Reflections on Treatment OptionsPrior to beginning work on this journal, please read Chapter 13 in History and Philosophy of Psychology. This journal invites you to engage in creative thinking regardi
History and Philosophy of Psychology , First Edition. Man Cheung Chung and Michael E. Hyland. © 2012 Man Cheung Chung and Michael E. Hyland. Published 2012 by Blackwell Publishing Ltd. 13 History of Clinical Psychology and Philosophy of Mental Health People who are mentally ill sometimes engage in deviant behaviour, that is, behaviour that would be described in common terms as ‘odd.’ There are two ways of interpreting that deviant behaviour. One way is to interpret it not as illness but as a morally wrong set of behaviours. The person is ‘normal’ and the only problem is that what they are doing is wrong. Such ‘wrong’ behaviour has to be controlled. The other way of interpreting the deviant behaviour is as illness, and so the emphasis is on treating the illness rather than controlling the behaviour. In essence, these two interpretations differ over whether deviant behaviour is labelled as ‘bad’ or ‘mad’. These two interpretations have co-existed at the same time in history, at least until about 200 years ago. If the person is ‘bad’ then they should live in the community but suffer the consequences of their atypical behaviour – unless they are dangerous in which case they need to be locked up. If the person is ‘mad’ then they need to be treated by therapies. The history of clinical psychology is so closely linked to psychiatry that the two need to be considered at the same time (Porter, 1987, 1988, 1991). The difference between psychology and psychiatry is one of training. Psychiatrists are trained in medicine, so the psychiatric approach to mental illness follows the medical tradi- tion, or at least, the medical tradition of the time. Medical treatment of mental illness has a history of more than two thousand years. By contrast, psychologists have a psychological training, and their approach to mental illness can also be con- sidered as part of the psychological tradition of the time. Psychological treatment of mental illness is comparatively recent. Neither the medical nor psychological traditions have remained static, so the relationship between the two changes over time. Over time there have been various ‘tensions’, sometimes between different psychiatrists, sometimes between different psychologists and sometimes between psychiatrists and psychologists. These tensions include: C hung_c13.indd 270 Chung_c13.indd 270 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Clinical Psychology and Philosophy of Mental Health 271 a. a tension between religious and a natural science interpretation of mental illness; b. a tension between the Hippocratic system and the system of modern Western medicine; c. a tension between a biological versus a psychological interpretation; d. a tension between psychoanalytic versus behaviourist interpretations. Religion Versus Natural Science The Greek physician Hippocrates (460–377 BC) was born of a family of priest- physicians but rejected the current superstitious belief that illness, including mental illness was the work of the gods, and could be cured by superstitious charms and prayers. He suggested an empirical method in understanding illness, but also believed in a spiritually restoring principle or essence that the physician could use to effect a cure (Alexander & Selesnick, 1966; Bynum, Porter & Shepherd, 1985; Jackson, 1986; Maher & Maher, 1985a). He believed that the brain was the source of epilepsy and dementia and provided a variety of cures, including bleed- ing, but also a variety of lifestyle and dietary recommendations. The technique of bleeding a patient was not invented by Hippocrates himself – it can be traced back to ancient Egyptian medicine. The assumption of Hippocratic medicine that disease was caused by an imbal- ance of bodily humours was accepted in the west for the next two thousand years. There are four bodily humours: black and yellow bile, phlegm and blood. Ayurvedic (i.e. traditional Indian) and traditional Chinese medicine also adopted similar assumptions that disease was caused by an imbal ance – an imbalance of three doshas in the case of Ayurvedic medicine and of the five elements in traditional Chinese medicine (Deng, 1999). The consequence of these assumptions is that mental illness is located firmly within a biological conceptualization of illness, and that mental illness is not seen as separate from physical illness. For example, Hippocrates believed that hysteria was a purely female complaint and caused by a wandering uterus (the Greek word hysterion means uterus). Galen, who was a phy- sician during the 1st century AD (he was born in Turkey but often described as a Roman physician), transmitted and extended Hippocrates’ ideas throughout the Roman Empire and believed that mental and physical disease were linked. For instance, he believed that melancholia (depression) in women caused breast cancer. It is a noticeable feature of all the main traditional medical systems (Hippocratic, Ayurvedic and traditional Chinese) that lifestyle, diet and psychology are important parts of treatment, as well as herbs and other treatments (e.g. acupuncture, enemas, massage). In Ayurvedic medicine, for example, the most important therapeutic technique is meditation, and there is a clear emphasis on the need to treat the psychological state of a person in order to achieve physical cures. This link between the mental and the physical extends to recommendations for diet – a vegetarian diet is assumed to promote the ability to meditate. Not only are diets C hung_c13.indd 271 Chung_c13.indd 271 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. 272 History and Philosophy of Psychology recommended according to the type of person (note: not the type of disease) but in the case of traditional Chinese medicine, dietary recommendations also depend on the weather. For example, spicy food is supposed to be better when the weather is wet and cold. In sum, the traditional medical approach does not treat mental illness as separate from physical illness. Traditional medical practitioners do not have specialisms because they treat the whole person not the disease. Thus, in the traditional medical system, there is no such person as a psychiatrist or clinical psychologist, there is a simply a therapist working within that medical tradition. An important feature of all these traditional medical systems is that they reject supernatural explanations which have always occurred in parallel with them. They also assume that mental illness has a biological basis which is caused by an imbalance in the principles that are supposed to be in balance. Where there are strong religious belief systems, then mental illness is assumed to have a supernatural origin. This supernatural view occurs in various guises throughout history, both in the West under the influence of the Catholic Church, and all other countries. In Africa, for example, the superstitious beliefs have led to the idea of voodoo. Underlying this view is the belief that illness (often mental and physical) is caused by another person, often a witch, and often but not always as an intention of that other person to cause harm. This view fuelled the persecution of witches that occurred between 1450 and 1750, which was officially sanctioned by the Catholic Church. Pope Innocent VIII authorized the persecution of witches in 1484 and the practice was guided by a book called Malleus Malef icarum (The Witches’ Hammer) written by two Dominican priests who acted as inquisitors in Germany. Malleus Malef icarum was used extensively by judges throughout Europe as a guide to detecting witches. Anyone who behaved oddly (i.e. the mentally ill) could be accused of being a witch, and these unfortunate individuals were tortured if they refused to confess to gruesome witches’ practices. Whether or not they confessed, these people were then killed, by burning, hanging or beheading, and their confessions fuelled further belief in the existence of witches (Trevor-Roper, 1967). The idea that people who are mentally ill are possessed by the devil is consistent with the ‘bad’ not ‘mad’ perspective, and leads to a variety of sometimes inhumane treatments, as a way of making the devil leave the person’s body, typically involving some kind of physical pain on the basis that devils don’t like pain. Not all such treatments are inhumane. Some undeveloped tribes in Africa and South America use ritualistic ‘theatre’ where a healer, often with the help of the whole tribe, tries to drive out the devil by exhortation. However, in the West, the supernatural belief in the cause of mental illness led to the mentally ill being confined in difficult circumstances. In the 15th century, mentally ill people were sometimes confined to a ‘ship of fools’ (Foucault, 1962, 1967). The first mental Asylum was founded in Valencia in Spain in 1409 with the explicit purpose of locking up those who were unable to live in society. In 1547 Henry VIII founded an asylum at the priory of St Mary of Bethlehem in London. This ‘hospital’ or Bedlam as it came to be known housed mentally ill people in sordid, degrading conditions (MacDonald, 1981; Scull, 1979; C hung_c13.indd 272 Chung_c13.indd 272 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Clinical Psychology and Philosophy of Mental Health 273 Shorter, 1998). Londoners would come to view the madmen through the iron gates for a Sunday excursion, and viewing of madmen for entertainment (tickets were sold for a view) went on into the early 19th century. The exceptions to poor treatment occurred where mild mental illness occurred amongst wealthy people (e.g. nobles). In the middle ages, ‘odd’ people from the nobility were often sent to live in monasteries – which provide a safe and generally caring environment. Nevertheless, for the majority the only treatment was incarceration in Bedlam, or some similar degrading institution. Robert Burton’s (1577–1640/1836) Anatomy of Melancholy was first published in 1621 and then went through six ever expanding editions with a last edition in1651. The book can be seen as part of the Renaissance – the belief in rationality rather than divine authority of the church. Burton provides a very detailed account of what various authorities had said about the cause of melancholy – what would be now called depression – as well as the various cures. Burton’s writing spans the wide range of religious and scientific treatments then available, and included cynical and often witty comments about some of the interpretations and treatments and causes. Burton believed that melancholy had a physical not a supernatural cause. His book can be interpreted as rational man trying to find a  rational solution when none was readily available. The following quotes are taken from the electronic version of the book at http://www.gutenberg.org/ ebooks/10800 (no page numbers are given) and which the interested student might care to examine in more detail: ‘To give some satisfaction to melancholy men that are troubled with these symptoms, a better means in my judgment cannot be taken, than to show them the causes whence they proceed; not from devils as they suppose, or that they are bewitched or forsaken of God, hear or see, &c. as many of them think, but from natural and inward causes, that so knowing them, they may better avoid the effects, or at least endure them with more patience.’ ‘Tis a common practice of some men to go first to a witch, and then to a physician, if one cannot the other shall,‘ ‘We must use our prayer and physic both together: and so no doubt but our prayers will be available, and our physic take effect.’ Stanley (2000) provides a useful review of Burton’s book, pointing out that not only was prayer suggested as cure but also herbal remedies such as marigold, black hellebore, and mugwort featured as possible remedies. Wine was a possible cure as was blood letting, leeches (particularly if applied to haemorrhoids) as well as boring holes in the head to let out the vapours. Burton examined a whole variety of techniques for curing depression, some of which he dismissed as fanciful, but many others he suggested might be effective, and these effective therapies included remedies based on the Hippocratic tradition such as blood letting (to reduce levels of blood) and purging (to reduce levels of phlegm). Purging involved either getting the person to vomit or causing diarrhoea. C hung_c13.indd 273 Chung_c13.indd 273 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. 274 History and Philosophy of Psychology Burton’s book was popular because it fitted with the growing trend in society for rational thought. Of course, neither marigolds, boring holes in the head nor blood letting are effective treatments for mental illness, but at least there was an attempt for rational rather than supernatural interpretation. Burton was writing at a time when persecution of witches was at its height, and which continued for some time afterwards. The last legal execution of a condemned witch occurred in Switzerland in 1782. Modern psychiatry can therefore be seen as the consequence of the success of a rational, scientific cause of mental illness in contrast to a religious interpretation. Hippocratic Versus Modern Medicine The principles underlying Hippocratic medicine continued to be applied to mental illness right up to the 19th century. William Battie 1 published his Treatise on Madness in 1758. Battie believed in consequential illness – that particular events and experi- ences could cause illness, and he was not optimistic about treatments. Battie wrote: ‘Madness is frequently taken for one species of disorder, nevertheless, when thoroughly examined, it discovers as much variety with respect to its causes and circumstances as any distemper whatever: Madness, therefore, like most other morbid cases, rejects all general methods, e.g. bleeding blisters, caustics, rough cathartics, the gumms and faetid anti-hysterics, opium, mineral waters, cold bathing and vomits.’ (cited in Morris, 2008) Battie’s treatise was the subject of considerable debate. John Monro who was the physician to the Bethlem hospital (Bedlam) believed that it was possible to cure madness and was a strong believer in the ‘cure’ effected by causing the patient to vomit. Monro (1758) disagreed with Battie’s treatise and published the reasons for his disagreement in a book published two months later. He provided strong support for the method of getting patients to vomit. The rationale for this treatment was that madness was caused by an excess of phlegm, and phlegm could be reduced by vomiting. Incidentally, an excess of phlegm did not cause only madness – it also could lead to other diseases that affected breathing (nowadays called bronchitis and asthma). ‘Notwithstanding we are told in this treatise , that madness rejects all general methods, I will venture to say, that the most adequate and constant cure of it is by evacuation; which can alone be determined by the constitution of the patient and the judgment of the physician. The evacuation by vomiting is infinitely preferable to any other, if repeated experience is to be depended on…’ (Munro, 1758, p. 50) ‘I never saw or heard of the bad effect of vomits, in my practice; nor can I suppose any mischief to happen, but from their being injudiciously administered; or when they are given too strong, or the person who orders them is too much afraid of the lancet .’ (Munro, 1758, p. 50) Chung_c13.indd 274 Chung_c13.indd 274 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Clinical Psychology and Philosophy of Mental Health 275 ‘The prodigious quantity of phlegm, with which those abound who are troubled with the complaint, is not to be got the better of but by repeated vomits ; and we very often find, that purges have not their right effect, or do not operate to so good purpose, until the phlegm is broken and attenuated by frequent emeticks .’ (Munro, 1758, pp. 50–1) If one considers that being made to vomit is an aversive experience, it would follow that people would be less likely to exhibit ‘unusual’ behaviours if someone was to treat them with the vomiting cure! During the 19th century, other aversive treat- ments included cold water baths and showers based on the principle of shock, swinging chairs that induced fear and disorientation of the disturbed senses. The Benjamin Rush’s ‘Tranquilizer, consisted of a box placed over the patient’s head and the patient being strapped into a chair. The ‘tranquilizer’ was designed to inhibit sensation and therefore irritation but in fact it was an early form of sensory deprivation. Inhibition could be achieved by the straitjacket (invented in 1790) – which inhibited movement of the arms but allowed the patient to walk around. Although these inhibitory techniques were introduced with the best intentions, the idea of sensory deprivation as a punishment was in fact used in the Model Prison in Tasmania in the 19th century, as it was recognized that isolation was, as a type of psychological punishment, more effective than the physical punishment of beating. While mental illness was being treated using techniques deriving from the Hippocratic tradition, an alternative to Hippocratic medicine was being developed, which was being applied to physical illness and so could potentially be applied to mental illness (Maher & Maher, 1985b). Instead of seeing illness as being caused by an imbalance in humours, the new approach believed that there was a specific and local cause for all illnesses. This new belief was based on an analogy of the body as a mechanical system – and reflected the earlier development of clockwork and other mechanical devices. So, for example, heart disease was caused by pathology of the heart, rather than by an excess of blood. According to this perspective, disease is caused by something analogous to a broken cog. There is something that is wrong in the body which if corrected will cure the disease. A  number of physicians were behind this new approach, but the best known is Rudolf Virchow (1821–1902), a pathologist who is famous for his declaration that there was no such thing as non-specific illness (the basis for Hippocratic medicine) only specific illness (Rather, 1958). This new type of medicine formed the basis of modern Western medicine, and became increasingly successful during the 19th century for several reasons. First, there was evidence from the examination of corpses that diseases did indeed involve specific pathophysiologies. Second, different diseases were associated with different types of tissue abnormality. Finally diseases were shown to have distinct characteristics at a cellular level. Each disease was found to be associated with a particular physiological abnormality. If physical illness could be shown to be caused by physiological abnormalities, it became logical to look for the causes of mental illness in terms of pathophysiology of the brain. C hung_c13.indd 275 Chung_c13.indd 275 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. 276 History and Philosophy of Psychology The idea of specific pathophysiology was applied to mental illness in the early 19th century, with several authors suggesting that some kind of pathology in the brain was responsible. This view was supported particularly by Wilhelm Griesinger who was a psychiatrist working in Berlin. His textbook, Pathology and Therapy of Mental Illnesses for Doctors and Students was published in 1845. One reason for supporting this new form of biological cause of illness was the discovery that syphilis was caused by a microbe. Advanced syphilis leads to a form of dementia, and so it is logical to conclude that this dementia is caused by the microbe. Griesinger believed that other specific and local explanations would explain other mental diseases. Although there was little in the way of new therapies, there was now a belief that each mental illness was due to a different physiological abnormality, and therefore each mental illness would respond to a different type of treatment, namely a treatment that corrected that physiological abnormality. Hippocratic techniques such as blood letting and purging were used both for physical and men- tal problems. The same treatment would be used irrespective of the disease. The hope engendered by the new biological theory of mental disease was that in time new treatments would be discovered that applied solely to mental illness. The pioneers in the new way of thinking about mental illness also suggested an alternative approach to treatment. When Philippe Pinel (1745–1826) was put in charge of a mental asylum in Paris, he decided that inmates should no longer be shack led (Pinel, 1801/1962). Vicenzio Ciarugi (1759–1826) in Italy and Benjamin Rush (1745–1813) in America also encouraged humane treatment of mentally ill people. All three believed that the cause of mental illness was a specific pathology of the brain, not an imbalance of humours. Rush, in particular, was dismissive of the techniques based on the older Hippocratic medicine suggesting that they did no good at all (Rush, 1812). Moral Treatment During the 19th century, the view that mental illness was caused by a pathophysiology was gaining momentum, bolstered in part by the success of this particular approach in other areas of medicine. However, in parallel with this scientific approach a rather different religious inspired view of mental illness was developing. During the late 18th century, Christianity and Protestant Christianity in particular had moved away from an emphasis on the supernatural and towards a moral position on contemporary life. Christianity was a moral framework for understanding the world, and this moral framework included the concept of charity. These moral Christians were instrumental in setting up an alternative psychological framework for understanding mental illness. The psychological framework was one where mental illness was seen as a psychologically caused illness, and one where unsatisfactory environmental factors could contribute to disease. So, in the 19th century an alternative type of treatment was development, C hung_c13.indd 276 Chung_c13.indd 276 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Clinical Psychology and Philosophy of Mental Health 277 called ‘moral treatment’. In England, William Tuke (1732–1822) established the York Retreat as an asylum with calming and religious overtones – Tuke was a Quaker and philanthropist (Tuke, 1813/1964). In the United States Dorothea Lynde Dix (1802–1887) was a teacher who, on realizing how terrible asylums were, campaigned for better and more humane treatment of the mentally ill (Dix,  1971/1843–1852). Neither of these were medically trained. Both they and others like them provided a means for caring for the mentally sick, where the money was often raised by charitable donations. Moral treatment had several characteristics. One was the idea that a person, such as a doctor, could impose moral authority on the ill patient and so change the ‘vicious chain of ideas’ which the patient was prone to experience. The idea of moral authority ties in well with the idea of Church authority. There should be a person or institution in charge which imposes on the will of others. A second feature of moral treatment was that the mentally ill should be restrained in cir- cumstances of harmony and peace – so they should be placed in pleasant rather than degrading circumstances. A third feature of the moral treatment was the idea that the patient should be subjected to discipline so as to lead a regular and orderly life. Those approaching mental illness from the point of view of ‘moral treatment’ as well as those adopting the new biological framework both believed in the humane treatment of the mentally ill. The old asylums for restraining the ill were built in cities. The new institutions for the care of the mentally ill were built in the country, and there was an attempt to make them attractive. The new institutions were also shielded from the public so that the degrading spectacle of the mentally ill being ‘exhibited’ would not occur – though this also shielded the public from the uncomfortable truth that the mentally ill existed. Mental institutions were built with a curved drive way so they were not visible from the road – which is the origin of the expression ‘going round the bend’. Many institutions were built in the 19th  century based on a mixture of moral treatment as well as the very limited treatments offered by the biological perspectives. One of these latter treatments, invented by Rush, was the tranquilizing chair. The patient was strapped into a chair so as to prevent movement, and prevented from seeing or hearing anything, for hours at a time. So although there was a belief in humanity in the 19th century treatment, this humanity was tempered by a somewhat strict view about how to achieve good behaviour. The mental asylums of the 19th century were large institutions with attractive grounds that were to a large extent self-sustaining. There would be a farm, and a laundry, and when electric lighting was invented, many asylums had their own electric generator. As far as possible all work on the asylum was carried out by inmates. There is a curious parallel between the asylums of the 19th century and monasteries of the middle ages. Both were safe havens for the mentally vulnerable. Both were self-contained societies that operated, to some extent, independently of the world outside. Some, such as Tuke’s York C hung_c13.indd 277 Chung_c13.indd 277 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. 278 History and Philosophy of Psychology Retreat (see above) which was founded by the Quakers (a religious, protestant group) in York, England opened in 1796, were founded on genuine caring principles in response to the harsh treatments at the latter part of the 18th century (Digby, 1985). So far, our history of mental illness has focused on (a) the Hippocratic idea of imbalance, (b) the idea of specific pathophysiology which forms the basis of modern western medicine, and (c) the idea of moral treatment which owes its origins to religious beliefs. There is one other development which needs to be taken into account: the science of classification. Classif ication of Mental Diseases Science in the 19th century involved classification. Systems were developed for classifying plants, for classifying animals, and for classifying the elements. It is not surprising therefore, that classification of mental illness was also part of Victorian scientific thinking. An early classification of mental illness can be found in a report prepared in 1844 for the Metropolitan Commissioners in Lunacy – a body of people responsible for funding mental asylums in London. The classification consists of I. Mania, which is thus divided: 1. Acute Mania, or Raving Madness. 2. Ordinary Mania, or Chronic Madness of a less acute form. 3. Periodical, or Remittent Mania, with comparatively lucid intervals. II. Dementia, or decay and obliteration of the intellectual faculties III. Melancholia IV. Monomania V. Moral Insanity The three last mentioned forms are sometimes comprehended under the term Partial Insanity. VI. Congenital Idiocy VII. Congenital Imbecility VIII. General Paralysis of the Insane IX. Epilepsy These classifications were influenced by Hippocratic medicine but in reality were a simply a brave attempt to make a classification system for observed behaviour of mentally ill patients. There was no attempt to link the classification to any underlying biological cause. Emil Kraepelin (1856–1926) had studied with Wundt and was impressed by Wundt’s attempt to classify the mind. Kraepelin believed he C hung_c13.indd 278 Chung_c13.indd 278 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Clinical Psychology and Philosophy of Mental Health 279 could do the same for mental illness. Furthermore, Kraepelin was an admirer of Griesinger (see above) and shared with him the view that mental illness had a biological basis. As the director of an eighty-bed University clinic at the University of Tartu (now in Estonia), Kraepelin had plenty of opportunity to observe and classify mentally ill patients. Starting with the earlier descriptions provided by Hippocrates, Kraepelin developed a system of classification of mental illness that became highly influential, and which form the basis for modern classification systems of mental illness, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association (1994). The basis of Kraepelin’s system was to examine patterns of symptoms, because no one symptom of itself was able to classify a mental illness (Berrios, 1996). Kraepelin’s classification (Kraepelin, 1899/1990) was based on an underlying assumption that different mental diseases had different forms of biological pathology. Kraepelin used concepts such as mania and melancholia which dated back to Hippocrates, but also invented new classifications. One of these, dementia praecox, was defined as ‘sub-acute development of a peculiar simple condition of mental weakness occurring at a youthful age.’ Kraepelin believed that dementia praecox was an incurable degenerative disease. However, later, Eugene Bleuler (1847–1939) showed that the disease could sometimes be cured and it was renamed schizophrenia. Although Kraepelin and Bleuler used different terms for what is now known as schizophrenia (Bleuler, 1911, 1924), there is one more important difference between them. Kraepelin based his classification on the principle that there must be a unique pathophysiology associated with each mental illness, and so each mental illness was distinct. Each mental illness fell into a distinct category, just as each physical illness fell into a distinct category. The idea that mental illnesses are distinct – i.e. they form types or categories – is the basis for the modern clas- sification of diseases. By contrast, Bleuler believed that people varied along  dimensions of mental illness, leading to the idea that there are not distinct categories (i.e. you either have it or you do not) but rather continua of mental health problems. The idea of continua was used later by Hans Eysenck and other psychologists who favoured a psychological (i.e. variation along continua) rather than medical (i.e.  variation between types) approach to mental illness (see an earlier chapter). Traditionally, psychiatrists have favoured types whereas psychologists have favoured traits, the former reflecting the assumption of specificity on which Kraepelin based his classification system. The search for a biological basis for mental illness was a common preoccu- pation amongst psychiatrists at the end of the 19th century. Kraepelin defined manic-depression as a disease, and with his colleague, Alois Alzheimer, defined a dementia now known as Alzheimer’s disease. It was Alzheimer who discovered the patho physiology associated with this particular dementia, but the name Alzheimer’s disease was given by Kraepelin as part of his classification system. Alzheimer’s disease was an important discovery in that it was possible to C hung_c13.indd 279 Chung_c13.indd 279 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. 280 History and Philosophy of Psychology demonstrate abnormal brain tissue in people who died of the disease, showing that the cause of Alzheimer’s disease was specific, local and in the brain (Goedert & Ghetti, 2007). The discovery of Alzheimer’s disease was the only case at the time where mental illness could be positively identified with a specific pathology. Many historians of psychiatry believe that Kraepelin, not Freud should be considered the father of psychiatry. The reason is that Kraepelin used a biological model of mental illness that would, almost a century later, form the basis for modern psychiatric drugs. The idea that there were different types of mental illness led to the emergence of a distinction which was important in the history of mental illness. The distinction was between madness and what were called ‘nervous disorders’. Nervous disorders were given a variety of names, including neurasthenia or ‘weakness of the nerves’. Nervous disorders were treated with a variety of methods such as hypnosis, but included a variety of common-sense therapies such as rest, and travel and good quality food. The basic assumption of these therapies was that nervous disorders had a physical basis and required a cure which focused both on the body and on the mind. Sanatoria or spas were developed in Europe and had a very different function to either the older or newer asylums. For nervous diseases patients were actively treated rather than placed in a safe, moral environment until they got better, and they were treated by neurologists. One of the best known cures was called the ‘rest cure’ and it was developed by Silas Weir Mitchell (1894) in the United States and then widely used in Europe. The rest cure was used in particular for women who had hysterical nervous disorders. Florence Nightingale came back from her legendary work helping the wounded soldiers in the Crimean War, and developed neurasthenia – now known as Chronic Fatigue Syndrome. She was prescribed the rest cure and never rose from her bed again until the day she died. The old cures are not necessarily the best! The Development of Psychoanalysis The early days of psychoanalysis was described in Chapter 9. As reviewed in that chapter, Sigmund Freud was trained in physiology. He also collaborated early in his career with others who believed in a biological basis of mental illness, such as Charcot. Additionally, his ‘scientific project for psychology’ was based on the assumption of a biological basis for mental illness. However, Freud rejected this biological interpretation in the development of psychoanalysis (Ellenberger, 1970). Some, such as Roith (2008), have suggested that this change was in part motivated by the current belief that mental illness had a hereditary basis and that Jews had a proneness to degeneration and hence mental illness, which coupled with the negative stereotypes towards mental illness at the time may have fuelled Freud’s acceptance of an alternative, non-biological, non-genetic, interpretation. What is clear, however, is that when Freud abandoned his ‘scientific project for psychology’ he was adopting an approach to mental illness that was inconsistent with the way C hung_c13.indd 280 Chung_c13.indd 280 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Clinical Psychology and Philosophy of Mental Health 281 In the 19th century, having a mentally ill relative was associated with social stigma. People readily bought into the idea that madness ran in families and so those with mad relatives should be avoided as future spouses. However, there is another very obvious reason why the medical community turned its back on the biological interpretation of mental illness at the beginning of the 20th century and embraced psychoanalysis. The reason was that the therapy was at least capable of doing some good. Compare Freud’s talking therapy to the operations Fliess was carrying out on patients’ noses (see Chapter 9). Talking to patients can help, even if it is for reasons different from those believed by the therapists. Operating on noses just does harm. At the end of the 19th century and during the early 20th century, the biological model of mental illness was not confirmed by the data. Despite careful examina- tion of the brains of mentally ill patients, nothing wrong could be found with schizophrenics, depressives, or manic depressives. Not only had the biological model yielded little in the way of diagnosis, it yielded even less when it came to treatment. Medical treatment of mental illness followed a psychoanalytic route simply because it was more successful than anything else at the time, and even though its success was limited to nervous diseases. It is a feature of the intractabil- ity of mental illness that anything that works, however, little, can be greeted as a major breakthrough. medicine was developing at that time. At the same time he started a distinction which was to persist – between mental and physical illness. Box 13.1 Mental Versus Physical Versus Brain Illness It is common to distinguish mental illness from physical illness. Mental illness includes depression and schizophrenia. Physical illness includes heart disease and cancer. However, this distinction is based on a logically fallacy. How can an illness be mental and not physical? Unless one believes in the  medieval idea that mental illness was something visited by Divine intervention, all mental illnesses must be physical. There are no minds without bodies. Mental illness must involve some form of physical represen- tation. Of course, it would make sense to distinguish brain illness from illness in other parts of the body, but that is not what is done. Brain illness makes sense – Alzheimer’s disease is one of the few diseases where a pathophysiology of the brain is identified. Why do we use the term mental illness, then? The reason is that the term is applied because we are unable to find a physiological basis for the disease. But any rational person will realize that a physiological basis must exist – even if that physiological basis is best treated by psychological interventions. C hung_c13.indd 281 Chung_c13.indd 281 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. 282 History and Philosophy of Psychology During the first half of the 20th century psychiatry was based almost entirely on psychoanalysis. Freud and Jung were reviewed in detail in Chapter 9, but it was Freud’s rather than Jung’s theory which was dominant in the medical community. Jungian therapists did not require a medical degree whereas Freudian ones did, and this difference meant that Freud’s theory was more accepted within the medi- cal community. The first clinical psychological clinic The history above is one of psychiatry not psychology. The only link we have made with psychology as a discipline is that Kraepelin was an admirer of Wundt. We now turn developments that were taking place in psychology at the end of the 19th century. We showed in previous chapters that there were two major trends in psychology: a European trend, started by Wundt, for examining the structure of the mind and where psychology is not considered an applied science; and an American trend, started by James, for examining the function of the mind and where psychology is considered to have applications, in particular educational applications. Lightner Witmer (1867–1956) trained under Wundt in Leipzig and on returning to the USA in 1892 took up a position in the University of Pennsylvania where he taught psychology, the kind of psychology taught by Wundt. Witmer also joined the American Psychological Association (APA) as a charter member when the APA was formed in 1892. In 1894, his university put on courses for school teachers and Witmer became involved in teacher education. One teacher described a boy who had difficulty learning to spell – the boy would now be called dyslexic – and Witmer Box 13.2 An Excerpt From ‘Medicine’ in the Encylopaedia Britannica, Published in 1926 In mental diseases little of first-rate importance has been done. The chief work has been the detection of chronic changes in the cortex of the brain, by staining and other histological methods, in degenerative affections of this organ… An enormous accumulation of lunatics of all sorts and degrees seems to have paralysed public authorities, who, at vast expense in buildings, mass them more or less indiscriminately in barracks, and expect that their sundry and difficult disorders can be properly studied and treated by a medical superintendent charged with the whole domestic establishment with a few young assistants under him. The life of these insane patients is as bright, and the treatment as humane, as a barrack life can be; but of science, whether in pathology or medicine, there can be little. C hung_c13.indd 282 Chung_c13.indd 282 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Clinical Psychology and Philosophy of Mental Health 283 saw the child to see if he could help. Soon after that, Witmer offered a course on how to work with students who were ‘mentally defective, blind, or criminally disturbed’, and formed the world’s first psychological clinic at his university in 1896. Witmer coined the term clinical psychology to name this new profession which he set about ‘promoting, publishing an article entitled ‘Practical work in psychology’ in the journal Pediatrics also in 1896 (Witmer, 1896). In 1908, Witmer set up a residential school for the care and treatment of children with intellectual or behavioural problems (McReynolds, 1997). Although the diversity of Witmer’s clinical cases increased, there was always an emphasis on educational aspects of clinical psychology (Witmer, 1907). Witmer’s approach was one which emphasized measurement, in particular physical and neurological traits, and has been criticized as being somewhat limited, but this criticism is not entirely justified. Witmer was interested in the dynamic psychology being developed in Europe by Freud, but was unconvinced. He was also interested in the work of Galton and others, and at first believed that hereditary was important for mental illness, but later came to the conclusion that the environment was more important. This shift in emphasis from hereditary to environment had an immense impact on the development of clinical psychology. If mental illness is purely genetic, then there is little that can be done about it, other than lock up the poor wretches out of harm’s way. However, if mental illness is brought about by an unsatisfactory environment, the implication is that improving the environment of patients will help them get better. Witmer promoted an approach whe reby the mentally ill were helped to overcome the circumstances of their lives, and instead moved the mentally ill to better environments. This environmental focus was consistent with the emphasis on learning and education which characterized early psychology: mentally ill people had learned things incorrectly, and this idea was to resurface in the behaviourist approach to mental illness. Witmer’s clinic was headed by a psychologist and was staffed primarily by psychologists and was a starting point for psychologists, rather than medical trained staff managing mental illness. Other and later clinics in the USA also had a focus on mentally ill people. William Krohn started a laboratory for the study of the insane in 1897 in Illinois, and in the early part of the 20th century several hospitals in the USA introduced the practice of a psychological examination of patients on admission. Psychologists worked alongside psychiatrists in a way which was later to be characteristic of clinical psychology in general, however, these early psychologists focused on measurement not on treatment (Reisman, 1991). Behaviourism The history of behaviourism was covered in Chapter 7. Behaviourism was the dominant type of theory in psychology at the same time that psychoanalysis was the dominant type of theory in psychiatry. Behaviourism and psychoanalysis were therefore competitors in terms of therapy, but as Freudian Psychoanalysts were medically trained, they had the authority for treating patients. One of the major C hung_c13.indd 283 Chung_c13.indd 283 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. 284 History and Philosophy of Psychology advocates of behavioural techniques was Hans J. Eysenck (1916–1997) who argued that psychoanalysis produced no benefits at all compared with natural history (Eysenck, 1953, 1957). Eysenck provided evidence to support the view that only behavioural techniques worked, but, importantly for a medical audience, he suggested a physiological basis for individual differences, so that his behavioural theory was based on a biological understanding of psychology, and the biological orientation coincided with the discovery of psychoactive drugs. According to behaviourist principles, mental illness is understood in terms of some form of conditioning. Watson and Raynor’s famous study (Watson & Raynor, 1920) with little Albert (see Chapter 7) provided a clear rationale, at least to behaviourists, about the cause of mental illness (see Chapter 7). The cure of such illness had therefore to reside in conditioning. The cause and the cure had the same mechanisms. In the 1950s, homosexuality was classified as an illness. Hence a behavioural technique for treating homosexuality was to give gay men electric shocks while they looked at naked pictures of men. Fortunately, such interpretations and treatments are a thing of the past. However, behaviourism has left one particular type of therapy  that is in use today. Systematic desensitization was developed by Joseph Wolpe  (1915– 1997), a technique which gets its name from a technique used in immunotherapy (Wolpe, 1958). If a person is allergic to bee stings, then immun- otherapists use a technique called desensitization in which minute quantities of bee venom are injected under controlled conditions. Systematic desensitization uses the same principle, but for anxiety. In the case of systematic desensitization, anxiety is deconditioned, by exposing the person to the anxiety producing object under controlled conditions. So for example, if a person has an irrational anxiety over dogs, the dog will be presented at very large distance, and then gradually brought closer to the person. Systematic desensitization is in fact one of two behavioural techniques for curing anxiety. The other is flooding. If someone is frightened of lifts, then using the flooding technique, the person is locked in a lift. The result is an intense fear, but over time the fear subsides as the person becomes exhausted. The important point to note about all behavioural techniques is that they do not involve talking – they are not talking therapies. Instead they are behavioural the- rapies in that behaviour is modified by introducing special reinforcing conditions. The techniques which have derived from behaviourism are all techniques of behaviour modif ication. Humanistic/existential psychology The development of humanistic/existential psychology was reviewed in Chapter  11. Humanistic/existential psychology grew out of a rejection for both behaviourism and psychoanalysis. A primary focus of humanistic psychology was the way people find meaning in their lives is important to well-being and mental health. Like psychoanalysis, but unlike behavioural techniques, humanistic/ existential therapies involved talking – either the patient or therapist or both C hung_c13.indd 284 Chung_c13.indd 284 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Clinical Psychology and Philosophy of Mental Health 285 talked. Hence, it is also a talking therapy. However, the humanistic/existential approach did not compete with psychoanalysis in the sense that medical power remained with the psychoanalytically trained medical doctors. The humanistic/ existential therapy tended to be used as a way of achieving personal growth rather than as a therapy for mental illness. One type of techniques developed by those who were part of the ‘Third Force’ in psychology was called the encounter group. The encounter groups were popularized during the 1960s particularly under the Esalen Institute in California, an institute that characterized the counter-culture movement of the 1960s. The basic idea of the encounter groups (also called the t-group or tension group) was that people should be completely honest and open with each other. This honesty stands in opposition to what was perceived as the hypocrisy of the previous generation and, according to those promoting the idea, would contribute to growth. Two points should be made about the encounter group movement. One was that it was based on the idea that people who were not trained could help others. This idea that non-specialists could be therapeutic runs counter to a medical framework where training and accreditation is the basis for practice. Hence, the encounter group movement represented a type of therapy which was unacceptable to conventional medical opinion. The second point is that because the group members could quite legitimately say hurtful things in the interests of honesty, they had the potential to damage emotionally vulnerable people (Fuller, 2008). Critics of encounter groups therefore viewed them with suspicion and considered them a potentially dangerous form of therapy. The strange case of nude psychotherapy Nature provides an opportunity for people to gain meaning in life. Several studies show that an association with nature – for example looking at a natural rather than a built environment – leads to better health (Ulrich, 1984). One of the most curious, and largely forgotten, therapies associated with the humanistic movement stems from the idea that to become one with nature it was necessary to be nude. Nude psychotherapy was introduced by the psychotherapist, Paul Bindrim in the 1960s and stimulated both academic and popular interest (Bindrim, 1969; Nicholson, 2007). The idea of nude psychotherapy can be traced back to an article which appeared in a prestigious psychology journal in 1933, written by Howard Warren (Warren, 1933). The author argued that nudism, which was popular in the 1930s particularly in Germany, was a therapeutic return to nature, and that nudism provided an escape from the repressive and perverted morality of modern society. Several other psychologists shared the view that there was something intrinsically healthy in nudism, but the idea did not achieve main stream acceptance. In 1967 Paul Bindrim conducted the first nude psychotherapy session (Nicholson 2007). His rationale was that nudism would encourage intimacy between participants. Aware of the impact of his suggestion, Bindrim ensured that the press were notified, which made sure that his work was recognized not only by the general C hung_c13.indd 285 Chung_c13.indd 285 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. 286 History and Philosophy of Psychology public but also by academic psychologists. Nude psychotherapy was supported by Abraham Maslow, who had previously shown he was sympathetic to n udism as way of overcoming inhibitions and discovering the real person. Bindrim developed the use of nudism in ‘psychological marathons’ which were encounter groups lasting 18–36 hours. Despite original support from Maslow, Bindrim was investigated by an ethics committee of the American Psychological Association, and although he was exonerated, support gradually waned for what was perceived as a wacky and morally questionable activity. Maslow’s report waned on reading negative reports from those taking part. Nude psychotherapy is just one of several types of therapy that derived from the belief that a particular activity is therapeutic. Other less contentious types of therapy include music therapy, art therapy and dance therapy. The rise of drug therapy, physical treatments and the antipsychiatry movement The history of medicine is not one of gradual accumulation of knowledge and clinical skill. On the contrary, there is one period during the last 100 years when medicine has advanced far more rapidly than at other times, and that is the period around the Second World War and for the next two decades. Developments as diverse as the polio vaccine, antibiotics and steroids all dated from this period. Not  only were there new drugs for otherwise incurable somatic diseases, but psychoactive drugs were developed. The first anti-psychotic drugs and the first anti-depressant drugs were both developed in the 1950s, with the first clinical trial of the anti-psychotic drug chlorpromazine being carried out in 1952 and its widespread use by the late 1950s (Tuner, 2007). These drugs had a revolutionary effect, with the rapid reduction of the inpatient populations of hospitals. Biological psychiatry had at last arrived. The exact nature of mental illness had not been discovered – no-one had any idea about the biological basis of schizophrenia – but at last the disease was responding to the kind of treatments that were familiar in medicine. Although drug therapy was the major break through for biological treatments, other treatments were also being developed. Electroconvulsive therapy or ECT as  well as insulin shock therapy were pioneered during the late 1930s (Endler, 1988). Although these latter treatments are highly controversial and now seldom used, at the time they reflected a growing confidence in biologically based treatments. The increased use of pharmacological medication preceded the cultural revolution of the 1960s. The 1960s was a time when freedom of expression was valued in contrast to the perceived control of earlier generations. It is possible to criticize all psychiatric treatments as being controlling – and indeed that criticism has been made very powerfully by Masson (1988). One of the criticisms of anti- psychotic drugs was that they acted like a chemical cosh. That is, they did not cure the patient; they just suppressed the patient’s symptoms but at the same time C hung_c13.indd 286 Chung_c13.indd 286 11/25/2011 8:49:55 PM 11/25/2011 8:49:55 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Clinical Psychology and Philosophy of Mental Health 287 suppressed any motivation that the patient may have had for themselves. Additionally, it was suggested that anti-psychotic drugs have been used to control behaviour, including the control of ‘naughty’ children, a use to which these drugs cannot ethically be put. The result of these criticisms was the development of the anti-psychiatry movement (of which Ronny Laing was one of the most influential figures (Laing, 1959, 1961, 1971). The anti-psychiatry movement was part of the 1960s counter-culture which rejected the authority of current psychiatric treatments (Tantam, 1991). This rejection of the authoritarian nature of medical control was attached not only to drug therapy, but also to behavioural therapies, particularly those using electric shock as an aversive stimulus. Anthony Burgess wrote a novel in 1962, called A Clockwork Orange which was later to be made into a film. The essential idea of the film was that although socially undesirable behaviour was itself bad, it was equally bad to control such behaviour through electric shock therapy as such actions destroyed the individual who was being treated. It is important to stress how mental illness remains a problem today even with the rise of pharmacological treatments. Neither anti-depressants nor anti-psychotic drugs actually cure mental disease. All they do is control symptoms. Indeed the extent to which depression is actually controlled by drugs is controversial. Meta- analyses suggest that even the best anti-depressants today have only a small pharmacological effect – at least 80% of the improvement observed in clinical practice is due to placebo, namely the psychological effect of taking a drug which is believed to work in contrast to its biological effect (Kirsch, 2009). The rise of cognitive psychology, rational emotive therapy and cognitive behavioural therapy Cognitive psychology has several precursors in earlier ideas in the history of psychology. Hull (see Chapter 7) believed that it made sense to analyse behaviour using mechanical principles. Tolman (see Chapter 7) suggested that rats could form cognitive maps of their surroundings. Chomsky’s critique of behaviourism showed that behavioural principles could not explain higher mental processes (see Chapter 7). Kelly (see Chapter 11) suggested that people understand the world using a process of judgement which, to many, would be considered cognitive. Cognitive psychology does not start at any one point, but a notable beginning was Donald Broadbent’s (1958) book Perception and communication which was published in 1958. Ulrich Neisser coined the term cognitive psychology in the book with that term as its title in 1967. The essential idea of cognitive psychology was that humans were rational, information processing machines, and could be understood as that. The idea that people are rational leads to the conclusion that mental illness can be managed by appealing to people’s rationality. Rational-emotive therapy was published in a jour- nal article by Albert Ellis in 1957 and later as a book in 1962. Cognitive behavioural therapy (Beck, 1967) was developed a decade later and incorporates not only the idea of cognitive change but also ideas of behavioural management which owe C hung_c13.indd 287 Chung_c13.indd 287 11/25/2011 8:49:56 PM 11/25/2011 8:49:56 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. 288 History and Philosophy of Psychology their origins to behaviourism. Thus cognitive behaviour therapy can be seen as mixture of cognitive and behavioural techniques. Conclusions and Some Remaining Issues Nowadays there are two options to treating mental illness. One is to use the biological approach of drugs, with or without any other form of ph ysical tr eat- ment (ECT therapy is seldom used). The other is to use talking therap y – i.e. where the patient or therapist or both talk. Talking therapy was developed by a psychiatrist, namely, Freud. Although psychodynamic therapies are still used, talking therapy nowadays is seldom used by psychiatrists. Psychiatrists have returned to their original medical roots: treating mental illness with biological therapies. Instead, talking therapies have become the province of psychologists, despite the fact that the earliest psychological therapy, that of behaviour modification, was not a talking therapy. Nowadays, most psychologists either use therapies which have arisen out of the cognitive revolution, most frequently cognitive behavioural therapy (CBT), or those which have arisen out of the humanistic/existential tradition, most commonly that labelled counselling, or, less commonly, some therapy that is based on a modern interpretation of psychoanalysis. Whereas CBT therapy is a commonly accepted form of therapy within state and private health care systems, counselling has always a lower status. Why is this? Modern medicine is based on an assumption that each disease is associated with a particular physiological abnormality. This assumption is sometimes called the assumption of specificity. Each disease has a specific cause. There are no non-spe- cific diseases, and it was the rejection of non-specific diseases that distinguishes modern medicine from the earlier Hippocratic medicine. The aim of modern medicine is to (a) find out what is wrong by a process of diagnosis and (b) correct that which is wrong by an intervention of some kind. This idea of correcting ‘that which is wrong’ is not only a feature of biological interpretations for mental illness but also most psychological interpretations. In Freud’s theory ‘what is wrong’ is the effect of repressed trauma. In the case of CBT theory ‘what is wrong’ is that people have incorrect cognitions. In each case, whether drug or psychological, the therapist intervenes and corrects that which is wrong. Disease can be treated like a broken clock: the clockmaker repairs the bit which is faulty and only that bit. The assumption of specificity is central to medical theories, and hence acceptance in medicine. CBT is accepted within medicine in part because it assumes the prin- ciple of specificity. By contrast Rogers believed that the body was self-healing given the right circumstances. Because the body is self-healing, the therapist doesn’t correct that which is wrong – people heal themselves. This difference is a fundamental one: Clocks are not self-healing. Moreover, Rogers’ ‘right circumstances’ remain the same irrespective of the nature of the disease. All people need unconditional C hung_c13.indd 288 Chung_c13.indd 288 11/25/2011 8:49:56 PM 11/25/2011 8:49:56 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Clinical Psychology and Philosophy of Mental Health 289 positive regard. Thus, Rogers’ theory and approach doesn’t fit the medical model, because it does not fit the medical assumption of specificity. Who is right and who is wrong? Students should make up their own minds, but it is worth reflecting on the following. The heart pumps blood round the body, and so acts as a mechanical system. Other parts of the body fit the mechanical analogy very well– from the action of the muscles to the way nerves provide a form of communication. The idea of treating the body as a mechanical system makes a lot of sense. There is one little problem. Clocks, are like all mechanical systems: they go wrong and don’t repair themselves. Big jumbo jets do not grow from little jumbo jets. Living organisms have this strange property of being able to self-heal. And big people grow from little people – who we call children. Mechanical systems behave differently from living systems. The reason why living systems differ from mechanical systems has exercised people for hundreds of years. For some, life is inanimate matter plus some special vital force. In the 19th century, the vital force was often electricity – in Mary Shelley’s Frankenstein dead bodies come to life with the action of electricity obtained from a thunderstorm. We now know that the vital force argument is not valid and the difference between living and non-living systems is one of organiza- tion. Living systems are parallel processing systems, in contrast to the sequential processing of familiar mechanical systems. The difference is one of organization of the bits which make up the system – not in some magical force. The idea that the body is both a parallel and sequential processing system raises new ways of thinking about people – who can sometimes self-heal but sometimes cannot (Hyland, 2011). It is possible that the reason that it has been so difficult to find a specific pathology of mental illness is because mental illnesses have a different underlying biology to that of other diseases, namely dysregulation in parallel processing system, rather than an error in a mechanical system – but this is beyond the scope of this book (see Hyland, 2011). Box 13.3 Something To Think About Here are some final thoughts to ponder. In his book The Great Psychotherapy Debate Bruce Wampold (2001) shows that (a) all psychotherapies are approximately equally effective (b) there are large differences in therapist effectiveness that cannot be explained in terms of type or length of training and (c) there is no evidence that the specific components of any psychotherapy is effective. The conclusion is that psychotherapy is a kind of ‘non-specific’ effect which is the result of therapeutic encounter. Furthermore, Kirsch’s analysis (2009) shows that at least 80% of anti-depressant therapy is due to the placebo. The research shows that therapy works, but in many cases, including complementary medicine, not for the reason most therapists think it is working (Hyland, 2005). C hung_c13.indd 289 Chung_c13.indd 289 11/25/2011 8:49:56 PM 11/25/2011 8:49:56 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. 290 History and Philosophy of Psychology Philosophy of mental health Peter believes that he is the President of the United States. Sometimes, instead of saying that he ‘is’ the President, he will say he ‘works’ for him. So, everyday, he sits in front of the television and follows the news about America. He also sees President Bush in the White House. He believes that Olivia Newton-John (a well- known singer) is his wife. In fact, he went to America to try to ‘make’ her his wife, and was arrested outside her home. Mark believes that he is the Virgin Mary. He dresses accordingly, with a long robe and a veil to cover his head. He puts on a female voice, talks softly and often talks about ‘baby Jesus’ and looks at the ground as he walks. He has turned one of the rooms in his flat into ‘a chapel’ where he worships and prays to ‘Baby Jesus’. At one time, he heard a voice telling him to cut off his penis because, he said, it makes him commit sin, in the form of sexual thoughts. Paul believes that some people, probably the Americans and Russians, are plotting against him by implanting bugs in his ears. These bugs control his thoughts, broadcast his thoughts to other people, comment on his behaviour, even discussing it with each other, and make him aware of what other people are doing. Simon believes that an invisible Being is controlling his thinking, behaviour and indeed his life. He had never been an artist in his life until one day when, according to him, this invisible Being decided to guide his hand to paint. That is, he is not the one who is doing the painting. Consequently, he has produced some massive paint- ings with colourful and imaginative images. This invisible Being also controlled his driving one day. He drove a long way and said that he was unable to stop because this Being was leading him to a particular place. He finally stopped in a shop where he was offered a job as a shop assistant, but he turned it down. Mary believes that she is being raped every day at home by different men. She can see her rapists around where she lives. Although she tries to avoid them on the street, she cannot avoid them at home. As soon as she arrives home, they will come up to her flat and rape her. John believes that when the political parties sitting in the House of Parliament in London are having a debate, they are in fact talking about him or about the policies that he set for the politicians. He also believes that certain gestures from the Prime Minister are in fact giving special messages to him. One time, he wrote a very long letter to warn the Pope that someone was going to assassinate him. The letter explained detailed reasons as to why they wanted to carry out the assassination. Subjective experience and meaning of schizophrenics For many of us, psychiatric phenomena, exemplified by the patients above (with pseudonyms), are strange phenomena and difficult to comprehend. While we can understand them in terms of some biological or psychodynamic explanations, in recent years, some philosophers or philosophically informed psychiatrists or C hung_c13.indd 290 Chung_c13.indd 290 11/25/2011 8:49:56 PM 11/25/2011 8:49:56 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Clinical Psychology and Philosophy of Mental Health 291 psychologists believe that philosophical explorations can also help us understand them (Bolton, 2001; Bolton & Hill, 1996; Fulford et al., 2003, 2006; Graham & Stephens, 1994; Hundert, 1989; Parker et al., 1995; Radden, 1996, 2004). To dem- onstrate this, in what follows, we wish to present a philosophical understanding of some psychiatric phenomena, particularly that manifested by people who have been diagnosed with schizophrenia (Chung et al., 2007). For some philosophers or philosophically informed psychiatrists or psycho- logists, to try to understand these psychiatric phenomena is to, first and foremost, challenge the whole notion of schizophrenia. To say that people suffer from schizophrenia is to say that they have fulfilled some diagnostic criteria and have consequently been given a label of schizophrenia. However, one could argue, this does not tell us their subjective experience of being in this so-called schizophrenic world. The more clinicians use and develop diagnostic classification (i.e. the more they observe patients’ behaviour, affects, speech, etc and fit them into some diagnostic check lists), the further they get from understanding patients’ subjective experiences and the more they undermine the importance of such experiences. In addition, some scholars argue that diagnostic classifications are  intrinsically problematic in that they are full of uncertainties, confusion, conceptual difficulties, omissions and naïve philosophical assumptions (Poland et al., 1994; Sadler et al., 1994). This is why some scholars argue that to understand psychiatric phenomena, diagnostic criteria and classification is not a good place to start. In fact, this diagnostic approach should be relinquished (Bentall, 1990, 2004; Boyle, 1990; Wing, 1988). Instead, one should start from patients’ subjective experience and meaning. One should pay attention to their beliefs, values, the deep significance of their subjective experience and the way they organize and express their mental disorders. How can we understand schizophrenic patients’ subjective meanings and experience (the first person data)? One approach which is often thought to be  appropriate for examining subjective meanings and experiences is that of phenomenology (see Chapter 5) (De Koning & Jenner, 1982; Mishara, 1997; Schwartz et al., 1997). The phenomenological movement in psychiatry was started by Karl Jaspers (1883–1969/1963, 1968) (Belzen, 1995). On the basis of Husserl’s phenomenology (see Chapter 12), he described his patients’ subjective experiences or states of con- sciousness (Walker, 1994a, 1994b, 1995; Wiggins & Schwartz, 1997). He pointed out that there are two types of symptoms, namely, subjective and objective symp- toms. Patients’ subjective symptoms can only be understood by empathy by which he meant for clinicians to be able to transfer themselves into or ‘feel into’ patients’ psyche. Patients’ objective symptoms (e.g. patients’ movement, speech, affects) can only be understood on the basis of clinicians’ rational thinking rather than empathy. He then went on to say that understanding objective symptoms would not help us obtain a true understanding of the importance or significance of patients’ experiences. Only the systematic subjective approach through empathy would help us gain a real understanding of patients. C hung_c13.indd 291 Chung_c13.indd 291 11/25/2011 8:49:56 PM 11/25/2011 8:49:56 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. 292 History and Philosophy of Psychology The literature has drawn our attention to the works of four phenomenological psychiatrists, namely, Eugene Minkowski (1948, 1997, 2001), Wolfg ang Blankenburg (1969, 1971, 1991, 2001), Kimura Bin (2001) and R.D. Laing (1959, 1961, 1971). Through a phenomenological approach, Minkowski showed us how we can enter into schizophrenic patients’ world and understand their subjective experiences and how their experiences determine their behaviour. Through phenomenology, we can explore the central factors which constitute the essence of a disorder (the trouble générateur). The latter refers to a generative disorder and the underlying core of patients’ manifest symptoms. According to Minkowski, the pheno menological nature of schizophrenia (the trouble générateur) is char acterized by an altered existential pattern, a reduced sense of basic, dynamic and vital connection with the world (the loss of vital contact with reality (VCR) (élan personnel)) with exaggerated intellectual and static tendencies (morbid rationalism, morbid geometrism), and by the manifestation of itself in an autistic form. Two of the above characteristics, namely the loss of vital contact with reality (VCR) and autism are worth elaborating on. In terms of VCR, Minkowski meant that schizophrenic patients behave without a sense of natural, contextual con- straint or worldly demand. In other words, they have lost vital contact with reality. VCR originates from the ‘inner’ core of patients’ personality, while patients simul- taneously relate to the ‘outer’ fast-moving world. To Minkowski, psychopathology such as schizophrenia is characterized by the distorted relationship between the inner, the subjective, and the outer world. With regard to the notion of autism, Minkowski distinguished two types: ‘rich autism’ ( autisme riche ) and ‘empty autism’ ( autisme pauvre ). Rich autism (also called plastic autism) is characterized by a degree of normal and vital elements that patients preserved in their personality. It is also characterized by imaginary attitudes and living in a dream or fantasy world. This world consists of rigid, stereotyped fantasy ideas which substitute reality and determine patients’ behaviour. Patients also display sulking, irritability, extreme egotism, obstinacy, remorse and regret. On the other hand, empty autism (also called aplastic autism) is characterized by a more pure or primary autistic state, i.e. the loss of vital contact with reality (Urfer, 2001). Turning briefly to Blankenburg, he also used Husserl’s phenomenological approach and the epoché to conceptualize schizophrenia. To him, schizophrenic patients suffer from a ‘basic change of existence’ in the structure of their con- sciousness. Consequently, they have lost their ‘common sense’ ability. That is, while they may still retain their ability to use logic and to discuss abstract con- ceptual  issues, they have lost their ability to see things in the right light, make interpretations and arrive at sound judgements, and carry out daily practical activ- ities and relate to others. Blankenburg, however, believed that the loss of common sense is not an  exclusive phenomenon for those who suffer from schizophrenia. We are all vulnerable to it. However, those who are called normal are those who are able to resist the loss of common sense (Mishara, 2001). C hung_c13.indd 292 Chung_c13.indd 292 11/25/2011 8:49:56 PM 11/25/2011 8:49:56 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Clinical Psychology and Philosophy of Mental Health 293 With regard to Bin, we should not conceive schizophrenia in terms of patients’ inability to use intellect, logic, judgement or memory. Instead, one should concep- tualize schizophrenia in terms of the distortion of the ‘I’ or, more precisely, in terms of the profound uncertainty of the ‘I’ as personal subject of experience and action. As a result, patients are not able to experience representations of things as ‘their’ representations or to see that certain things belong to them. This distortion of self hood also leads to a distorted relationship between patients’ own subjectiv- ity and the group subjectivity (the social or community group) to which they belong. Patients find themselves wanting to keep their individual subjectivity from being engulfed by the group subjectivity. Thus, for Bin, schizophrenia is a disorder of the self or self-experience. There are fundamental changes in patients’ posses- sion and control of their own thoughts, actions, sensations, emotions, feelings and the like. They feel uncertain about their self hood and often struggle to restore or maintain their self-identity by means of reflecting obsessively upon themselves. R.D. Laing’s phenomenological approach to schizophrenia has been both influ- ential and controversial in clinical psychology and psychiatry. To him, schizo- phrenic patients suffer from what he called ontological insecurity. This insecurity means that they have lost trust in their physical and concrete existence in the world. Patients have also lost trust in their dysfunctional families who, they believe, have not helped them to integrate with society in an acceptable way. Instead, patients feel suffocated or engulfed by their family because they are not allowed to develop their own independence and identity (Laing believed that families, through double-bind interactions [i.e. contradictory messages between the family and the schizophrenic], can make it impossible for the schizophrenic to find their own identity, to achieve independence and a sense of self and to live accordingly). Meanwhile, patients are desperately trying to find ways through which they can be real to themselves and others, trying to develop or preserve their own identity and resist the possibility of losing their own self. In other words, schizophrenia results from the dysfunctional interactions between the schizophrenics and their families. When patients are experiencing ontological insecurity, they also experience a strong sense of anxiety for different reasons. Firstly, they feel anxious that they might be engulfed, overwhelmed and indeed destroyed by others. Secondly, they feel anxious that they may develop a sense of complete emptiness. Thirdly, they feel anxious that they may be turned into an object or a thing. In other words, their own self and autonomy would disappear altogether. Instead, they may develop a false self which is being controlled, observed and manipulated by others, and which feels that it can only survive by conforming to the expectations of the outside world. Schizophrenia and the self One implicit message from the foregoing phenomenological approach is the idea that if we want to understand schizophrenia, we should start from patients’ concept of self or, perhaps more precisely, distorted self. Some scholars believe C hung_c13.indd 293 Chung_c13.indd 293 11/25/2011 8:49:56 PM 11/25/2011 8:49:56 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. 294 History and Philosophy of Psychology that to understand the disorder of the self is to understand the psychopathological core of schizophrenia. For example, recent research shows that schizophrenia can be conceptualized in terms of the doctrine of solipsism (Sass, 1994, 2001; Sass et  al., 2000). This doctrine says that the whole of reality, which encompasses the external world and other human beings, is only a representation appearing to the individual who holds the doctrine. In other words, solipsists are those who would say that only their feelings, emotions and perceptions are real. Thus, solipsism implies a mixture of increasing subjectivization of the world and a specific type of grandiosity. In the light of this doctrine of solipsism, schizophrenia can be seen as the manifestation of a ‘pervasive sense of subjectivization’. This means that the schizophrenics are unable to regard others as subjects and engage with them by means of normal forms of communication, exchanging reason and developing interpersonal relationships. This is because to engage in such communication implies a relation of reciprocity or cooperation which the solipsists (the schizophrenics) are unable to do. The literature shows another way of understanding schizophrenia in the light of the disorder of the self: schizophrenia is a self of ipseity-disorder in which patients have a strong sense that they are the centre of their own experiences, that their own self is separate from the objects that they are perceiving and that their representation of these objects is experienced as that which is different from the  object itself. At the same time, they feel an acute self-consciousness and a heightened awareness of aspects of their own experience (hyperreflexivity). Patients with hyperreflexivity increasingly monitor or examine their mental lives or mental phenomena. In so doing, ideas or thoughts have become objects of focal awareness, i.e. they have been objectified as if they existed in an external or outer space. Consequently, patients may feel that certain thoughts or ideas can be felt in certain locations of their brains (Parnas & Sass, 2001; Sass & Parnas, 2001). Schizophrenia and agency To look at schizophrenia from the notion of self, some researchers have focused on the self as an agent or the action of the self (agency). What follows consists of some examples of research looking at schizophrenic symptoms in terms of the notion of agency. Some philosophers argue that the schizophrenic symptom of thought-insertion (e.g. patients often say ‘someone keeps putting thoughts into my head’) should be seen in terms of an error of agency. That is, certain thoughts occur in the patients but are independent of their intentional stance. In other words, patients feel that they are not the agent of their own thoughts or other mental activities. In their experience, the thoughts express the agency (the intention and attitude) of others rather than themselves. Thus, patients conclude that their thoughts are others’ thoughts (Stephens & Graham, 1994a, 1994b, 2000). C hung_c13.indd 294 Chung_c13.indd 294 11/25/2011 8:49:56 PM 11/25/2011 8:49:56 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Clinical Psychology and Philosophy of Mental Health 295 Some philosophers argue that symptoms of illness can be characterized in terms of the feature of the things that patients do (i.e. hurting themselves) and things that are done to them (i.e. they are being hurt). Similarly, in the case of thought- insertion, while other people might conceptualize it in terms of something wrong with the patients, the patients themselves perceive it as something which is done to them (i.e. action failure of the self ) (Fulford, 1989, 1993, 1994a, 1994b). The literature also suggests that schizophrenic symptoms can be conceptualized in terms of patients’ intention to act (Frith, 1987, 1992). There is a type of intention called willed intention. This refers to the fact that we may intend to buy a German dictionary because we want to pursue a goal of learning German. There is an internal cognitive monitor which monitors this intention and the kind of actions that we have actually chosen, as a result of the intention. This monitor also metarepresents an intention which would also bring that intention into our consciousness. Schizophrenic symptoms, such as hallucinations and thought-insertion, which involve the loss of the sense of control or possession of patients’ own thoughts or movements, in fact result from the dysfunction of the monitor to represent willed intentions. For example, if we want to pursue our goal of learning German, we form the willed intention to buy a German dictionary. The monitor in us metarep- resents that willed intention and subsequently brings it into our consciousness. After having formed the intention to buy the dictionary, we then carry out the action in the form of buying the dictionary. Our internal cognitive monitor metarepresents both our intention and action and can confirm that the action that we have carried out has satisfied the relevant intention. For the schizophrenic patient, there is a dysfunction of the monitor. It fails to represent the intention to buy a dictionary and fails to bring it into their consciousness. As a result, they might buy a dictionary without being conscious of the fact that they had formed their intention to do so. That is, they have performed their action, while they had no consciousness or awareness of any intention to carry out such action. To explain this, thus, they might opt for the explanation that some external forces have in fact performed the action, hence, a delusion of control (alien control) (Cahill & Frith, 1996; Cocoran et al., 1995; Mlakar et al., 1994). C hung_c13.indd 295 Chung_c13.indd 295 11/25/2011 8:49:56 PM 11/25/2011 8:49:56 PMChung, Man Cheung, and Michael E. Hyland. History and Philosophy of Psychology, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=826882. Created from ashford-ebooks on 2018-07-27 10:08:05. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved.