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More Aristotle, Less DSM: The Ontology of Mental

Disorders in Constructivist Perspective

Article in Philosophy, Psychiatry & Psychology · January 2009

DOI: 10.1353/ppp.0.0192


18 271

3 authors, including:

Pérez-Álvarez, Marino José Manuel García-Montes

University of Oviedo Universidad de Almería


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More Aristotle,
Less DSM
The Ontology of
Mental Disorders
in Constructivist
Perspective Marino Pérez-Álvarez, Louis
A. Sass, and José M. García-

Abstract: This work begins by proposing the need oth psychiatry and clinical psychology
for exploring the mode of being of mental disorders. It have developed rapidly in the last half
is a philosophical study in an Aristotelian perspective, century or more, at scientific and technical
with special emphasis on the anthropological–cultural levels, and also in terms of social prestige and
dimension. It is difficult for such an inquiry to be car-
services provided to society. Neither field seems,
ried out from within psychiatry or clinical psychology,
committed as these fields are to their own logic and however, to have developed a very clear position
practical conditions. The issues are, in any case, more on the nature of the mental disorders that they
ontological than strictly clinical in nature. We there- study and treat. Generally, mental disorders have
fore turn to Aristotle, and specifically his doctrine of been assumed to be natural formations, objective
the four “causes,” to flesh out the social and cultural entities that exist “out there,” independent of the
dimensions of mental disorders. In accordance with the clinical practices that study them. In this line, men-
present analysis, the material cause of disorders would
tal disorders, like physical illnesses, are typically
be found in the contingencies of life; the formal cause
would pertain primarily to the way clinical conditions understood to derive from dysfunctions of one or
themselves can serve as models of ‘being ill’ in our another kind of internal mechanism.
society; the efficient cause would correspond to the pa- The supposed internal dysfunction is, however,
tients themselves, understood as active (albeit less than conceived rather differently depending on the prac-
fully conscious) agents as well as to the pharmaceutical titioner’s clinical approach or overall theoretical
industry and the mass media; the final cause would be perspective. In contrast with other mainstream
found in different adaptive functions served by the dis-
medical and health specialties, psychiatry and clini-
order. We conclude that the “mode of being” of most
(if not all) mental disorders—in particular, their status
cal psychology contain a variety of highly diverse
as mental disorders—can often have more to do with approaches, including some that reject the “internal
cultural forms than with biological factors. dysfunction” assumption mentioned. This plurality
of approaches does not seem to be a consequence of
Keywords: Efficient cause, final cause, formal cause,
material cause, social drama, Charcot effect, clinical
the scientific immaturity of psychiatry and clinical
psychology, psychiatry psychology but, rather, of the open or ambiguous

© 2009 by The Johns Hopkins University Press

212  ■  PPP / Vol. 15, No. 3 / September 2008

character of mental disorders themselves, which mentioned) ontological issues to come from the
are inherently susceptible to various reconstruc- clinical disciplines themselves. Then we indicate
tions and interventions. One question concerns the the path to be followed in the rest of this paper.
extent to which mental disorders might, in fact, be
constructed entities of a historical–social nature, Exposing the ‘Charcot Effect’
cultural forms that provide models of ‘being ill’ An exploration of the ontological status of
for persons who are experiencing crises, conflict, mental disorders requires a “critique of clinical
or dramatic situations of various kinds. Such a reason.” A key reason why such a critique is not
suggestion would not deny the reality of mental likely to emerge from the disciplines of psychiatry
disorders, but poses the question as to the genesis or clinical psychology concerns what might be
and nature of these realities. termed the ‘Charcot effect’ (Pérez-Álvarez and
Clarification of this issue is not likely to come García-Montes 2007).
from within psychiatry or clinical psychology, It is widely recognized that J.-M. Charcot
committed as these fields are to their own logic and (1825–1893), the eminent French neuropatholo-
perspective. The issue is, in any case, more philo- gist of the late nineteenth century, was responsible
sophical than scientific or technical in nature—it is for inducing attacks of hysteria under the assump-
one of many examples of the need for philosophi- tion that he was merely describing them. To the
cal thinking within the mental health professions. extent that Charcot’s clinical expectations actually
Indeed, the key question here is ontological: It functioned as prescriptions of what was to be
concerns the type of reality or “way of being” of observed, Charcot was himself immersed in a self-
mental disorders. The sort of ontological inquiry confirmatory system, with the admiration of the
we propose in this article may help to unsettle the audience who attended his lectures serving mainly
often taken-for-granted view of mental disorders to support this effect. But the ‘Charcot effect’ is
as deriving primarily from interior dysfunctions, not merely a particular historical occurrence. The
whether neurobiological or psychological in na- phrase refers not only to Charcot’s work at the
ture. Such an inquiry can reveal certain blind spots Salpêtrière hospital in Paris, where he described
of clinical know how, in particular, a tendency to the grand attaque de l’hystérie in the 1890s
“discover” what clinical practices themselves may, (Shorter 1992), but also to a far more general
in fact, have brought into play. clinical phenomenon that may occur, to a greater
In this essay, we proceed as follows. First, we or lesser extent, in virtually all psychodiagnostic
attempt to illuminate the general terrain—to open and psychotherapeutic processes (Berkenkotter
a clearing in the jungle of psychiatric and clinical– and Ravotas 2002; Borges and Waitzkin 1995).
psychological theory and practice, with a view to An important current instance of what might
identifying the problems faced and the path to be be termed the Charcot effect is the tendency,
followed. Second, we introduce Aristotle’s concept common in both research and clinical practice in
of the four causes: material, formal, efficient, and contemporary psychiatry, to define or diagnose a
final. This serves as a critical instrument for the disorder by its response to medication. This is the
ontological inquiry we propose. In the end, we strategy that Peter Kramer (1993), in Listening to
draw some conclusions about the mode of being Prozac, called ‘listening to the drug.’ In clinical
of mental disorders. Although our ontological in- practice, the medication actually serves to specify
quiry is intended to apply (at least to some extent) the diagnosis. Thus,
to all forms of mental or emotional disorder, we
if a supposed manic-depressive does not respond to
nevertheless focus on certain disorders that we lithium or to another of the mood stabilizers, a psychia-
consider exemplary, particularly schizophrenia. trist will wonder whether after all he’s schizophrenic.
If a supposed schizophrenic is managed effectively
Clearing the Terrain on anti-anxiety agents or even without medication, a
psychiatrist will question whether she is, in fact, schizo-
In this introductory section, we consider why phrenic. (Luhrmann 2000, 49)
one should not expect clarification of the (above-
Pérez-Álvarez, Sass & García-Montes / More Aristotle, Less DSM  ■  213

As David Healy has pointed out, pharmacologi- The now-prominent strategy of defining the dis-
cal companies engaged in psychiatric research can order by the medication can be seen as a case of the
now “not only set out to find the key to the lock ‘Charcot effect.’ In a certain sense, disorders found
but can dictate a great deal of the shape of the lock in clinical practice are propagated by the research
to which a key must fit” (1997, 212). Certain dis- strategy itself, in conjunction with pharmaceutical
orders seem, in fact, to owe their existence to their marketing. It is doubtful that such conditions are
status as targets for medications that companies optimal for exploring the understanding of the
wish to market: for example, panic disorder in re- true status of mental disorders.
lationship to alprazolam (Xanax; Valenstein 1998) The ‘Charcot effect’ is also quite prominent in
and social phobia in relation to paroxetine (Paxil; clinical psychology, where disorders also tend to be
Moynihan and Cassels 2005). In similar fashion, defined according to the procedures used to treat
the proliferation and popularization of a variety them. We know, of course, that Oedipal complexes
of medications seem to be converting depression tend to present themselves to psychoanalysts,
into a supposed “epidemic” (Pignarre 2001). depressive schemas to cognitive therapists, and
This new drug “cartography,” as Radden inappropriate behavioral repertoires to behav-
(2003) terms it, seems to be at the root of a grow- ior therapists. A patient may adopt not merely
ing discrepancy between diagnostic proliferation, the vocabulary of the therapist, but an entire
on one hand, and etiological knowledge, on the configuration—including forms of experience and
other. Diagnoses proliferate and become estab- expression as well as of self-understanding—that
lished even though (despite mountains of biologi- derives, at least in part, from the way the problem
cal data) very little has actually been established is clinically viewed. The point is that each psy-
regarding the actual causes of many disorders. It chiatric or psychological system and associated
is true that, in medicine, diagnosis has typically ideology creates its own universe of discourse,
preceded the discovery of causes. The reality is, within which a patient’s problems are interpreted
however, that many contemporary psychiatric and modeled. In this sense, we are indeed faced
diagnoses do not fulfill (nor is there much prospect with a kind of ‘Charcot effect,’ an effect that is
of their fulfilling) the requirements of biologically mirrored in the finding of apparently similar ef-
oriented psychiatric research, either in the sense fectiveness of different psychological treatments
of being precisely defined or of taking underlying (Huble, Duncan, and Miller 1999). There seems
psychopathological processes into account (van little doubt, then, that psychiatric expectations
Pragg 1997). and diagnostic trends do influence the presenta-
In view of these developments, it should come tion of symptoms and the nature of the disorders
as no surprise that the traditional interest in that manifest themselves. The question remains
psychopathology—in studying the nature and as to just how these expectations and trends have
etiology of mental disorders as distinct from their their effect, and also how much of the domain of
treatment—seems practically absent from much mental or emotional disorder can be understood
contemporary research and clinical practice, as in this way.
several recent psychiatric editorials have lamented In any case, the ‘Charcot effect’ makes it
(e. g., Andreasen 1998, 2007; Maj 1998; Tucker highly unlikely that any ontological clarifica-
1998). Indeed, if viewed from a psychopatho- tion will come from mainstream psychiatry or
logical standpoint, much of the research enterprise clinical psychology. And this is so, not because
seems to be bogged down in clinical trials of treat- of any supposed conflict of interests, but because
ment response, without much promise of leading of epistemological obstacles arising from clinical
to deeper knowledge of underlying pathologies practices and conceptions themselves. Each clinical
(Pignarre 2004). Psychiatric practice has been conception involves a specialized mode of ‘seeing,’
largely reduced to the dispensing of drugs, often ‘talking,’ and ‘writing’ that ends up constructing
not even by psychiatrists, but by general practi- its objects, as Byron J. Good (1994, ch. 3) has
tioners equipped with questionnaires for making shown in relation to the medicine taught at Har-
rapid diagnoses. vard Medical School. Therefore, it is unlikely that
214  ■  PPP / Vol. 15, No. 3 / September 2008

those adopting these clinical conceptions will be be converted into mental disorders—that is, how
aware of their participation in the production of they become the clinical phenomena they are.
the objects they study, especially when they see We do not deny, of course, that mental disorders
themselves as reaffirmed in what they do. The typically involve biological factors. But, often,
scientific attitude of contemporary psychiatry what matters most is how the person responds
and clinical psychology is to take for granted that to or deals with the factor or its effects. The way
mental disorders are “out there” to be discovered, in which one manages one’s biological alteration
described, and treated. However, such an attitude is what usually gives the alteration its specifi-
can be simplistic and misleading as the basis of cally psychiatric meaning. In the case of hearing
ontological inquiry. voices, for instance, it seems to be not the voices
themselves, but the person’s beliefs about hearing
The Road to Follow voices, and also the social consequences of these
An ontological inquiry such as that proposed beliefs and attitudes, that actually determine
here must take as the object of analysis the real- whether or not they come to constitute a disorder
ity that constitutes the clinical field. That reality (Romme and Escher 1993). This is but one of the
includes both patients with their problems and ways in which, as Sass and Parnas (2007) note,
clinicians themselves, with their theories and “subjective experience can play an important
procedures. Such an inquiry demands a global causal role in the progressive experiential trans-
view that can encompass all the different actors formations of a developing schizophrenic illness”
(including patients and clinical professionals) (p. 86). We propose that Aristotle and his theory
and place them within the cultural and scientific of the four causes offer a useful way of approach-
context. Such a view is comparable to that of ing the processes at issue. Our application of the
an anthropologist doing a field study, where the four causes should be viewed as an exploratory
“natives” are patients and clinicians. Analogies attempt, a way of calling attention to some gener-
from the world of theater are also relevant, for the ally neglected ways in which the realm of so-called
development of mental disorders can be fruitfully mental disorders may be understood.
viewed as the unfolding of a drama, taking into
account the reciprocal role of the different actors. The Four Causes of Mental
Here we might employ the notion of ‘social drama’ Disorders
proposed in Victor W. Turner’s anthropology of
experience and performance (Turner 1982, 1986;
Prior Considerations
Turner and Bruner 1986). Clinical professionals do Aristotle presents the theory of the four causes
not, after all, actually see ‘cerebral disturbances’ or in his works Physics and Metaphysics (Aristotle
‘mental processes’; these are their assumptions (hy- 1999, 1994/2000). The four causes refer us to
potheses, explanations). The ‘things themselves’ aspects of explanation that are necessary for a full
that are faced by clinical professionals would be, understanding of things and events, both natural
above all, social dramas, dramas in which the and artificial. The four causes (perhaps better de-
clinicians themselves also play their role. scribed as four fashions in which we cite the cause
The notion of social drama can be applied to [Lear 1988, 27]) refer us to aspects of explana-
diverse situations and in different cultures. Turner tion that are necessary for a full understanding of
(1982) defines social dramas as units of aharmonic things and events, both natural and artificial. They
or disharmonic process that arise in conflict situ- are what allow us to grasp what might be called
ations. Typically they have four phases: breach, “the why” of something (van Fraassen 1980, 26),
crisis, redressive action, and reintegration; and the “reason why it is so” (van Fraassen 1980,
these can be neatly applied to the psychological 25). Aristotle begins with the material element
and sociocultural trajectory followed by mental of which something is made, the material cause;
disorders. The question, then, is to see how certain then turns to what constitutes the element as a
social dramas, involving breach and crisis, come to particular something, which is the form it takes
Pérez-Álvarez, Sass & García-Montes / More Aristotle, Less DSM  ■  215

or model it follows, in other words, its essence or rial of tragedy consists in human conflicts and the
formal cause. The efficient cause is what brings general vicissitudes of life—disappointments, frus-
about the change from the previous condition, trations, existential conditions, personal dramas,
namely, the agent, constructor, or architect. The and the like. We suggest that the nature of mental
final cause constitutes the function for which a disorders derives, in large measure, from the way
thing was created.1 this sort of “material” comes to be moulded by
It should be borne in mind that the terms Ar- various cultural forms or ‘cultural idioms’ (e.g.,
istotle uses (aition, aitia) actually have a broader by the notions of folk psychiatry described be-
meaning than our own word ‘cause.’ Although low, in the section on formal causes).3 Thus, for
some scholars, such as Guthrie (1981), argue example, people learn to frame certain conflicts
that the English term “cause” is the best term for and vicissitudes—sadness, poverty, misfortune,
capturing Aristotle’s intended meaning, others suffering—in terms of “depression,” thereby giv-
seem to prefer the phrase “explanatory factor” ing rise to the era or “epidemic” of depression
(Falcon 2006; van Fraassen 1980, 32, 34, 43). that emerges after the late 1980s (Dworkin 2001;
Aristotle’s “causes” refer, in any case, to explana- Healy 1997; Pignarre 2001).
tory factors that address “why-questions” (van Other life problems and circumstances, such as
Fraassen 1980, 42), that is, that help to explain certain fears, conflicts, tensions, or interpersonal
why something exists, and in the way that it does. difficulties, would constitute the material that is
They concern a fundamental kind of knowledge manifest as panic disorder or social phobia, to
that has a metaphysical or ontological rather than mention two recently created disorders (Pérez-
purely empirical status. To focus on the four causes Álvarez and García-Montes 2007). It is consistent
is not, of course, to deny the crucial relevance of with Aristotle’s view to recognize that there are
empirical knowledge, but rather to consider the constraints on what kind of material can be used
diverse frameworks within which such knowledge to form a particular kind of entity. More or less
can be considered and integrated. specific materials would therefore be at the basis
Although we assume that our application of the of particular disorders; for example, sadness
four causes covers all disorders, we recognize that with respect to depression, or fear with respect to
it is easier to see in disorders where the cultural anxiety or phobia. Here, however, these specific
dependence is more clear. Our application does material causes, such as sadness and fear, are
not rule out possible neurobiological factors, but considered more as conditions of human existence
nor does it give them pride of place. (And we note, or ways of being-in-the-world than as explana-
in passing, that surprisingly few, if any, neurobio- tory biological mechanisms. Our starting point
logical factors have been reliably established in for the understanding of mental disorders is not
psychiatry and clinical psychology, either as etio- biological substrates (although without denying
logical factors or even as predictive or diagnostic their implication in all human activity), but rather
markers ([Scott 2006; Valenstein 1998]). the vicissitudes of life. This would also apply to
Let us turn, then, to the first of Aristotle’s four the case of schizophrenia.
causes. Of what material would schizophrenia be
made? According to our perspective, the material
Material Cause of schizophrenia could be largely found in the
The material cause relates to the material of crisis of common sense and the allied social dis-
which a thing is made.2 Aristotle often uses the location this involves (Blankenburg 1971, 2001;
example of a statue, which can be made of bronze Stanghellini 2001, 2004). It would therefore be
or another substance. But mental disorders have to necessary to study the reality of the life-world
do, of course, not with physical objects but with (Schutz 1962) to study schizophrenic crises. The
people, who feel and act in relation to one another. reality of the world of life or of common sense, as
In this sense, mental disorders are more akin, for Schutz (1962) points out, includes, among other
example, to tragedy than to sculpture. The mate- elements, the experience of the self, life projects,
216  ■  PPP / Vol. 15, No. 3 / September 2008

sociability, and belief in the world as it appears. In Formal Cause

an anthropological–cultural perspective, it would The formal cause concerns the form or pattern
be necessary to study the way the self is constituted adopted by mental disorders, the overall pattern
in a particular society. As Fábrega (1989) argues, of being ill.5 These patterns can be established in
the self is the key to the mediation of cultural cultural practices in ways that are informal or
factors in the experience, course, and duration formal, implicit or explicit, with such nosological
of the crisis called ‘schizophrenia.’ As a crisis, systems as the DSM (American Psychiatric Asso-
schizophrenia represents both a difficult situation ciation, 1994) being the principal formal source
(the collapse of the taken-for-granted world) and a in contemporary Western society.
possible adaptive reorganization or reconstructive The sociologist Alan Horwitz offers a useful
effort on the part of the person who undergoes description of a key difference between physical
it (e.g., formation of delusions). On the basis of and mental illnesses:
these materials, which, as pointed out, already
involve a certain form, schizophrenia will take its Unlike physical illness, where symptoms are usually
indicators of underlying disorders, the symptoms of
course, which may involve only a single psychotic
mental disorders are symbolic representations of
episode or, alternatively, may involve the process underlying vulnerabilities that are structured to fit
of chronification necessary for the current DSM dominant cultural models of ‘appropriate’ disorders in
diagnosis to be applied. Which of these alternatives particular times and places. In this sense, the symptoms
(among others) actually occurs, can itself depend of mental disorders are part of ‘cultural tool kits’ no
on various cultural factors that we discuss in rela- less than language, fashion, and musical or culinary
tion to other Aristotelian ‘causes.’ tastes. (2002, 268)
Given our perspective, it is noteworthy that In our view, the “dominant cultural model” for
Aristotle (in De anima) laid down the bases for mental illnesses, at least in contemporary Western
studying common sense (koiné aisthesis). Recently, society, is largely provided by such systems as
Stanghellini (2004, 2007), following Blankenburg the DSM itself. In this sense, clinical labeling can
(1971, 2001), has argued that the theory of koiné be understood as playing a role that is perhaps
aisthesis provides a solid philosophical basis for less descriptive than prescriptive—that is, not so
understanding schizophrenic psychopathology. much a matter of capturing prior phenomena as
In turn, schizophrenia would indeed shed light of trimming and shaping their form. This process
on common sense or koiné aesthesis, insofar as it occurs not only in the course of clinical practice
highlights structures of common sense understand- but also in the extra-clinical contexts of everyday
ing that are otherwise difficult to perceive.4 psychological culture, as we shall also see presently
In sum, the materials of which mental disorders in relation to the efficient cause (Pérez-Álvarez and
are made are to be found in the challenges and García-Montes 2007).
vicissitudes of life. There is, of course, never any According to our perspective, the role of
lack of life problems. It is, however, only in mod- cultural forms in mental disorders is not merely
ern society that these problems of life are turned expressive, but constitutive. In this regard, it
into psychological or psychiatric problems. What should be said that our perspective is philosophical
previously was likely to be perceived as a chal- rather than simply cultural. Our starting point is
lenge, attributed to luck or destiny, or conceived a philosophical anthropology according to which
in religious, moral, or ethical terms, comes in our the fundamental mode of human existence is en-
era to be characterized as a dysfunction resulting gaged activity. We are referring to a philosophical
from some supposed cognitive, emotional, or anthropology based on Heidegger (being-in-the-
behavioral process, and whose solution must lie world) and also on Ortega y Gasset (“I am myself
in some technical procedure. This leads us to the and my circumstances”; see in this same issue [van
issue of formal cause. Fraassen 1980, 26]), and developed in line with
an ontological hermeneutics following Gadamer
and Ricoeur (Sass 1988).
Pérez-Álvarez, Sass & García-Montes / More Aristotle, Less DSM  ■  217

Within this sort of philosophical anthropology, structure the form in which people experience,
what should be stressed is the horizonal nature and give meaning to, and react to the situations they
the linguisticality of the human being. Horizonal face (Vanthuyne 2003). Likewise, we would high-
nature means that the human being is always in light medicalizing and psychologizing practices as
some circumstance and within some horizon, the most well-established forms of pathologizing
which constitutes the context in which all human (more so, for example, than moralizing) in folk
activity occurs, including mental disorders. Given psychiatry (Haslam 2005).
the public nature of the horizon—because it is a Given this clinical culture, it should come as
socially shared context—our self-interpretations no surprise that the DSM can be considered as a
or self-understandings are broadly determined by source of ways of ‘being ill’ in Western society, as
the possibilities given in culture. As for linguisti- suggested at the beginning of this paper. It is not
cality, such a perspective assumes that language is that people actually read the DSM or similar noso-
not merely a part of man’s equipment for dealing graphic systems, but its ‘idiom’ ends up shaping
with the world, but indeed is—to a significant the experience of ‘everyday nerves’ (Healy 2004).
extent—what permits us to have a world, because We might say that, in practice, folk psychiatry and
it provides the principal source of our interpreta- formal psychiatry are intimately allied factors, rel-
tions and understanding of both the world and evant to ‘formal cause’ (the latter to be discussed
oneself. Thus, the function of language in relation below). Examples of this intimate alliance, studied
to experience would be not expressive but, rather, by Healy (2004), are the prevalence of anxiety in
constitutive (Sass 1988, 246). In sum, culture times of diazepam (Valium), the transformation of
would be the condition of possibility of the hu- cases of anxiety into depression in times of fluox-
man being, including the possibility of mental etine (Prozac), and the emergence of panic disorder
disorders. and social phobia in relation to the correspond-
On this philosophical view, the cultural perspec- ing new drugs (see also Horwitz 2002; Medawar
tive takes on a transcendental and fundamental and Hardon 2004; Moynihan and Cassels 2005).
dimension. This goes beyond traditional tran- This consideration of the social shaping of the
scultural psychiatry, which covered only general experience of ‘everyday nerves’ and the like does
categories (e.g., developed versus developing coun- not deny the reality of the disorders presented by
tries), and at best, particular aspects (e.g., exotic patients—in this case anxiety, depression, panic
beliefs and rituals). We would be talking here disorder, and social phobia—but rather attempts
about a cultural perspective that puts meaning to clarify some of the factors whereby this reality
back into the center of psychiatric research and comes to be made real.
practice, and that studies how culture comes to Cultural forms are also critical in schizophre-
constitute the experiences, actions, and reactions nia. Jenkins and Barrett (2004) make this point
of mental disorders (Fábrega 1989; Good 1994, forcefully:
1997; Jenkins and Barrett 2004; Kleinman 1988; [W]hat we know about culture and schizophrenia at the
Vanthuyne 2003). outset of the twenty-first century is the following: Cul-
In this perspective, Western culture itself is the ture is critical in nearly every aspect of the schizophrenia
object of study. The question would be to adopt illness experience: the identification, definition and
an anthropological or dramaturgical point of view, meaning of the illness during the prodromal, acute and
as indicated, which provides a global picture that residual phases; the timing and type of onset; symptom
formation in terms of content, form and constellation;
includes patients with their problems and clinical
clinical diagnosis; gender and ethnic differences; the
professionals themselves with their theories and personal experiences of schizophrenic illness: social
procedures. Important in this regard would be the response, support and stigma; and, perhaps most
‘cultural idioms’ in the articulation of the experi- important, the course and outcome of disorders with
ence of mental disorders. A “cultural idiom” is respect to symptomatology, work and social function-
made up of value systems, forms of interpretation, ing. (pp. 6–7)
and epistemological assumptions, all of which
218  ■  PPP / Vol. 15, No. 3 / September 2008

More specifically, the crisis of common sense in schizophrenia as an illness of the brain, as there
which schizophrenia consists (in terms of its ma- are for, say, Alzheimer’s disease (even though we
terial cause) would be molded, first of all, by the are not clear on its etiology). To borrow a contrast
forms of selfhood or self-experience that are cur- framed by Kleinman (1999), it is crucial to view
rent in the culture of reference (Fábrega 1989), and schizophrenia not as a “disordered modulation”
also by prevailing conceptions of mental disorders of a universal “human nature,” but, rather, as a
in particular. In this regard, we might propose particular configuration of a diversity of “human
the schizoid personality, characteristic of modern conditions” which, of course, include biological
society (Devereux 1970; Pérez-Álvarez 2003; Sass aspects (Jenkins and Barrett 2004, 10).
1992), as a model for schizophrenia (Pérez-Álvarez
2006). The fact that the crisis of common sense in Efficient Cause
‘schizophrenia’ involves certain alterations of self- The efficient cause relates to the issue of who or
awareness, with a marked solipsistic and autistic what force makes it that, or brings it about that,
character (Parnas and Sass 2001), is related to the something comes to be as it is—in this case, who
prominence of schizoid tendencies or, in Foucault’s or what brings it about that life problems take
terms, with that ‘strange empirico-transcendental the form of ‘mental disorders.’6 Obviously, people
doublet’ that would be modern man (see Sass do not just have mental disorders in the way that
1992, 1994). This means that disorders in some they have, say, hepatitis; nor do mental disorders
ways akin to ‘schizophrenia’ would adopt other emerge in the same way as, say, teeth. Nor is it
forms, relatively distinct from the Western form, the case, obviously, that mental disorders are the
in different cultures, according in this case both products of deliberate steps taken to achieve a de-
to the mode of selfhood characteristic of the con- sired outcome. Still, what we call mental disorders
text and also to prevalent models of ‘being mad.’ always do involve, at some level, active (although
Thus, for example, one might speak of the ‘Asian not necessarily fully conscious) responses to the
model’ of psychosis (Corin, Thara and Padmavati problems that life puts in a person’s way. After
2004; Good and Subandi 2004; Wilce 2004), in all, even passivity is an “action” in the sense that
which both the experience of the disorder and the it nearly always involves at least some degree of
associated behavior seem more interpersonal than choice among alternative possibilities or ways
intrapsychic in nature. For example, in such cases of being. And this active element means that a
the characteristic ‘withdrawal’ is not so much so- given disorder is always subject to, or bound up
lipsistic and autistic as social in nature: wandering with, various kinds of psychosocial and cultural
around outside the village, ‘talking bad.’ behaving forces.
rudely, and so on. Patients typically present their problems to
In our perspective, clinical practices themselves clinical professionals, in whose presence the prob-
(nosographic systems and the like) also contribute lems undergo a kind of ‘secondary elaboration.’ To
to the molding of schizophrenia. Thus, for exam- begin with, the prevailing clinical perspective will
ple, diagnosis based on a series of symptoms and shape the “material” by giving special weight to
use of ‘antipsychotic’ medication as the preferred some aspects or features of the patient’s experience
treatment contribute to conceiving disorders as and behavior rather than others (Berkenkotter and
illnesses of the brain. As Horwitz (2002) says: Ravotas 2002), thereby molding symptoms that
“The view that real illness must have biological may previously have had a more undefined form.
causes is, paradoxically, a cultural construction” That the problem presented typically takes the
(p. 156). The point is that this consideration as an form of a diagnostic condition, which from that
illness of the brain forms part of folk psychiatry point on structures the original problem, is, in part,
or cultural idioms, so that it ends up giving form a response to a practical need for the problem to
to the disorder presented. But things do not neces- take some recognizable, quasi-medicalized form,
sarily have to be this way. First of all, there are, with treatment-oriented implications (Neimeyer
in fact, no firmly established bases for considering and Raskin 2000). In this sense, the issue is the
Pérez-Álvarez, Sass & García-Montes / More Aristotle, Less DSM  ■  219

selection not so much of a ‘natural kind’ as of a difficulties by construing them as direct conse-
‘practical kind,’ that is, of a category that responds quences of traumas experienced in war (Young
primarily to functional and practical demands, for 1995). The re-structuring of ‘clinical reality’ by
example, by serving to simplify understanding and diagnostic categories is apparent in the rapidity
guide action toward solution of a problem.7 Thus, with which a wide range of problems—from psy-
for example, a problem of “everyday nerves,” to chosomatic problems to problems related to social
re-employ the expression used previously, could adjustment—were woven into ‘PTSD.’
be conceived of as ‘stress’ or as ‘depression,’ Even schizophrenia is affected by the kind of
depending on which was more practical with a ‘efficient causality’ conceptualized here. In Creat-
view to helping the client, without either choice ing Mental Illness, the sociologist Alan Horwitz
being a diagnostic error. (By contrast, it would be (2002) excludes schizophrenia, together with
a monumental error for a doctor to confuse, say, bipolar disorder and the psychotic forms of depres-
pneumonia with tuberculosis; see Haslam [2002a] sion, from what he terms the “creation” of mental
and Zachar [2000, 2002]). disorders on the grounds that the etiology is so
Patients and clinical professionals are, of largely biological.8 There is, however, consider-
course, both embedded in a cultural context. The able evidence that sociocultural factors do have a
psychological and biomedical culture of contem- significant role in the course of schizophrenia as a
porary society encourages people to present as chronic, debilitating illness. The well-established
mental problems what might otherwise be seen finding of poorer prognosis of schizophrenia in
as merely problems in living, or even, perhaps, developed countries compared with developing
not as problems at all (they might, for example, countries (Warner 2004) may well be due, at least
experience themselves as sad, perhaps appropri- in part, to the reifying propensities of Western
ately so, rather than as depressed). Thus, patients conceptions of mental illness and the pathologizing
may already arrive at the clinician’s office with a impact of diagnosis, medication, hospitalization,
more or less sophisticated, ‘primary elaboration’ of and other clinical practices that can steer people
their problems as, for instance, ‘panic disorder’ or with life crises toward a veritable ‘psychiatric ca-
‘depression.’ And because patients (like clinicians) reer.’ It is worth noting, for example, that patients
are targets of marketing by the pharmaceutical with schizophrenia in the psychotropic era seem
industry, they may end up having the disorders that to spend on average more time in the course of
the drugs treat. This cultural framing of experience a psychiatric career in a hospital than they did
can have various problematic consequences for the before modern drugs came ‘on stream’ (Healy
individual. One Moroccan psychoanalyst makes 2004, 236).
this very point when he describes the consequences Fortunately, the Western health care framework
of establishing the first psychiatric institutions does offer some alternative ways of approaching
during the colonial period. “The symptom,” he schizophrenia that tend to normalize the crises
writes, “has been increasingly addressed to the rather than fostering the kind of ‘psychiatric
representatives of modern science, while people are career’ referred to above. Some examples are
increasingly alone with their suffering” (Pandolfo Open Dialogue (Seikkula and Olson 2003), where
2000, 117, citing Bennani 1995, 113). clinical professionals deal with the psychotic crisis
The pharmaceutical industry is not, of course, within the family context (visiting homes); Making
the only promoter of new disorders. Here an Sense of Voices (Romme and Escher 2000), which
interesting example is the case of posttraumatic involves understanding voice hearing in biographi-
stress disorder (PTSD). PTSD entered into the cal context and normalizing these experiences; and
DSM III (American Psychiatric Association 1980) Acceptance and Commitment Therapy (Bach and
in the context of the moral and political but also Hayes 2002; Veiga-Martínez, Pérez-Álvarez, and
economic claims of Vietnam War veterans who García-Montes 2008), which proposes the ac-
needed a diagnostic concept that could include ceptance of symptoms and fosters an orientation
and, in some sense, ‘objectivize’ a diffuse set of to values. All three approaches seek to avoid or
220  ■  PPP / Vol. 15, No. 3 / September 2008

minimize both medication and hospitalization. Within these general functions (alarm, truce,
We see, then, that the efficient cause in the cul- cry for help, way of life), each symptom would
tural construction of mental disorder can involve have its specific functions. Thus, for example, one
various actors. Both patient and clinicians play function that the sadness of depression probably
their role, and they do so in a context that includes fulfils is that of not wasting effort on lost causes.
the psychological culture, the biomedical research But as Sartre (1948) has pointed out, sadness also
industry, marketing by pharmaceutical companies, involves what he terms ‘turning the world back
and also advocacy by nonprofit groups that may to zero,’ an experience of being equidistant from
have their own private interests and agendas, in everything, which can have the effect of opening
particular, an interest in defining disorders as one up to becoming interested in new projects
brain-based diseases. These latter include the Na- that were unthinkable when one was interested
tional Alliance for the Mentally Ill (McLean 1990) in what turned out to be a lost cause. As far as
and Children and Adults with Attention-Deficit/ psychotic symptoms (hallucinations, delusions)
Hyperactivity Disorder (Fukuyama 2002, ch. 3). are concerned, these may imply adaptive efforts
of self-maintenance in the face of the crisis that
Final Cause is occurring or has occurred in the patient’s life.
Aristotle’s notion of final cause, applied to men- Thus, for example, auditory hallucinations can
tal disorders, refers to the purposes these disorders have pragmatic functions, such as providing ad-
may serve, and the meanings associated with these vice, warning, or criticism, and may even simply
purposes.9 It is important to recall that what we be a source of company (Leudar et al. 1997). The
conceptualize as a mental disorder represents, point is that hallucinated voices may have their
at the same time, a problem and an attempt at a biographical–personal sense—which is the aspect
solution—a point that has, in various ways, been focused on in the above-mentioned Making Sense
recognized by practically all psychotherapeutic of Voices approach (see also Open Dialogue). In
approaches. If the dysfunctional (or purposeless) the case of delusions, we might speak of existen-
aspect is often the most obvious or prominent, tial meanings that these symptoms may have for
this is, at least in part, the result of viewing these the patient, even to the point of representing a
“disorders” in a biomedical or psychiatric con- preferred reality (Roberts 1991).
text. One must recognize as well a set of possible The final cause or adaptive function of symp-
functions that conditions of mental or emotional toms may also have a phylogenetic origin, ac-
disorder can serve. One such function is that of cording to evolutionary psychiatry. Evolutionary
alarm, indicating that something is wrong in the psychiatry provides examples of the possible
life system—as may be the case with anxiety in adaptive value, during evolution, of traits and
relation to a relationship crisis, or depression in states that we view today as pathological, because
relation to coping with a life change. Another the cultural context is now very different (Fábrega
such function is that of creating a haven, a kind 2002). In this regard, it might be said that culture
of truce in the vicissitudes of life that permits one can channel and modulate these functions on a
to reorganize energies and readjust one’s course. historical scale.
Another might be that of a cry for help or recogni- We see, then, that diagnostic categories provide
tion that is directed at the social environment. And the patterns of being ill in modern society—which
indeed, it is also conceivable for the disorder to accords with the idea that each society tends to
represent a way or a style of sorting out problem- have its own preferred patterns, as Devereux
atic situations, or even an actual way of life. In this (1970) argued. In this way, mental disorders, as
perspective, particular symptoms or signs would practical kinds rather than natural kinds, would
be viewed as environmentally directed actions or be socially instituted ways of channeling ‘social
signals, rather than primarily as indications of an dramas’ and ‘everyday nerves’ or other forms of
underlying or internal condition, whether neuro- malaise. The personal problem or crisis is socially
biological or psychological. ‘processed’ through the forms instituted in each
society for that purpose.
Pérez-Álvarez, Sass & García-Montes / More Aristotle, Less DSM  ■  221

Conclusions (i.e., they are said to exert ‘merely’ pathogenic

effects)” (Kleinman 1988, 25; see Sass [1994,
This work has set out to explore the ‘mode 98–9]). In contrast with this mechanistic model,
of being’ of mental disorders in an ontological whose root metaphor is the machine, we propose
perspective, with special emphasis on the anthro- a contextual, anthropological–cultural model,
pological–cultural dimension. In doing so, we whose root metaphor is the historical event (fol-
have applied Aristotle’s theory of the four causes. lowing Stephen C. Pepper’s classic distinction in
This application calls attention to some generally his book World Hypotheses [1942]). According
neglected ways in which the realm of so-called to the contextual model, mental disorders would
mental disorders can be understood. not be something one has but, rather, something
Specifically, the material cause concerns the one becomes; something that cannot be properly
problems of life (conflicts, vicissitudes, crises) that understood outside a biographical, historical, and
can be understood as the starting point of mental cultural context. As Sass and Parnas note with
disorders. The formal cause concerns the role of regard to schizophrenia:
cultural forms (cultural idioms, folk psychiatry,
[symptoms] cannot be considered to be mere epiphe-
clinical theories and procedures) in the shaping
nomena of neurophysiological changes. Indeed, they can
of life problems into the mental disorders they be neither understood nor explained without making
eventually become. The efficient cause concerns reference to the subjective or phenomenological dimen-
the role of diverse actors (patients, professionals, sion. This is not to deny the key role of neurobiologi-
the pharmaceutical industry) in fashioning life cal abnormalities. Indeed, these latter may well have
problems into these mental disorders. The final ultimate causal primacy—as the main source of the
cause concerns the adaptive function the symp- early experiential abnormalities. . . . Once the field of
toms may have. The Aristotelian perspective has experience is transformed, however, this gives rise to
forms of attention and modes of experience involving
the advantage of integrating these four aspects
developments-from or reactions-to subjectively experi-
into a unified theory, which we propose as an enced aspects of both self and world. (2007, 86)
ontology of mental disorders, at least in their
anthropological and cultural dimensions. In any As far as practical implications are concerned,
case, our approach is not merely social construc- our approach questions the traditionally assumed
tivist or cultural–constructivist, but rather, as we separation of medication on the one hand and
have pointed out, philosophical–anthropological psychological therapy on the other. According
in nature. In this perspective, mental disorders to this traditional model, medication is typically
have more to do with the human condition, with seen as the first line of action and psychological
its social, cultural, and linguistic aspects, than with therapy as a secondary complement. A particular
human nature understood in biological terms. Two aspect of this model is its focus on elimination of
implications, one conceptual the other practical, the symptoms (e.g., sadness in depression, voices in
arise from our approach. schizophrenia) as a principal objective, and often
As regards the conceptual implication, our as a first step before psychotherapy or psychosocial
approach can be offered as an alternative to the rehabilitation.
pathogenicity/pathoplasticity model, according In opposition to this therapeutic dichotomy, our
to which it is assumed that biology ‘determines’ approach would propose ‘psychosocial rehabili-
the cause and structures the form of the mental tation’ as a framework in which to combine the
illness, while culture and social factors ‘shape’ and different possible forms of help, including medica-
‘influence’ only the content of the disorder. This tion. Thus, the elimination of symptoms would not
model, as Kleinman argues, is a “stratigraphic have to be the prime therapeutic objective, or even
version of the mind/body dichotomy, [where] biol- an objective at all; the principal aim would in this
ogy is bedrock (the source of pathogenesis), and case be reconstruction of the world of life (projects,
psychological and especially social and cultural values, personal empowerment). In this line would
layers of reality are held to be epiphenomenal be current therapies such as Behavioral Activation
222  ■  PPP / Vol. 15, No. 3 / September 2008

as well as Acceptance and Commitment Therapy. of which they are composed, and so on. However, Ar-
Behavioral Activation has shown, in depression, istotle’s proposal does not require a process of infinite
that the activation of behaviors aimed at modify- reduction. The point is to identify the elements or level
at which to establish knowledge about something. As far
ing one’s environment can offer an alternative to
as mental disorders are concerned, and at least accord-
medication and to cognitive therapy (Dimidjian et ing to our perspective, the appropriate level at which
al. 2006). It is relevant to underline that Behav- we should understand them would be the molar level
ioral Activation is not based on the assumption given by experiences and actions, and not the molecular
of a neurochemical or cognitive deficit that needs one given by biological substrates (see the discussion in
to be ‘treated’ as a condition for improvement; Changeaux and Ricoeur 1998).
nor does it approach symptoms (such as sadness 4. Schizophrenia, leaving aside the disorder and suf-
fering it involves, can provide us with an understanding
and depressogenic thoughts) directly. For its part,
of human functioning (Jenkins 2004) and of culture,
Acceptance and Commitment Therapy consists particularly of modern culture, given the affinity be-
basically in promoting the acceptance of symptoms tween madness and modernism (Sass 1992, 1994).
that tend to be exacerbated by attempts to control 5. The words ‘formal cause’ were used in the his-
them, and also in helping the client recover a sense tory of psychiatry, in the early nineteenth century, as
of meaningful living that is consistent with his or equivalent to ‘proximal cause’ and in reference to a
her values. Acceptance and Commitment Therapy supposed ‘internal mechanism’ (Berrios 2000). Here we
has demonstrated its effectiveness for a range of understand the words ‘formal cause’ to refer to a model
in the Aristotelian sense (see Lear 1988).
mental disorders, including psychotic symptoms
6. The ‘efficient cause’ figured in the history of psy-
(Bach and Hayes 2002; Gaudiano and Herbert chiatry, in the early nineteenth century, as ‘distant cause,’
2006; Veiga-Martínez et al. 2008). in reference to the biographical and cultural antecedents,
which today would be called ‘risk factors’ (Berrios
Acknowledgments 2000). However, the sense of efficient cause here relates
This work was financed with a research project rather to ‘actors’ than to ‘factors.’ According to Lear
(1988), the notion of antecedent event does not capture
from the Spanish Ministry of Science and Tech-
the importance of Aristotle’s insistence that what con-
nology (ref. SEJ2005-24699-E/PSIC) awarded to stitutes the real cause is the builder who builds.
the first author. 7. In the perspective of the present work, as has been
noted, “mental illnesses” would be seen as “practical
Notes kinds” in Zachar’s (2000, 2002) pragmatic and func-
1. As Lear (1988, 27) notes, although Aristotle tional sense, rather than as “natural kinds” in Wake-
identified four ways in which cause can be cited, there field’s (2002) essentialistic sense. Even if one adopted
are, in a certain sense, only two causes for him: form the taxonomy proposed in Haslam (2002a)—where
and matter. This is because Aristotle considered “the Zachar’s distinction is refined and the possibility of
so-called formal, efficient, and final causes [to be] three “natural kinds” of mental illness is defended—it remains
different aspects of form itself.” clear that (as Haslam [2002b_ notes), natural kinds “are
2. The material cause, as an explicit concept, does not plausible, but probably vanishingly rare, inhabitants of
figure in the history of psychiatry. The notion of material the psychiatric domain” (240). It is noteworthy that,
cause can, however, be considered equivalent to the clas- as a possible instance of a natural kind, Haslam sug-
sic psychological/philosophical notions of both “object gests Williams syndrome, an entity with known physi-
of experience” and “sensory input.” In accord with this ological and anatomical markers and not, for example,
distinction (which presumes the modern subject–object schizophrenia.
separation), the perceiving subject would be understood 8. Horwitz (2002) himself does, however, stress the
to provide the form, and the external object or sensory decisive role of context in the final determination of
input would provide the material. the ‘illness.’
3. It should be borne in mind here, as is made clear in 9. The final cause has not been prominent in the
Aristotle, that all material, however elementary, involves history of psychiatry. But in recent years it has been
a certain form, because otherwise it would not even receiving considerable attention, as evolutionary psy-
be recognizable. For example, bricks are the material chiatry use evolutionary biology and psychology to seek
of which a house is made, but they themselves have a the adaptive purposes that mental illness and symptoms
certain form, whose material would be the compounds may serve or may have served in the Environment of
Evolutionary Adaptedness (Stevens and Price 2001).
Pérez-Álvarez, Sass & García-Montes / More Aristotle, Less DSM  ■  223

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