ the natural attitude, in order to investigate the world in its
significance and manifestation for consciousness.
• Merleau-Ponty (1962): “the difference between phenomenology and
introspective psychology is a difference in principle: whereas the
introspective psychologist considers consciousness as a mere sector of
being, and tries to investigate this sector as the phycisist tries to
investigate the physical world, the phenomenologist realizes that
consciousness ultimately calls for a transcendental clarification of how
the (life-)world is constituted.”
ØWhat are the conditions of possibility for reality-as-experienced? Inquiry
into the a-priori conditions of experience
ØConsciousness not conceived as an object in reality, but as subjectivity,
‘being-in-the-world’, the world-as-experienced
What is empathy?
• Emotional contagion, ‘implicit’ empathy, explicit/reconstructive empathy, ...  emotional
contagian: catching on to the same experience, terwijk empathy youre not concerned with
your own experience but the other persones experience????
Implicit: hoef je niet over na te denken, is meteen duidelijk bv als iemand zn hoofd stoot
Explicit: als iemand naar je verhaal luistert ofzo
• Simulation theory and its critics (e.g., Zahavi and Stein): basically what jaspers was talking
abt. In de ander verplaatsen I guess, what would i do if i was in situation that the other
person is in: try to simulate the other person. Op die manier voorspellen wat de ander zal

46
doen. Hierop veel kritiek van fenomenologen: thats wrong description of phenomonology of
empathy: you are now projecting your own experience on the other. Projecting what you
simulate on the other is wrong desciription of what empathty is. Empathy has to do with the
otherness of the experience (ofzo? Dit is van Stein) of the other not making sense of the
other in terms of yourself
The phenomenological stance (Ratcliffe 2012)
• Emotional contagion, ‘implicit’ empathy, explicit/reconstructive empathy, ...
• Characterizing the sense of ‘belonging to the world”

...the experience of belonging to the world is not a matter of having a

belief-like intentional state with the content “the world exists”.
Rather, it involves—amongst other things—having a sense of reality,
by which I mean a grasp of the distinction between “real”, “present”
and other possibilities, without which one could not encounter
anything as “there” or, more generally, as “real”. We generally take
for granted that others share this same modal space with us and
that they are able to encounter things in the same ways we do.
(Ratcliffe 2012)
The phenomenological stance (Ratcliffe 2012)
• Characterizing the sense of ‘belonging to the world”
• The horizonal structure of perception (cf. Husserl) - incorporating a range of (practical)
possibilities: we can pick it up, sit on it, walk around it. An object is never just an object.
• The ‘universal horizon’: the world. All kinds of possibilities for action, thinking,
experiencing. Sense of reality and Our sense of belong to the world We take for granted in
the natural attitude. fenomenologische methode is take into account the structures we
take for granted normally
Our sense of reality and belonging is the “world” that we take for granted
in the natural attitude. Hence the world operates as a “universal horizon”
or “world horizon”, a space of possibilities that determines what kinds of
experience are intelligible to us [...] the universal horizon is what
determines the kinds of possibility we are receptive to, and thus whether
we are able to experience anything as possessing or lacking that type of
possibility. (Ratcliffe 2012)
Ratcliffes claim: Psychopathology (leer van psychische ziekte) as radical shits in this space of
possibilities. Groundstructure of experience is altering so we cannot communicate about this
in our ordinary beliefline??? (Idk kan niet verstaan) language, because this already
presupposes this. We should try to understand psychopathology by looking at those type of
experiences that we normally take for granted.
‘Radical’ empathy and mental illness
1. “All instances of radical empathy are united by a qualitative difference from mundane
empathy—their recognition of a variable sense of belonging to a shared world, something

47
that is more usually overlooked.” (Ratcliffe 2012)
2. “Radical empathy, I propose, is a way of engaging with others’ experiences that involves
suspending the usual assumption that both parties share the same modal space
(lifeworld/space of possibilities). It is
comprised of something akin to the attitude described by Stein, along with openness to
kinds of phenomenological difference between people that are not usually
acknowledged.” (Ratcliffe 2012)  when ppl act out of the ordinary we often ask questions
enzo to pull them back into our shared world. But empathy is not about trying to understand
ppl within the public space of reasons and our normale taken for granted shared world, its
making explicit that ppl have different ways of experiencing and perceiving the world.
3. “[P]sychiatric illness can involve changes in the form of experience, rather than just
content (so basic structure of experiences might alter), and that this implicates a habitual,
background sense of being immersed in a
shared world.” (Ratcliffe 2012)  so it is basic structures of experiences that might alter, dit
is wrm het inadequate is to talk about delusions as beliefs. Because when were taling abt
beliefs were talking about the contents of beliefs. The contents are bizarre. Bv. You cannot
believe youre dead (the content) and say it at the same time. But if we see it as an
expression of a radically altered form of experience then perhaps we have some entry into
understanding it. Not looking at it from our mundain natural attitidue view, listening to what
ppl say as expressing believes that ‘p’, given a shared world, no were seeing it as expression
of radically different forms of experience.
• Patient quoted by Horne and Csipke, 2009, p. 663
It’s almost like I am there but I can’t touch anything or I can’t connect. Everything
requires massive effort and I’m not really able to do anything. Like if I notice something
needs cleaning or moving, it’s like it’s out of reach, or the act of doing that thing isn’t in
my world at that time (so they don’t have the possibility of cleaning). . . like I can see so
much detail but I cannot be a part of it.  groundstructure of agency isn’t there?? Practical
significance of things isn’t there. Its not a belief abt sth in the world but an alteration in the
way the world appears to you: then there might be an opening to understanding.
suppose feeling disconnected is the best way to describe it.
• Patient quoted by Horstein (2009 pp. 212-213)
It became impossible to reach anything. Like, how do I get up and walk to that chair if
the essential thing that we mean by chair, something that lets us sit down and rest or
upholds us as we read a book, something that shares our life in that way, has lost the
quality of being able to do that?
36
“What this person describes seems to involve a loss of tangible possibilities from experience
and, with it, an alteration of perceived space. Things no longer have their usual practical
significance and therefore seem distant, detached. Without such possibilities, a sense of
being part of the world is eroded; one becomes disconnected.” (Ratcliffe 2012)
• Autobiography of a Schizophrenic Girl (Sechehaye 1970): “Renee”
“[I]t was as though reality, attenuated, had slipped away from all these
things and these people”. Renee describes how, initially, she was drawn

48
back into the world through practical activities and routines, which partially
restored a sense of reality. But then she “lost the feeling of practical things”
and “sensed again the atmosphere of unreality”. She later describes herself
as “rejected by the world, on the outside of life, a spectator of a chaotic
film unrolling ceaselessly before my eyes, in which I would never have a
part”
Example: ‘radically’ empathizing with schizophrenia
• Autobiography of a Schizophrenic Girl (Sechehaye 1970): “Renee”
• Lack of a background sense of belonging: “sense of unreality”
“When . . . I looked at a chair or a jug, I thought not of their use or
function—a jug not as something to hold water and milk, a chair not as
something to sit in—but as having lost their names, their functions and
meanings; they became ‘things’ and began to take on life, to exist.”
• A brief return to reality
... useful things, having sense, capable of giving me pleasure. Here was the
automobile to take me to the hospital, cushions I could rest on. With the
astonishment that one views a miracle, I devoured with my eyes everything
that happened. “This is it, this is it,” I kept repeating, and I was actually
saying, “This is it—Reality”.
 Does this type of analysis make it more accessible to for example
understand ppl who say I feel like im dead
Intermezzo: cf. Phenomenological psychopathology
• E.g., Messas et al. (2018):
• phenomenological psychopathology not just as a description of the subjective
experiences of patients suffering mental disorders, but as a search for their
conditions of possibilities —the structures of subjectivity that underpin the
experience of reality, which, when modified, determine psychopathological life-worlds
• Phenomenological psychopathology assesses the life-worlds of mental disorders
• In each symptom the change in the framework of experience becomes manifested.
The experience of time, space, body, self, and others are the basic dimensions of
the life-world within which each single symptom is situated:
 Idk luister terug. Iets van, there are dimension of experiences we can
study phenomenologically and we can see how different mental illnesses
score on these dimension; experience of time, yourself etc. Dan krijg je
miss andere categories of mental health problems ipv based on
symptoms that are observable from within the natural habitat.
‘Radical empathy’ and the limits of understanding

49
• But is is possible to engage empathetically with ways of belonging to the
world that fall outside of one’s own modal space?
• “I would not want to maintain that radical empathy is without limits; even with its aid,
most or all of us might be constitutionally incapable of empathising with certain forms of
experience.” (Ratcliffe 2012)
ØHowever, understanding that the other lives in a qualitatively different ‘possibility space’ is
an empathic achievement  it has practical significance in interacting with mentally ill
people (als ze zegmaar het gevoel hebben dat mensen hen proberen te begrijpen helpt dat
de recovery, empathic listening. Heft te maken met die openness van stein vgm ook)
• Cf. Rümkes ‘praecox feeling”: interaction met iemand met schizo was of a whole different
qualitative nature. Its making explicit dat je met iemand te maken heeft met een whole
different life world i guess? Idk man
• “Feelings like this incorporate, I suggest, some appreciation of the other person as not
open to interpersonal possibilities in the usual way, of her inhabiting a modal space that
differs from one’s own.” (Ratcliffe 2012)
radical empathy’, openness, engagement and acceptance?
• Radical empathy, like empathy more generally, incorporates a stance of
openness to others, a willingness to be affected by them, to have one’s own
experience shaped by them.
• It involves appreciation of the other person as not open to interpersonal
possibilities in the usual way, of her inhabiting a modal space that differs
from one’s own.
• “Empathy need not amount to fellow feeling.”
• “Empathy need not amount to fellow feeling.”
ØSocial, ethical, and political dimensions of empathic understanding?
ØAcceptance? Inclusion? Diversity?
ØNext class...

College 8
•Slade (e.g., 2009, 2010, 2014):
•Clinical recovery: focus on symptomatology, social functioning, prevention,
risk management
•Personal recovery: cf. Anthony (1993):
'a deeply personal, unique process of changing one’s attitudes, values, feelings, goals,
skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even
with limitations caused by the illness. Recovery involves the development of new
meaning and purpose in one’s life as one grows beyond the catastrophic effects of
mental illness. Recovery from mental illness involves much more than recovery from the
illness itself.’  Dus recovery mentall illness involves more than clinicial recovery (recovery
from the illness itself?)
•The clinician’s illusion (Cohen and Cohen 1984: sample bias (long term
prognosis).

50
Ø‘consulting room bias’: professionals don't see people as often when they are coping , so
they gain the false impression they cannot cope or self-manage.
When were looking at recovery we should look also at recovering personal identity and
restoring relationships etc.
CHIME 5 factors he (slade) found through research (interviews met mensen who have been
in mental health care ofzo) wat belangrijk is voor recovery.

Zie hier wat die CHIME inhoudt

Clinical
recovery (reducing symptoms)
Functional recovery (being able to
function in your day to day life;
eat, clean etc.)
Societal/social recovery (regaining
social roles)
Personal recovery (building new identity that goes beyond your mental illness, which is
dependent on all these kinds of recovery.)
Recovery process
a deeply personal, unique process of
changing one’s attitudes, values, feelings,
goals, skills and/or roles. It is a way of
living a satisfying, hopeful, and
contributing life even with limitations
caused by the illness. Recovery involves
the development of new meaning and
purpose in one’s life as one grows beyond
the catastrophic events of mental illness.
Recovery from mental illness involves
much more than recovery from the illness
itself

51
al deze plaatjes zijn verschillende visies op
aspects van recovery vgm
recovery movement started as a civil rights
(social-political) movement
The recovery movement
•Started as civil rights movement
•Influencing political agenda’s
•Slowly gaining priority on research
agenda’s  ppl with mental health issues
felt like they didn’t have a voice ofzo ook
regarding research questions ofzo. Its about
us so we should have a say in it.
•Some empirical findings:
•Qualitative: the CHIME model.
•Quantitative: mental illness and well-being dissociate (minder correlatie tussen de twee
dan verwacht), variance in measures
of mental illness and mental health only partly shared
Positive psychology (study of well-being)
•Started as an alternative paradigm in academic psychology: the move away from
‘negative’ (clinical) psychology (focusing on pathology rather than well-being).
•Seligman (2002):
“Psychology is not just the study of disease, weakness, and damage; it also is the study of
strength and virtue. Treatment is not just fixing what is wrong; it also is building what is
right.”
•Seligman (2000):
The field of positive psychology at the subjective level is about valued subjective
experiences:
well-being, contentment, and satisfaction (in the past); hope and optimism (for the future);
and flow and happiness (in the present). At the individual level, it is about positive individual
traits: the capacity for love and vocation, courage, interpersonal skill, aesthetic sensibility,
perseverance, forgiveness, originality, future mindedness, spirituality, high talent, and
wisdom. At the group level, it is about the civic virtues and the institutions that move
individuals toward better citizenship: responsibility, nurturance, altruism, civility,
moderation, tolerance, and work ethic.
 If you look at positive psychology in this way its not only about mental
healthcare but about society at large. Healthcare domain and social
domain are intertwined; its hard making change in one of the domains
without making change in the other; so if you want to study well-being its
also relevant to study this at a societal level.
•Started as an alternative paradigm in academic psychology: the move away from
‘negative’ (clinical) psychology (focussing on pathology rather than well-being).
•Seligman (e.g. 2011)
PERMA: Positive emotions, engagement, positive relationships, meaning, accomplishment.

52
Positive psychology are not only for ppl involved with mental healthcare, its for everyone.
Most studies also include normal ppl and what helps them to maintain or increase level of
well-being
Positive health
• WHO (1948) definition of health: “A state of complete
physical, mental and social well-being and not merely the
absence of disease or infirmity.”  maar op basis van deze definitie is niemand healthy lol.
Deze definitie was political statement; aganda had to do with making life better for ppl
around the world, ethical statement. Nogsteeds vinden ze dat maar wel beetje veranderd
ofzo
• WHO (1986): “Health is, therefore, seen as a resource for
everyday life, not the objective of living. Health is a positive
concept emphasizing social and personal resources, as well
as physical capacities. Therefore, health promotion is not
just the responsibility of the health sector, but goes beyond
healthy lifestyles to well-being.”
• WHO (2004) definition of mental health: “a state of well-
being in which the individual realizes his or her own
abilities, can cope with the normal stresses of life, can work
productively and fruitfully, and is able to make a contribution
to his or her community“ aka healthy=being resilient
• Huber et al. (2011): the ability to adapt and self-manage, in
the face of social, physical and emotional challenges
map developed by huber. Health being
determined by multiple factors. We
moeten naar alle aspecten kijken en niet
wat we traditioneel doen (alleen concerned
with bodily functioning i guess)

term patient problematic for recovery

movement; term patient fits the traditional
medical model: youre ill and receive treatment.
Here you are an agent struggling w/mental
health you don’t need someone tot take over
but someone to give you advice and facilitate your own abilities to improve your own life.
Also the success can only be judged by individual

53
 normative theories: what is a
life that’s worth living like.
Normative theory on what the
good life is.
Descriptive theories (empirical
data from qualitative research):
tell us sth about what ppl say
when trying tot express their
own subjective experience on
wellbeing
empirical study of well-being rechterplaatje: scheiding eudaimonic wellbeing (flourishing:
aristotelian notion) en hedonic wellbeing (pleasure)
Feeling good vs living good life (slade) has to do with what notion of well being you have????
58:00 ish
evaluative concepts that are
deemed important for the
good life vs. descriptive
concepts that are implied by
your theory of well-being.
Dus when we start to think
about wellbeing en health we
cannot …..? things like that

Recovery and positive

psychology
•However: a lot of conceptual
issues:
•The good life, well-being, happiness, health...
•Normative versus descriptive...
ØRecovery and positive health framework: what are the implications for (mental)
health care? 1;00 ish
ØIs increasing happiness a proper goal for mental health care? Why (not)?  would be
problematic form of medicalization of happiness; if youre unhappy you have a medical
problem and should be treated
mental health and mental
illness do dissociate: some
ppl have high rates of
mental illness and report
having high rates of mental
health: conceptially
incoherent want health
means absence van illness
but no! niet met notion van
positive notion of health

54
model of keyes: 2 axis; mental health en mental illness. Hight mental illness leidt niet
meteen tot low mental health or vice versa. Four quadrants: these are the ones that we are
familiarwith in olur classical way of thinking….. idk luister gwn terug ofzo 1;13 ish  anw dit
allemaal zou laten zien dat health en illness niet op 1 spectrum horen maar 2

Recovery & Positive psychology: implications?

•E.g., Keyes (2002, 2007): the complete state model of mental health
•Slade (2010) Such empirical results have two profound implications:
1. “Is languishing a diathesis (precurser to mental illness?) for, and is flourishing a protective
factor against, (the
onset and recurrence of) mental illness?” so increasing flourishing would then be the way to
protect from mental illness ofzo. Miss is het in society dus beter to increase wellbeing than
prevent all kinds of danger.
2. ”it is possible to be moderately mentally healthy, or even flourishing, despite the
presence of ongoing mental illness.” (zou opzich kunnen bij positive psychology view)
−“Feeling good is not always necessary for well-being/a good life” ipv focus on feeling
good/getting rid of depressed feelings that might not be only goal in treatment er zijn ook
andere manieren to live a good life/increase wellbeing
ØWhat are the proper goals of mental health care?? Promoting wellbeing, treating mental
illness, both?
ØWhat are the proper goals of mental health care?? Where does it stop?
•Slade 2010: “... the aim may not be to help the person to feel better, but to re-engage in
their life.” Recovering paradigm
•Promoting individual and societal well being, fostering relationships, improving social
inclusion
•Treatment organized around recovery goals, set by the service user
•Promoting wellbeing: four dimensions
1. Deficiencies and undermining characteristics of the person
2. Strengths and assets of the person
3. Lacks and destructive factors in the environment
4. Resources and opportunities in the environment
 Is this something all departments in our government are responsible for
or just mental health care. Changing mhc seems to apply changing society
as a whole (bv. Housing/poverty issue)

55
ØWhat are the proper goals of mental health care??
•Slade 2010: “... the aim may not be to help the person to feel better, but to re-engage in
their life.”
•Promoting individual and societal well being, fostering relationships, improving social
inclusion
•Treatment organized around recovery goals, set by the service user
•Promoting wellbeing: four dimensions
•Societal implications:
−Slade (2010): Five Ways To Wellbeing: Connect (to others, individually and in
communities); Be active; Take notice (of the world); Keep learning; and Give (e.g.
smile, volunteer, join in). It is no coincidence that these are all outward-looking
recommendations, more about engaging in and living life to the full than sorting
out any internal or intrapsychic disturbances.

ØSlade (2009): reform of mental health care practice:

•There is much to value in (current day) mental health services. The ability to connect with
people in chaotic
circumstances, the authority to carry out short-term psychiatric rescue, clinical models
which provide a
coherent way of making sense of experiences, and tried-and-tested interventions which help
many  clinical recovery and focus on mental illness is something we should not lose but we
should do sth next to that as well: promote wellbeing (ppl with lived experience are needed
for this)
people are some of the assets of the system.
•However, just as recovery is often described as a journey rather than an outcome, there is
also a
journey of change for services. New skills are needed to promote well-being, with effort
targeted
towards helping the individual in their struggle to develop and consolidate identity-
enhancing
connections and relationships. Spirituality, cultural connectedness, informal carers and
intimate
relationships are influential components of identity which mental health professionals can
actively
support. The involvement of people with lived experience of mental illness in all parts of the
mental health system is an indicator that the necessity for partnership relationships is
understood.
ØThe most challenging part of the journey may be shifting values. For example, there may
be a trade-off between acting in the person’s best interests and supporting self-
management, pointing
to the need for a new balance in professional ethics. More profoundly, a shift is needed so
that people
with mental illness are seen as part of the solution not part of the problem.
Critical psychiatry
•This shift in focus towards personal recovery and positive health is
•not merely an empirical thesis about attaining/recovering health and

56
well being
•It touches upon an underlying dimension in psychiatry: a moral and
political dimension: power, human dignity and recognition.
•This is the focus of critical psychiatry as introduced by Bracken and Thomas
(2013).
•Bracken and Thomas (2013):
•The modernist, technological approach (on mental illness) works to separate our discourse
about mental
distress from background contextual issues. It systematically seeks to sideline of non-
technological aspects of mental health and privileges those aspects such as biological or
factors that are the domain of the expert.
•As this move empowers the doctor, it works to disempower the service user. Service users
are not the ones who develop the concepts, plan the research, or set the service priorities.
•We have proposed the concept of "postpsychiatry" as a way of thinking about how we
might
move away from the modernist orientation that currently shapes psychiatric thinking
(Bracken and Thomas 2005). Postpsychiatry represents an attempt to imagine a different
sort of medical engagement with states of madness, distress, and alienation. It is not anti-
medical or anti-psychiatry. But in its challenge to the dominant modernist, technological
version of psychiatry, postpsychiatry seeks to diminish the power and authority assumed
by the profession. (political agenda)
•Bracken and Thomas (2013): modernity and technology
•We see modernity as that period, post Enlightenment, when science became the road to
progress and religion became of lesser importance. We use the term modernism to
indicate a faith that our problems (including human problems in the territory of
relationships, conflicts, and power) can be framed scientifically. This faith extends to a
belief that technical, not moral, religious, or political interventions should be at the
forefront of our quest to deal with human pain and suffering.
•Cf. Ivan Illich (1976): iatrogenesis (harm done by doctors)
−Clinical
−Social
−structural (bracken en Thomas beschrijven deze, niet alleen in clinical setting of way we
organize society but part of thinking/framing challenges in life as technological problems to
be solved??)
Implication about this way of thinking about our problems 
•So, one central aspect of modernity is the major role given to experts and their systems
of knowledge in shaping how we understand ourselves and how we live our lives.
So what we should do is develop set of interventions that might reduce the problems so that
we might have successful treatments, goal then is not primarily care…..
•Bracken and Thomas (2013): psychiatry
•focus on individual minds, orientation towards reason
•“Since its origins in the asylums, psychiatry has endorsed the Enlightenment goal of
ordering the world according to reason. Its territory was that of madness and its aim has
always been to map this territory accurately, provide scientific explanations and models,
and to end develop a set of technical interventions.”
57
•The goal was not primarily care, understanding, or comfort, so words such as
"kindness;' "respect;' "empowerment;' and "solidarity” have never figured centrally in
any major psychiatric text.
•Foucault (1971): the history of psychiatry is the history of a “monologue of reason about
unreason”
•Bracken and Thomas (2013): service user movements, redefining expertise
•Service user movements from 1980’s onwards:
1. Developing alternative, non-technological ways of understanding and responding
to madness and distress (epistemological dimension)
2. Redefining expertise and empowering service users (moral/political dimension en
epistemological dimention)  if you have another way of understanding madness than in a
medical way than meical experts are not the only ones who have a say on how to deal with
madness/what it is
•Two Branches in service user movement/recovery movement
a) Compatible with (bio)medical approach (dat andere aspect moet er alleen ook nog bij)
b) critical (bracken en Thomas) of or even hostile (anti-psychiatry movement) to the
(bio)medical approach
−regarding technological approach as deeply disempowering: frames the person with a
mental health issue as a patient who should undergo treatment and who has nothing to
bring in as to what kind of treatment cuz doctor is expert + they do not accept a ….
−not accepting the medical framing of their experiences and thus not accepting
that doctors hold the "truth" of what they struggle with. Dus bracken en Thomas trekken in
twijfel that doctors hold the ‘truth’ in the matter.
•Bracken and Thomas (2013): ”Postpsychiatry”
“Postpsychiatry represents the belief that a different sort of medical engagement with
madness is possible. This approach does not seek or claim to hold the "truth" about
mental problems. It seeks to put "ethics before technology." By this we mean that the
non-technical aspects of mental health problems should have priority over the technical
aspects. We mean that our mental health discourse should begin with care and kindness,
dignity, and respect, and work with service users to keep these to the fore. From this
discourse, as a secondary event, specific technical questions will arise and will require a
response.”
Some conceptual issues...
•Do considerations about positive health and personal recovery affect our concept of mental
illness? Or do they merely add an extra (positive) dimension to our understanding of it?
•Recovery and positive health as a metaphysical claim about mental heath problems: the
central
unit of analysis is not illness/disease, but .... personal functioning/well-being?
•How does inclusion of social/moral/political dimensions affect our concept of mental
illness?
Does it matter, conceptually, to our understanding of mental illness whether we are
conceiving
of the mentally ill as ‘patients’, ‘clients’ or ‘service users’?
•Regarding critical psychiatry: can we coherently and responsibly conceptualise mental
health
problems without any kind of ‘illness discourse’?

58
•Should we even try to incorporate concepts of positive health and personal recovery into
our
existing analyses of mental illess? Or are we looking at two incompatible paradigms here (cf.
Kuhn)? Should we radically redefine the aims and scope of (mental) health care and
research?
Recovery ‘model’??
1. Not a model of mental illness itself, but a practical, ethical thesis, compatible with other
models
• Emphasis on other aspects of recovery that are also important, such as de-stigmatization
and empowerment
2. A rivaling model of ‘mental health problems’, not compatible with (biomedical) models:
• constructivism or eliminativism regarding mental illness
• Radically reversing priority: ethics first, technology second
3. A model pitched at a different level: primary unit of analysis at higher level. A meta-
theory, that might encompass other models?
• focus on (supraordinate) concept of (personal) well-being/meaningful life.
• Mental disorder as a derivative concept? Cf. ethics first, clinical/medical expertise second?
4. A methodological thesis at meta-level: democratic principles framing the problem and
doing research
• ‘Nothing about us without us’
College 9
Moral responsibility
• Moral responsibility?
• Kozuch and McKenna: “When an agent is accountable for her moral
wrongdoing – when she is blameworthy – she can justifiably be held to
account for what she has done.”
(e.g., directing one’s moral reactive attitudes to her aka being mad at her, make demands
upon
her to explain herself or apologize, being target of punishment, ...)
• Free will??
• ‘Free will is the unique ability of persons to exercise all the control
necessary for moral responsibility (McKenna 2013)’ ...
• Moral responsibility (w.r.t. an action) and moral responsible agency  moral agent vs
moral responsible agent? Moral agent maar niet intentioneel its doen aka per ongeluk of
kinderen idk luister terug
Conditions for moral responsibility
1. The knowledge condition (“I didn’t know” bv. In een delusion)
2. The control condition (“I couldn’t help it” je moet een bep mate van controle hebben om
morally responsible te kunnen zijn)
a) The choice condition (“I had no choice”)
3. The character condition (I wasn’t myself”)
•What is the exact relation between these conditions?
•Are they necessary and/or sufficient?
Conditions for moral responsibility
•Kozuch and McKenna (2015): conditions for blameworthiness
59
•Control (or freedom) condition (reason responsiveness)
•Knowledge condition
•Pickard (2013): “What makes a piece of behavior an action, as opposed to a mere bodily
movement, is that it is voluntary, where this means that the agent can exercise choice and
at least a degree of control over the behavior.”
BDS is disorder of agency; we have to regrd their behaviour as an instance of agency and not
as mere doing. We have to assume that these people do have the capability to exercise
choice and to control their behaviour. Ciurra also mentions this character theory
•The capacity to choose from a range of possible actions
•The capacity to execute this choice
•Ciurria (2018): the “character theory”
“People are responsible for actions and omissions that issue from their character, that
means: [...] that
stem from a causally integrated set of “psychological or physiological states” that are
“among the constitutive features of a particular self ”  so because of the way that your
personality/character has been shaped, that determines pattern of things you do. You are
responsible when what you do is something that actually fits with your personality/character
How can mental illness impingeon these conditions?
•Kozuch and McKenna (2015): ‘a taxonomy of pleas’
• Exempting vs excusing conditions (Strawson 1962)
−Exempting excuses: no morally responsible agency (zoals kinderen)
−Non-exempting excuses (je bent wel moral agent maar you might be excuses from moral
responsibility ofzo?): special circumstances exonerate morally responsible
agent from being morally responsible for a wrongful act
(1. ‘she did not know it’, 2. ‘she could not help it’)
• Full exculpation or merely mitigation?
• Justifications: explanation to the effect that there was no moral wrongdoing, hence
no blameworthiness (certain conditions might temporarily relieve you of certain
moral obligations/burdens)
How can mental illness impingeon these conditions?
•Kozuch and McKenna (2015): ‘a taxonomy of pleas’
• Mental illness as full exemption or ‘local’ excuse while retaining status as morally
responsible agent? (cf. ’moral residue’; people are still expected to apologise. Ook als je per
ongeluk op iemands tenen staat zeg je sorry. Als je dat niet doet heb je moral residue)
 Non-exempted mentally ill persons might still have moral responsibility in relation to
excused moral wrongdoing, e.g. apologies, taking steps to prevent it in the future
• Ways in which mental illness can mitigating/defeat blameworthiness for a (putative)
wrong act: you don’t meet knowledge or control condition
exempting conditions: reduce your status as
moral agent
Excusing conditions: Local excuses regarding
particular action (regarding an action)

60
How can mental illness impingeon these conditions?
•Kozuch and McKenna (2015): their main message
1. "When a plea of mental illness does carry exculpatory force, it does not always do so by
demonstrating that a person is not a morally responsible agent.” Mental illness is not always
exempting it might just be excusing
2. “Sometimes a person’s mental illness might play a nontrivial causal role in her actions (so
it could still influence someones actions) and
yet she could still be morally responsible and blameworthy for acting as she does.”  being
held responsible is important part of being part of society (heeft te maken met vorig college,
restoring identity)
‘Both of our main theses are meant to help make clear that the mere presumption that
one
is mentally ill, and that her behavior sometimes flows from her illness, does not provide
decisive grounds for one to conceive of herself merely as a patient and not as a competent,
accountable person, one who retains her dignity in the face of the burdens that plague her.’
 Heeft te maken met empowerment uit vorig college: empowerment also
entails that you should regard yourself as a responsible agent. Hoe moet
je jezelf empoweren in society als je denkt dat je niet responsible bent
How can mental illness impingeon these conditions?
•Kozuch and McKenna (2015): their argument
• What about cases in which a patient is morally responsible and blameworthy despite
the fact that her mental illness plays a non-trivial causal role in her wrongdoing?
ØA reason-responsive theory of free action: ‘when an agent acts freely, she acts from
causal sources that are sensitive to reasons/are expressive of her sensitivity to reasons’
 Your actions are informed by good reasons. Suppose I am not at all reason
responsive. I start throwing a chair (there might be good reasons for me
to be throwing with this chair bv. Ik wil chair door window gooien want
brand en ik wil ontsnappen), maar er kunnen ook goede redenen zijn om
niet met een stoel te gooien
 Youre free when your actions are responsive to a proper set of reasons
 Heeft te maken met being in control or not, miss is er goede reden iets
niet te doen maar je doet het alsnog
• Reason responsiveness: receptivity and reactivity to reasons; being receptive to reasons
−What is a suitable or adequate degree of responsiveness to reason required to
count as a morally responsible agent?
−How does mental illness affect reason responsiveness? And does it lead to sub-
threshold levels that excuse/exempt?
Stel iemand met autism raakt iemand aan die persoon zegt nee (dat is dus een goede reden
om t niet te doen) maar je hebt autism dus je bent niet receptive to that reason dan that
undermines your free agency  is er dan wellicht sprake van excuse/exempt??
How can mental illness impingeon these conditions?
•Kozuch and McKenna (2015): their argument

61
Mental illness can influence actions and still you are held fully morally responsible
• Mild depression: the case of Jenny and Sarah
• gedachte-experiment: ‘But if Sarah is morally responsible and blameworthy for
her freely doing morally wrong, and if her degree of
responsiveness to reasons is no different than Jenny’s,
then Jenny is also equally morally responsible and
blameworthy for her freely doing morally wrong.’  ookal heeft jenny dus mental illness
(mild depression) ofzo, ze heeft alsnog zelfde receptivity en reactivity als sarah (die gwn nou
eenmaal niet heel empathisch is ingesteld) dus ook jenny is gwn morally responsible
How can mental illness impingeon these conditions?
•Kozuch and McKenna (2015): their argument
• Mild depression: the case of Jenny and Sarah
• “Most fully morally responsible agents most of the time
act in suboptimal conditions which are such that, of things
were different in some way, then they would have
performed better[...] Should all of these agents also then
be excused, or should some mitigating factor also apply to
them? If not, why? Is it because mental illness is somehow
a special basis for excusing above and beyond the degree
to which it affects freedom [i.e. control condition]? If so, it
is our critic’s burden to state what the special basis is,
since it was originally assumed that mental illness in these
contexts excuses by impairing freedom.”
Discussion:
ØIs Kozuch and McKenna’s argument sound? Is it’s
conclusion correct?  je zou kunnen zeggen van nee want jenny is acting out of character
(en sarah is)
ØHow can we know whether the knowlegde and control
conditions for moral responsibility are met in particular
cases? How do we make these judgements in practice?
Responsibility without blame (Pickard 2013)
• Therapeutic community with service users with BPS
• “... I initially had no idea how this stance (holding someone responsible without blaming
them) was possible to achieve:
when a service user, who was not psychotic and knew what they were
doing, was angry and threatening toward me for no reason, and made
me feel angry and scared, how was I to hold them responsible for this
behavior without blaming them for it? I could make sense of the idea
that, despite appearances, they might not be responsible because
their disorder excused them, and hence not to be blamed. And I could
make sense of the idea tat, despite their disorder, they were
responsible, and hence to be blamed. But the combination of
responsibility without blame for wrongdoing struck me as a
philosophical and clinical conundrum.”

62
Responsibility without blame (Pickard 2013)
• Therapeutic community with service users with BPS
• Responsibility without blame
• How to do it? -> clinical challenge
• How is it possible? -> philosophical challenge
• BPS: “Core symptoms and maintaining factors of disorders of agency are
not mere bodily movements. They are kinds of actions and ommissions:
the kinds of behavior over which we have choice and control. [...] there is
at least a degree, and often a significant one, of choice and control.”
• “It is a presumption of treatment that service users have choice and
control over their behavior and can therefore be asked to take
responsibility for it...”  als je die assumptie niet hebt the whole treatment would lose its
rationale. You have to regard them as agents in order to make sense of the whole therapy.
Als je denkt dat ze helemaal geen controle hebben (over bv emotions enzo) dan heeft
therapie ook geen nut. Ook service users moeten zichzelf als agents zien
Responsibility without blame (Pickard 2013)
• “So how is this combination possible: how is it possible for clinicians to hold service
users responsible for actions and omissions that are central to their disorder and
cause harm and suffering, without blaming them for them?”
• Consider the following argument
1. Service users with personality disorders have control and conscious knowledge of
their behavior
2. Therefore they are responsible for their behavior
3. The behavior causes harm
4. Therefore they are to blame for the harm.  deze 4e wil ze dus voorkomen want ze wil
zeggen ze zijn not to blame maar wel responsible
• The rescue/blame trap (either we try to rescue them by saying you cant help it, you need
help or we blame them and say youre fully responsible ive had enough of this and with all
these emotionally charged reactions. Both of these are unhelpful volgens Pickard): either
deny 1 and 2 or embrace 4
• But both are incommensurable with effective treatment!
ØPickard: embrace 1-3 and deny 4  dat betekent that we need a different notion of
responsibility in order to make the argument (die hierboven wordt gegeven) invalid
Responsibility vs moral responsibility?? Idk luister terug if needed
Responsibility without blame (Pickard 2013)
• “... a conceptual framework that is adequate to account for clinical practice must clearly
distinguish between ideas of responsibility, blameworthiness, and blame.”
1. Responsibility: “ This idea of responsibility is essentially linked [...] to agency. [...] We
are responsible for our actions because we are their agents: insofar as we know what
we are doing, and can exercise choice and control our behavior, what we do is up to us.
[...] Most stringently, holding a person responsible may consist simply in judging that
they are responsible, that is, that they have conscious knowledge, choice, and a degree
of control over their behavior.
Responsibility without blame (Pickard 2013)
• “... a conceptual framework that is adequate to account for clinical practice must clearly

63
distinguish between ideas of responsibility, blameworthiness, and blame.”
1. Responsibility
2. Blameworthiness: “...the idea of holding another responsible can involve more. It can
involve judging a person not only to be responsible and therefor accountable for the
behavior, but to be blameworthy, and indeed blaming them.... We judge a person to be
blameworthy when they are responsible for harm, and have no excuse. 
Responsibility without blame (Pickard 2013)
• “... a conceptual framework that is adequate to account for clinical practice must clearly
distinguish between ideas of responsibility, blameworthiness, and blame.
1. Responsibility
2. Blameworthiness
3. Blame: distinguish between (being blameworthy does not mean that youre actually
blaming someone)
−Judging someone to be blameworthy
−Judging that it be warranted, appropriate or desirable to blame her
−Actual blaming her: a reactive attitude/emotion (with a ‘sting’: has to do with sense of
entitlement) that can be irrational
2 sorts of blame:
a) ‘Detached’ blame
b) ‘Affective’ blame: a second-order response the blamer has to their first-order emotional
reaction: their feeling of entitlement
we should hold ppl accountable in a detached way not an affective way
Ø“Responsibility without blame is responsibility without affective blame: without a
sense of entitlement to any negative reactive attitudes/emotions one might experience,
no matter what te service user has done.”
Responsibility without blame (Pickard 2013)
• “... a conceptual framework that is adequate to account for clinical practice must clearly
distinguish between ideas of responsibility, blameworthiness, and blame.
Ø“Responsibility without blame is responsibility without affective blame: without a
sense of entitlement to any negative reactive attitudes and emotions one might
experience, no matter what te service user has done.”
• Thus, the argument goes:
1. Service users with personality disorders have control and conscious knowledge of
their behavior
2. Therefore they are responsible for their behavior
3. The behavior causes harm
4. Therefore they are proper targets for detached blame for the harm.
Responsibility without blame (Pickard 2013)
•Concluding remarks:
“In the face of this complexity, one thing remains clear: clinicians, family, friends, and
others need to hold service users with disorders of agency responsible for their
behavior, and ask that they change it, when it causes harm to self and others. But
given this complexity, a second lesson that can perhaps be learned from clinical
contexts is this: We should all question, more often than we typically do, whether

64
or not our inclination to affectively blame others is warrented, appropriate, and
desirable, given the particular context.
If we hold others responsible for their behavior, it is incumbent on us to hold
ourselves equally responsible, and that may include holding ourselves responsible for
our inclination to affectively blame, by questioning our sense of entitlement to our
negative emotion, even if we ultimately judge those reactions warrented,
appropriate and desirable. If we do blame, we need to do so responsibly.
Why do we hold people responsible?
• Backward-looking accounts: justifying attribution of moral responsibility to an agent with
reference to the (causal) history of the agent’s action.  holding someone responsible bcuz
they were the source of the action, dan verdien je ook punishment???
• Forward-looking accounts: justifying attribution of moral responsibility with reference to
the effects that it has on the agent and/or community (so-called ‘new’ consequentialism) 
komt beetje neer op Holding ppl responsible because it enhances their agency net als ciuria
• The ‘agency enhancement view’ (Vargas)
• Aptness in therapeutic contexts
• Ciuria (2018): “Interestingly, Vargas’s view can be seen as construing all fitting
responsibility attributions as essentially therapeutic, inasmuch as they must function to
enhance the agency of the target individual—otherwise they are unjustified and
inadmissible.”
ØPickard (2013), although using a backward-looking account of responsibility, justifies
responsibility attributions to patients with BPS in terms of their effects.
A forward-looking account
• Pickard’s (2013) clinical stance: responsibility without ‘detached’ blame
• Brandenburg: the ‘nurturing (nurturing bcuz helping someone become a better moral
agent) stance’
• ‘reproach without blameworthiness’ (firm correction but not blaming them)
• Brandenburg and Strijbos (2020): philosophical analysis on the basis of a small
qualitative study amongst clinicians working in an inpatient treatment center for
adults with complex autistic spectrum disorders and (above) average IQ.
A forward-looking account
• The nurturing stance (cf. Brandenburg and Strijbos 2020):
• Adopting a professional attitude of ‘nurturing reproach’ (‘firm correction’, ‘disapproval’,
‘reproof’, ...) toward a patient in response to harmful conduct/moral transgression by the
patient
• For which the patient is not considered responsible or blameworthy (in a backward-
looking sense) because of agency compromising factors.
• Nurturing reproach embodies an attitude/practice of ‘holding responsible’ of the patient
• However, the patient is not held responsible for the harmful conduct, but rather for future
directed concerns (e.g., commitment to therapy). (cf. Kozuch & McKenna’s ‘moral residue’)
A forward-looking account
• The nurturing stance (cf. Brandenburg and Strijbos 2020):
• The practice of holding responsible embodied by nurturing reproach is not justified in a
backward-looking sense (in terms of blameworthiness for the moral transgression).
• Rather, it is justified in terms of agency enhancement that are the effect the nurturing
65
stance.
• Reasons clinicians provided for reacting with ‘nurturing reproach’
−Being congruent and authentic
−Providing a sense of safety
−Fostering agency
−Recognition and inclusion
−Exemplarity
A forward-looking account
• The nurturing stance (cf. Brandenburg and Strijbos 2020)
• The clinical stance vs the nurturing stance?
• Different populations?
• Degree of responsible agency?
ØInclude the perspective of patients in follow up research
 Heel dit stuk terugluisteren idefk
Discussion
1. Why do we hold people (e.g., patients) responsible for their behavior? Backward and/or
forward looking reasons?
2. Why should we hold people responsible? In other words: why do you think that the
reasons you cited in response to 1) are justified?
 Ook terugluisteren
College 10
‘The self’?

• What does it refer to?

• What does it feel like to be me?
• How do I feel and think about my self?
• What is my personality?
• Who am I?
• Who am I in relation to others?
• Who am I really?
• How do I know myself?
•'Subselves’ (Strawson 1999)
“[T]he cognitive self, the conceptual self, the contextualized
self, the core self, the dialogic self, the ecological self, the
embodied self, the emergent self, the empirical self, the
existential self, the extended self, the fictional self, the full-
grown self, the interpersonal self, the material self, the
narrative self, the philosophical self, the physical self, the
private self, the representational self, the rock bottom essential
self, the semiotic self, the social self, the transparent self, and
the verbal self”
• Descriptive (empirical) questions
• What is Self-experience like?, self-narration (questions abt how ppl talk abt themselves),

66
personality, social roles, etc.
• Normative questions;
• what is Personal identity, relation of the self to free will?; self-government, agential
authority
• Ontological questions
• What is that thing called ‘the self’?
• Epistemological questions
• How do I know myself? How do I know what is ‘me’ and
‘not-me’?
 How do these types of questions relate?
Self-illness ambiguity
- ”I am not feeling myself lately.”
- “Is it me or my mental disorder?”
- “I don’t know who I am anymore.”
- “Which of my experiences and motivating reasons express who I am, speak for me?”
- “Can I trust my own judgments about what (not) to do?”
- “Is it me or my medication?”
- “Is this me talking or (am I just rehearsing the things my therapist said to me) my
therapist?”
- “Who can or do I want to be, living with my illness?”
brief philosophical analysis
• Movement versus agency  behaviour might me a mere movement (bv. When youre
being pushed or epileptic seizure waardoor je beweegt  dan is er geen sprake van agency),
maar most behaviour we display is from of agency
• Agency: being motivated to act, by reasons (behavior that is motivated by reasons)
• ”Strong agency”: acting on reasons of one’s own higher order phenomena typically
associated with human agency en dat wordt vaak strong agency genoemd; acting on reasons
one identifies/agrees with aka acting on reasons of one’s own (bv. animals are also
motivated by reasons?????)
• E.g., Harry Frankfurt:
• The willing and unwilling addict: higher-order desires (mensen met addiction gebruiken
drugs; that is a form of agency; they are motivated by reasons, maar bij human agency is er
the higher order phenomenon; person might be in conflicr because the motivating reason is
niet een reden die fully expresses who she is/wants to be. De higher order desire might be
not to want to use drugs but this one is powerless
willing addict: iemand die wholeheartedly de first order desire to take drugs embracet
• Reasons ‘internal’ (reasons ppl identify with) and ‘external’ (reason you don’t necessarily
agree with but still act upn/are motivated by. Bv bij cohersion) to the person
• Internal: reflecting one’s own deeply held values, reflecting self-narrative, etc.
• ‘Wholeheartedness’  acting upon reasons that are truly your own (internal); doing sth in
a wholehearted way; you fully endorse/stand by the actions that your performing
egosyntony vs egodystony rond 20;00

67
intrinsic (not merely instrumental, value in intrinsically valuable, but might still wonder if it
really represents who you are or not???) vs extrinsic (extrinsic: doing sth in order to gain sth
else, or bcuz someone orders you to do it.)
• But what about ambiguity? Are there degrees of
‘mineness’ in this sense?  dus dat het niet per se of internal of external is ig
Self-ambiguity
• Dings and Glas (2020): “So understanding cases of self-ambiguity starts by acknowledging
that, from a phenomenological point of view, the source of an action (i.e. its moving
principle) need not be experienced as either internal or external. Rather, it may be felt as
somehow ‘in-between’, as ambiguous.”
• Self-ambiguity:
• Unreflective, phenomenological level  starting with a new job, maar you feel like it
doesn’t really fit with how you normally feel abt yourself. Its doesn’t feel like its rlly you who
is performing. Dus the moving principle? Dat je in t begin had van this is a good job for me, I
like performing this way: that doesn’t really mesh well with who you are that might
prompt self-reflection: is this what I truly want?
• Reflective, conceptual level
Those cases where youre not sure is er dus self-ambiguity
• Managing self-ambiguity: “resolving self-ambiguity, according to the current proposal,
entails achieving a form of congruence between one’s reflective self-understanding (e.g.
one’s self-concept) and the bodily and affective feedback one receives while unreflectively
acting on the world.” (Dings and Glas, 2020)  door die feedback ga je denken van doe sthis
affirm or disaffirm your choices??? Idk man rond 29:00
 Self-interpretation cycle/evaluation, helping bij managing selfambiguitiy they have to
‘intervening’ on both sides: try new things/experiences to get new feedback en ook op de
conceptual level: way ppl see themselves (unreflective and reflective)??
Self-illness ambiguity
• Sadler (2007): the difficulty of distinguishing the ‘self’ or ‘who one is’ from a mental
disorder or diagnosis
• ambiguitiy on Unreflective, phenomenological level:
• Disturbances in ‘sense of ownership/agency (being the author? of your movements dus
zovan ben ik dit wel die mijn bewegingen aanstuurt) and ‘sense of agency’, ‘something’s not
right’,
inchoate feelings of ‘being lost’, experiential disturbances in self-world relation,
confusion, uncertainty how to ‘go on’ in daily business
• Often leading to uncertainty and self-doubt
“I feel like everything I do is now somehow connected to my being sick. If I’m happy, it’s
because I’m manic; if I’m sad, it’s because I’m depressed. I don’t want to think that every
time I have an emotion, every time I get angry at somebody, it’s because I’m ill. Some of
my feelings are justified. People say I’m a different person every day, but that’s me! I’ve
never been a stable person.”

• Reflective, conceptual level: (how we should conceive of mental illness in the first place)
• self-interpretation, self-narrative, one’s own concepts of mental illness, influence of
one’s own personality, personal history, socio-culturally dominant concepts, self-stigma
“what makes self-illness ambiguity so complex, is that in addition to phenomenological

68
ambiguity, where one is uncertain about whether one’s feelings are really theirs or part
of something external, there is also ambiguity on the conceptual level.”
Self-illness ambiguity
• Ruth Henry (2000)
“For more than a decade I’ve been trying to
understand what’s wrong with me. I know I’m
insecure. I hate confrontation, I lack discipline, and I
have ugly legs. I’m also terribly out of shape, and I
ought to do something about my hair. What I don’t
understand, though, is why what I thought was a
sensitive disposition became in 1989 a diagnosis of
depression. (...) When the doctor first told me I was
depressed, I was puzzled. Of course I was depressed. I
was often depressed, loads of times, ever since I first
learned the word. But I certainly wasn’t depressed. It
would have been nice to blame all my problems on an
authentic mental condition, but I didn’t have one.”

“ The depression I experience never feels like an

illness. To me, it’s a bad attitude, a deficiency of
willpower, and something I brought upon myself. It is
a weakness that I’m ashamed of. When I’m
‘depressed’, this is how I reason: ‘I am not nauseated.
I don’t have a fever. I can walk and talk and eat and
read and shout hallelujah if I have to – I just don’t
want to. Which means I’m the one who’s
uncooperative. It’s obviously my fault – don’t go
blaming it on some disease. Maybe other people
have this disease, but not me’. It never occurred to
me that maybe all of my objections about having
depression were being fueled by it.
 Where does personality stop and depression start

“Real depression, in my mind, was validated by

tragedy, heartache, financial woes, abusive
parents, a family death – the powerful blows life
can deliver, not a few slaps on the wrist. It seemed
to me one had to earn the right to call herself
depressed. My loneliness and despair came from
character flaws within me, not from tragic
circumstances surrounding me...
I think I was born with the tendency to think
pessimistically and be overly sensitive and anxious.
At what point did my temperament

69
metamorphose into symptoms of a disease? Are
they distinct, or are they one and the same?”
Dus dit is goed vb van self illness ambiguitiy
Self-illness ambiguity
ØSelf-illness ambiguity is doubly ambiguous
1. Concept of mental illness has its own unclarities
and ambiguities
“is schizophrenia best conceptualized as a
disease entity that comes, as it were, from the
outside, and with which the sufferer must
contend, as with a burden or an enemy? Or is it
better seen as a more intimate factor:
something that emerges from within,
permeates the very core of one’s being, and
must, perhaps, be understood as an aspect of
the sufferer’s very soul?” (Sass 2007, p.395).
 Zijn mental illness entities that are a part of the person/self or not?
ØSelf-illness ambiguity is doubly ambiguous
1. Concept of mental illness has its own unclarities
and ambiguities
2. Mental illness affects self-relational attitudes
−The illness influences how one relates to
one’s illness  relating in a depressed way to their depression: some ppl avoid seeking help
because they think its their own fault, maar dát is dus eigk een symptom van their
depression nml relating in a depressed way to their depression
−In chronic conditions, the illness and one’s
dealings with it shape one’s personality; de distinctie is lastig
49:00
Kijk alleen naar bovenste rij
van Patient
Being ill is sth you as a
person are relating to at the
same thing being ill
determines how you relate
to your illness. Your
personality also influences
how you relate to being ill.
Contextual factors also
influence the way you relate
to your illness  distinctie is
lastig
Diachronic, dynamic process, resulting in (dis)equilibrium.. ???? idk

70
Complications in resolving self-illness ambiguity
1. Conceptual complications
• Reification: (making a phenomenon; dus bv mental disorder into a thing en er causal
powes aan toeschrijven. Example reification: I have a low mood bcuz im depressed. )
conceptualizing self and illness as two isolated entities with causal powers
Reification of self ánd illness might complicate resolving self-illness ambiguity ???? ik snap
niet wrm luister maar terug
Acc to derek it simplifies a complex reality en is often a category mistake (zoals ook bij het
hierboven genoemde vb want low mood is symptom van depression maar dus niet dat
depression low mood veroorzaakt of iets in die richting) maar of het echt resolving selfillness
ambiguity vermoeilijkt trekt hij in twijfel
Hyponarrativity of DSM classifications: idk luister terug 1:09 ish hij legt rond die tijd ook uit
wrm mensen reificiation problematisch vinden, maar dat moet je terugluisteren

−Self-management as ‘ disease management by the patient him/herself’

“[...]the relationship between selfhood and disease entity envisioned as enactable
in the self-management literature for bipolar patients/consumers (...) is
unsustainable in a way that draws particular attention to the limitations of
medicalized/somatic selfhood. As bipolar patients/consumers cultivate and perform
what is taken as expertise and responsible behavior within the self-management
paradigm, they must, paradoxically, index and increasingly recognize themselves
as uncertain, discontinuous, unreliable and never fully knowable. Furthermore,
their efforts to predict, calculate and discipline the bipolar “disease”, while
valuable, ultimately foreground the absence of a singular agentive subject and the
inextricability of bipolar phenomena from the expression of the managing self.”
(Weiner 2011, p.478)  luister terug
Complications in resolving self-illness ambiguity
1. Conceptual complications
• Reification: conceptualizing self and illness as two isolated entities with causal powers
ØSelf-management as ‘ disease management by the patient him/herself’
ØShould we incorporate the self-relational aspect of ‘being ill’ in our concepts of mental
illness/health?
Complications in resolving self-illness ambiguity
1. Conceptual complications
• Reification: conceptualizing self and illness as two isolated entities with causal powers
ØSelf-management as ‘ disease management by the patient him/herself’  luister terug, is
problematic want can affect your agency ofzo? idfkkkkk
• Hyponarrativity of DSM-classifications: usingdsm as a way of trying to make sense of
ourself then it comes at a cost. When u start understanding urself als I have low mood that
goes at the expense of other dimensions that explain your low mood
• prioritize symptoms over personality characterisics, context, and personal history, unfit
for self-understanding.
ØThe importance distinction between classification and diagnosis proper
ØFirst diagnosis, then classification!

71
Complications in resolving self-illness ambiguity
1. Conceptual complications
2. Epistemological complications
• Lack of trust in one’s own judgment and endorsements (e.g., uncertainty,
hypervigilance, tentativeness)  how do I know which of my desires I can trust
• Is there a basic frame of reference or baseline to fall back on?
“So how to make sense of your experiences, if those experiences themselves may be
unreliable or cannot be trusted? How to proceed when a strong feeling of not being in
the mood to go see your therapist might actually be an indication that you need to go
see your therapist?”
• Extended personal authority? Who’s expert about what, and how to integrate various
perspectives?  iemand anders kent me beter dan mezelf ik vraag wel aan hen what desire i
can trust ofzo
Complications in resolving self-illness ambiguity
1. Conceptual complications
2. Epistemological complications
3. Social and societal complications
1. What illness narratives are available in one’s socio-cultural group?
2. Stigma and self-stigma
3. Defining groups in terms of (reified) illness categories.
−‘Being autistic’: (self-)stigma or self-endorsement and self-affirmation?
−Diversity movements (cf. Hacking’s ‘human kinds’)
ØThe role of language: what illness discourse do we use?
ØNext class: developing new language (Redesigning Psychiatry)
 Laatste deel echt niet goed geluisterd
College 11
Conceptual analysis: finding necessary and necessary conditions for phenonemenon, then
you are clear for what the concept means
Conceptual design: what do we want our concepts (in this case of mental disorder) to
achieve? (  daarvoor hoeven we niet per se analysis of our current concepts te geven,
want miss heeft een current concept bep. Flaws/fails to achieve in certain ways ??)
Might have to revise certain concepts??
• philosophy as conceptual design
• Concepts as tools for... regulating our thinking and (inter)action
• Analysis or revision of dominant concept(s) of mental disorder?
• Assignment for this week:
• Think about this question: What do we want to achieve with our concept(s) of mental
disorder? What are its desiderata? : bv. It should help a patient to self-regulate/selfmanage ,
(perspective patient), make clear where mental disorder stops and person begins or should
help understand the person suffering from the disorder or how to interact with mentally ill
person (relatives perspective), structured way of diagnosing someone (clinicians
perspective), explain why ppl are not able to participate in society?/should not lead to
exclusion (society perspective),

72
ØThink of the concept of mental disorder as an artifact.
ØWhat are its features and design flaws?
ØWhat are missing features?
ØFrom the perspective of the patient, relatives, clinicians, society, science...
Positive feature & Flaws of concept of mental disorder as is put down in the DSM:
- Bv. Universality is positive feature ánd flaw (want is fijn op iedereen toepasbaar,
maar aa nde andere kant is mental illness ook een personal thing dat voor iedereen
anders kan zijn en daar houdt het geen rekening mee ook iets van dat daardoor
stereotypes kunnen worden gevormd)
• Versimpeling/ model van syndromen/ reïficatie
• Gericht op individu
• Gericht op eindstadia
>> ±80 miljard gaat naar zorg, ±2 miljard naar preventie
• Eendimensionale visies op de mens: òf biologisch, òf cognitief, òf
behaviouristisch, òf sociaal, etc
>> polarisering
• Onderbehandeling en overbehandeling
• Iatrogeniteit en stigmatisering
• Protocolleren op heterogene problemen
• Incrementele en technologie gedreven innovatie
• Schotten tussen sectoren en tussen jeugd en volwassenen
• Verschotte financiering en een verdienmodel van ziekte
• Analoog werken, praten in kamertjes
 Complex probleem: moeilijk op te lossen, were in a local minimum that
hard to get out of because there’s all kinds of conservative that pull it back
in. Moeilijk to really change the system
If you want to change the system you have to be proactive ipv reactive
To innovate you have to steop out of your usual way of thinking
Redesigning psychiatry network:
Door te anticiperen op de toekomst in
plaats van te reageren op de problemen van
vandaag en door de gebruikers en hun
waarden centraal te stellen, terwijl we ook
maatschappelijke waarden onderkennen,
willen we laten zien hoe het anderskan en

73
zo bijdragen aan de verandering van de
GGZ
Reframing methode/vision in product design, hekkert & van dijk
you have old and new product and want to
understand how can we design a new product
thatll satisfy our customers, when it comes to
product/tool that interact with complex issues
in society the way to do this is to look design
in this way:
what kind of interaction between
people and between the person and
the tool are in fact the ones that the
old product is supposed to be
facilitating
then we look at the context level and
see what is the context that this
product was built for and what is the
future context going to be; what kind
of interactions are important and
should be valued in the new context and what does that mean for the kind of product we
want to develop
hoe zal het landschap zijn in 2030 (aka what is the future context going to be)

Factors they discovered based on interviews ??

- More datadriven (we keep accelerating)
- Increase inequality
A Fluid age: societal constructs are becoming fluid (bv je zal wss niet altijd meer dezelfde
baan hebben maar vaak veranderen); based on this they developed certain values based of
what we think is important  dat gaat onvermijdelijk gebeuren (is al aan t gebeuren). Op
basis daarvan zijn dit de dingen die belangrijk zijn (from the perspective of mental health:
- You need a good start: Vulnerability for mental disorders is created at the first years
of life.
- Connecting environment: helping ppl be more resilient to challenges
- Human variation: we should embrace variation, fight inequality
- Stress of performing
- We need a society in which we are able to relax
 Dingen die nodig zijn to facilitate mental well-being
2.Agency
het vermogen om te handelen naar de doelen die
je stelt, maar ook om je doelen en waarden te
herzien door nieuwe dingen over jezelf te leren.
Zulke doelen en waarden bepalen in onze visie wanneer iets

74
een probleem is voor een persoon, in plaats van de mate
waarin het afwijkt van een medische norm.
When do you have a problem?: when it deviates from statistical/medical norm or
Sth is a problem for a person if it undermines the capacity of agency, de norm wordt dan dus
een persoonijke norm (should be able to lead your life acc to the goals that you set based on
your experiences/whats important for you)
Schema’s waar ik geen uitleg van heb terugluisteren
Een ander perspectief op welzijn en psychische problemen
1. Ecologisch perspectief
Adaptive cycle: understanding of what it means to be mentally resilient or vulnerable
when it comes to developing/recovering mental illness. Ipv straight line zien we
cycle; certain point in time you reach equilibrium that can lead to disruption (???) 
reovering/reorientation  lead to development/groet

resilience and
agency is hierbij
het meest
belangrijk
also disruption
is dus
oinevitable dus
bij designing
healthcare you
should facilitate
this process

2. Denken in termen van interaction patterns

Dsm focusses on individuals, instead lets focus on individuals in interaction with
themselves, other ppl, environment over time
Dus we moeten mental health issues begrijpen als result of all kinds of interaction
problems

mental regulation/dysregulating exhibiting

features of a dynamical system: this is a way
of modelling it
if from ecological standpoint you think
resilience is a very important thing
person who is in healthy state, which means
that if this person is confronted with
stresses/misfortune the state person is in
might go up and down but will revert to healthy state. The problem is in youre in a
75
 vulnerable state you might go into a local minimum which means you reach a tipping
point and might get stuck in a state of psychopathology

the idea is we can scientifically and clinically understand (psychiatric) vulnerabilities

that ppl have in terms of such dynamic states where a person who is healthy might
develop into a person with more and more mental vulnerability , which means they
might still be healthy but their resilience is reduced. In this case a person who has
had a week of bad sleep might still be functioning normally when stressor has gone
away and sleep is restored, they will then go back to healthy stage. But another
person whose had a bad week of sleep might reach tipping point and fall in a state of
psychopathology. (mania/depression etc.) Waar natuurlijk weer moeilijk uit te komen
is.

This might be a way of capturing what it means to be vulnerable (in a psychiatric way
bv.) but it might also help you understand the trajacotry is in (towards psychological
vulnerability or resilience. The goal here would be to help someone to lessen the
curve (?? Zie Plaatje ig. Denk dat hij bedoelt curve van in psychopatholgy state raken)

Hoe meer je mentally healthy bent hoe moeilijker het wordt to become mentally ill
en andersom. Dan bereik je minder snel die tipping point  laat dus zien hoe
belangrijk prevention is

Bij ecologische dinges kijk je dus neit ernaar

zoals linkse Plaatje maar zoals rechtse plaatje
There might be a way to go from one
equilibrium to a new one. This depends on your
abilities to adapt and transform and cope

•Een equilibrium bestaat uit interactiepatronen op meerdere niveaus die zichzelf in stand
houden
•Welzijn is een wenselijk equilibrium waarin veerkracht en actorschap een belangrijke rol in
spelen
•Een onwenselijk equilibrium wordt in stand gehouden door probleem instandhoudende
interactiepatronen (een pihip)  thinking about disorders as problem sustaining interaction
patterns (dat is from ecological perception)
•NB deze kunnen zeer complex, multilevel, persisterend en star zijn
incasseren ook aanpassen en transformeren
statisch dynamisch
Dus dit zijn de new pillars bij thinking of mental health bij ecological perspective. Taking
turns in interaction patterns, and because of dynamical perspective there should be more
focus on the development en dus ook prevention rather than only endstages en sth abt
actorschap. Als we actorschap belangrijk vinden zijn die interactionproblems dus
problematisch ofzo

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3 important tasks for healthcare network: develop new capabilities that help you deal with
society? And reach your own goals. Address the problems that are causing the problems
&Support transitions
New professionals die je dan nodig hebt: the system hacker, blablabla en wat betekent dit
voor de huidige professionals. Miss terugluisteren
You can submit your answers to the exam questions in Brightspace under ‘assignments’ in
the digital environment of our course, where you will find a new topic ‘Exam January 20th’.
You should submit the document containing your answers before the end of the exam! And
please make sure that you put your student number on the first page! 
Let op!
Je RU-nummer bestaat uit de letter 'u, e of s' + je nummer.
Dit vul je aan met '@ru.nl'.
Bijvoorbeeld: [email protected] of [email protected]
Volgnummer 22

1.

a.Reliability in this context is about agreeing on what to call/label things. It’s about
having a clear terminology. This way there are intersubjectively accessible
criteria for making a diagnosis. The idea is that based on that you can build a
scientific system. When two different psychiatrists diagnose someone with
schizophrenia, they will do so based on the same criteria. After taking care the
reliability, then we can try to understand and study empirical relations between
different factors. Study/science as to what mechanisms behind mental illnesses
are. Then we can make sure whether there is also validity; your classification
system represents what is going on in reality.
b. Depression is just a description of symptoms but ‘it becomes a thing.’ This
means people might start saying: ‘my depression is causing my low mood.’ But
this ofcourse is false. Depression is defined in terms of low mood, so how can it
be a cause of low mood. Slowly but surely the descriptions were reified into
essences, into the things that were causing the symptoms, rather than that they
were defined in terms of the symptoms. Because of this reification the DSM is
charged with being an impediment to the scientific progress, since imperfect
categories were informing our research. If we look at a heterogeneous group of
people with low mood, which we call depression we see all kinds of different

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 things when we look at the neurobiology of these people. So it is only expected
that you’ll never find an unequivocal neurobiological substrate. But if you let
those categories then determine our research questions/how we group patients
in order to do research you won’t get very far.
c.The process of epistemic iteration entails that in the beginning we might change
direction but at a certain point it gets more precise (in relation to our aim).
d. There are three key assumptions required for iteration to work:
1. There has to be something out there towards which the iteration is aiming.
So in order for epistemic iteration to make sense mental illness has to be a
real thing out there. Or a ‘natural kind’ as one may say.
Cooper said about this: “The basic idea is that the causal structure of the world is such that
certain entities are to a large extent interchangeable, in the sense that their similar
properties mean that they can be expected to behave in much the same fashion...”
So when we hit upon natural kinds we are discovering basic causal structure of the world.
Because its predictable we know we have hit some kind of basic causal structure
2. The process of iteration needs to have some stability over time. Even if ‘x’ is
in a stable position but our aim is going all over then probably we won’t get
pretty far. Suppose we are stressing different validators in different periods
of time, then we would come up with a different taxonomy if we focus on
one validator instead of the other. Choice of validator influences the
direction of your aim.
3. Are we looking in the right place? The iterative process is getting stuck in a
local minimum we’re dealing with a paradigm that is unsuccessful. How to
get out through epistemic iteration? Everytime you try to make progress
you get pulled back into the minimum. Cooper zegt hierover: “Classifications
like the DSM can be thought of as forming part of the infrastructure of
science, and have much in common with material infrastructure. In
particular, as with material technologies, it is possible for "path dependent"
development to cause a sub-optimal classification to become "locked in"
and hard tore place.” The DSM might just not be the right paradigm.
Infrastructure for new knowledge is based on DSM categories maar but to
get out of the local minimum we might need new categories.
e.As seen in assumption two the choice of validators influences the direction of
your aim. However, what validator you focus on depends on your values

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