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(2018) Mental disorder as a puzzle for constitutivism

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In the Nicomachean Ethics, Aristotle argues that the performance called for by being human is rational flourishing and a life that falls short of flourishing will fail to constitute a life lived in accordance with the norms governing human kind in
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  ORIGINAL ARTICLE Mental disorder as a puzzle for constitutivism Diana B. Heney BA, MA, PhD, Assistant Professor of Philosophy  Department of Philosophy, FordhamUniversity, Bronx, New York, USA  Correspondence Diana B. Heney, BA, MA, PhD, AssistantProfessor of Philosophy, Department ofPhilosophy, Fordham University, 441 E.Fordham Road, Collins Hall 101, Bronx, NY 10458, USA.Email: dheney@fordham.edu  Abstract In the  Nicomachean Ethics , Aristotle argues that the performance called for by beinghuman is rational flourishing and a life that falls short of flourishing will fail to consti-tute a life lived in accordance with the norms governing human kind in virtue of itsfunction. Against this constitutivist story, a puzzle arises: On Aristotle's criteria, itlooks impossible for a person with a mental disorder to flourish. I consider whetherthis puzzle can be satisfactorily addressed without abandoning Aristotelianconstitutivism. I regard this as a puzzle worthy of serious engagement because thereis a tension between the adoption of Aristotelian virtue ethics as a normative back-bone for applied ethics and the possibility that the theory would consign many, manypeople to being incapable of virtue or flourishing. I first set out the basic commitmentsof a constitutivist Aristotelian account and show how it generates the hypothesis thata person with mental disorder could never flourish. I then present two contemporaryconcepts of mental disorder — one from the fifth edition of the American PsychiatricAssociation's  Diagnostic and Statistical Manual of Mental Disorders  and one fromphilosopher George Graham's  The Disordered Mind . I show that Graham's treatmentof mental disorder supplies the basis for a compelling response to the puzzle forconstitutivism. That response is rooted in his conceptualization of disorder as involv-ing  truncated  rather than absent rationality. I suggest that Aristotle's discussion ofdeath can be construed as supporting a second response. Finally, I discuss possibleclinical implications under the auspices of  caring constitutivism , which treats Aristotle'saccount of the human function as a basis from which ideals of rationality and recoverycan be empathetically developed. KEYWORDS diagnosis, experience, medical ethics, metaphysics, value, virtue 1  |  INTRODUCTION In Book I of the  Nicomachean Ethics , Aristotle sets the frame for hisconstitutivist account of human nature and normativity. 1 Constitutivism holds that  “ certain norms under which an object fallsare given by the object's nature, and may be justified by that fact. ” 2 The key argument supporting the constitutivist reading of Aristotle isthe function argument of Book I. The performance called for by beinghuman is rational flourishing, and a life that falls short of flourishingwill fail to constitute a life lived in accordance with the normsgoverning human kind in virtue of its function. So far, so standard.Against this standard story, a puzzle arises: On Aristotle's criteria, itlooks impossible for a person with a mental disorder to flourish.Can this puzzle be resolved in a satisfying way — one true to theobservations and experiences of those in both patient and practitionerroles in mental health care? While the language of the virtues seemswell ‐ suited to psychiatric ethics, its undergirding theory of humannature needs to be carefully considered — for the adoption of virtueethics, at least of the Aristotelian variety, comes with constitutivismas a package deal. One might simply abandon the metaphysics andkeep the ethics, but this would be to sever the ethics from that whichis meant to legitimate it. That strategy is open to those who would Received: 21 March 2018 Revised: 1 June 2018 Accepted: 2 July 2018DOI: 10.1111/jep.13007  J Eval Clin Pract . 2018; 24 :1107 – 1113. © 2018 John Wiley & Sons, Ltd.wileyonlinelibrary.com/journal/jep  1107  seek justification for the adoption of an ethical framework elsewherethan in metaphysics, and the applied ethicist may be inclined toconsider whether that revisionary approach to traditional virtue ethicsmight suit the context of mental health care best. The present paperconsiders whether those who are attracted to virtue ethics for applica-tion in this domain could coherently accept the more robustly Aristo-telian picture, constitutivism, and all. The position that I ultimately findmost plausible is best characterized as  robust and revised : It presentsthe possibility that one could accept the language of the virtues anda modestly deflated version of constitutivism as a way of adaptingthe Aristotelian framework for the context of psychiatric ethics. Asto whether this is the most compelling philosophical framework forthis purpose  full stop , I myself remain tentative — my task is simply toexplore the possibilities for those interested in applying Aristotle. 2  |  THE ARISTOTELIAN MODEL ANDMENTAL DISORDER  I begin by setting out the basic commitments of Aristotle'sconstitutivist account and show how it appears to generate thehypothesis that a person with mental disorder could never flourish.In seeking to determine what is good for individuals and for thecommunity, Aristotle is more concerned to provide a useful accountthan a perfectly complete one. The aim of the  Nicomachean Ethics  isto begin with what is known to us and create an accurate but partialmodel on the basis of it.  “ If the sketch is good, anyone, it seems, canadvance and articulate it, and in such cases time discovers more, oris a good partner in discovery. ” 1 Aristotle observes that arts and crafts have functions, ends thatare part and parcel of their nature. The good of an action or a craftis  “ that for the sake of which the other things are done. ” 1 On arobustly constitutivist account, objects (or kinds) also have functions.As Christine Korsgaard has argued, Aristotle's ethics and metaphysicsare deeply intertwined at this point:  According to Aristotle, a thing is composed of a form anda matter. The matter is the material, the parts, fromwhich it is made. The form of a thing is its functionalarrangement. That is, it is the arrangement of thematter or of the parts which enables the thing to serveits purpose, to do whatever it does. 2 From observation of arts and crafts, Aristotle generalizes thateverything has a purpose and infers that it would be absurd if a humanturned out not to have a function. Thompson's discussion of  “ lifeform ”  develops an account of how our  “ natural historical judgements, ” rooted in observations that register a  “ shape that that something'sbeing something can take, ”  describe organism ends. 3 Humans, beinga type of organism, are not exempt from this way of understanding lifeform. To determine what the particular function of the human lifeform could be, Aristotle rules out what is shared with other species — nutrition, growth, and perception. By process of elimination, thisleads to the conclusion that  “ the human function is activity of the soulin accord with reason or requiring reason. ” 1 Aristotle adds thatperforming the human function well occurs in  “ a certain kind of life, ” and we  “ take this life to be an activity and actions of the soul thatinvolve reason. ”  With this function in view, the good for a humanbeing  “ proves to be activity of the soul in accord with virtue, andindeed with the best and most complete virtue. ” 1 In a nutshell, Aristotle's view is that to be human is to be of a kindwhose very nature places it under a rationality norm. The person whois good at being human is excellent as the kind of thing she is: She canbe said to be rationally flourishing, which is the highest good at whichall people aim. The proper — indeed, the perfect — exercise of rationalityis the lynchpin in this view; irrationality is a failure against a constitu-tive norm of human nature. Davidson puts this point rather starkly:For a person,  “ the irrational is not merely the non ‐ rational, which liesoutside the ambit of the rational. ” 4 Rather,  “ irrationality is a failurewithin the house of reason.  …  [a] rational process or state  …  gonewrong. ” 4,5 To be irrational is a failure in respect of one's own natureand a failure that closes off the possibility of succeeding in the activityof rational flourishing.Now the puzzle emerges. For what characterizes mental illness asa type of ailment is that, whatever other health demerits are simulta-neously expressed, such disorders are marked by irrationality.Connecting the dots, it seems that on Aristotle's account, a personwhose life includes navigating mental disorder (most especially as alife ‐ long condition) cannot flourish, cannot be happy, cannot be excel-lent as a human being. I believe that this is an unpalatable result, onewhich we should seek to avoid. Given the prevalence of mental disor-der, vulnerability to such disorder seems to be as characteristic ofhuman nature as rationality itself. I now sketch two ways in whichwe might try  “ easy ”  avoidance of this result and say why I do not thinkthat either will be satisfying.One straightforward way to reject the result would be to rejectthe whole Aristotelian picture and instead endorse a sort of liberalpluralism about the good life — one which does not rule out the possi-bility of a person with a mental disorder flourishing. A challenge to thissimple rejection —  just stop reading Aristotle and the problem goesaway! — is that contemporary bioethics treats virtue ethics as a liveand attractive option. This is, perhaps ironically, especially true in theethics of mental health care. The fine ‐ grained nature of the languageof the virtues, the specificity of their proper performance, and the pos-sibility of habituating them in role ‐ specific ways have all seemed liketheoretical features promising for application in psychiatric ethics. 6-8 Another possible path for avoidance would be to adopt the virtuetheoretical framework Aristotle begins in the  NE   but reject theundergirding theory of human nature. Keep the virtues, lose theconstitutivism. While some ethical naturalists do eschew teleologyaltogether, any approach that seeks to ground normativity in naturewill need some account of how human nature and human goodnessgrow up together. This turns out to be not so much avoidance asthe introduction of the alternate research programme I sketched atthe outset of this paper — a programme I will not take up here. Forthe animating question here is precisely  whether   the constitutivistpicture can be made consistent with the hypothesis that a person witha (potentially) life ‐ long mental disorder can flourish. Ultimately, I willargue that the answer is yes, if the constitutivism is adjusted for animportant insight about the nature of rationality:  Since  rationalityadmits of degrees, constitutivism  need not  imply rigid perfectionism 1108  HENEY   about what it takes to live up to our own rational nature. Indeed, whatAristotle believes essential for the rational creature — the cultivation ofvirtue — is possible when a person is  “ burdened ” . 9,10 This is not as antithetical to Aristotle's srcinal empirical approachas it might seem, given his conviction that anyone  “ can advance andarticulate ”  his account and that time can be  “ a good partner in discov-ery. ” 1 Scientific engagements with mental life and mental health havegiven rise to the fields of psychology and psychiatry, which naturallyshare fecund intersections with the philosophy of mind. Let us seewhether time has proven to be a good partner in producing resourcesto understanding rationality and irrationality in mental disorder. 3  |  TWO CONTEMPORARY CONCEPTS OFMENTAL DISORDER  In searching for a contemporary concept of mental disorder, it wouldbe reasonable to seek out the concept as it informs clinical practice.In psychiatry, the standard tool is the  Diagnostic and Statistical Manualof Mental Disorders  ( DSM ). 11 The  DSM  has a checkered history and hasbeen the subject of sustained philosophical critique. Critics havecharged that it is unscientific, steered more by the pharmaceuticalindustry than by the needs of mental health service users, and that itis insufficiently attentive to the causes of mental disorder. 12 Nonetheless, it is one of very few places where we can find anexplicitly stated concept of mental disorder on which people rely, aconcept that is in use. Per  DSM ‐ 5 :  A mental disorder is a syndrome characterized by clinically significant disturbance in an individual ' scognition, emotion regulation, or behavior that reflects adysfunction in the psychological, biological, or developmental processes underlying mental functioning.Mental disorders are usually associated with significantdistress or disability in social, occupational, or other important activities. [  …  ] Approaches to validating diagnostic criteria for discretecategorical mental disorders have included the following types of evidence: antecedent validators (similar geneticmarkers, family traits, temperament, and environmentalexposure), concurrent validators (similar neuralsubstrates, biomarkers, emotional and cognitiveprocessing, and symptom similarity), and predictivevalidators (similar clinical course and treatmentresponse). [  …  ].Until incontrovertible etiological or pathophysiologicalmechanisms are identified to fully validate specificdisorders or disorder spectra, the most importantstandard for the DSM ‐ 5 disorder criteria will be their clinical utility for the assessment of clinical course andtreatment response of individuals grouped by a givenset of diagnostic criteria. 11 The  DSM 's concept is vague, intentionally so. It leaves open thepossibility that  “ incontrovertible etiological or pathophysiologicalmechanisms ”  could be identified and thus the possibility that theentire category of mental disorder could be reduced to neurologicaldefect. At the end of the offered definition, the American PsychiatricAssociation hedges that it  “ was developed for clinical, public health,and research purposes. ” 11 In terms of clinical utility,  some  sortingmechanism seems to be required for the practice of psychiatry.However, the  DSM 's definition is problematically underspecifiedat key points. It relies at its core on the disjunctive recipe of a “ clinically significant disturbance in an individual's cognition, emotionregulation, or behavior that reflects a dysfunction in the psychological,biological, or developmental processes underlying mental functioning. ” It also does not offer any standard of rationality against which a judgement of clinically significant disturbance could be made, whichundermines the possibility that the  DSM ‐ 5  definition is a good toolfor developing the possibility of flourishing in a life marked by mentaldisorder.Philosopher Graham offers a competing concept of mental disor-der. 13 Graham argues that conceptual rectitude in the case of mentaldisorder requires working from core exemplars of disorder, as thecategory is heterogeneous and the spectrum from robust mentalhealth to deep disorder is one where there may be tipping points,but no clean lines of demarcation. Whereas the  DSM 's rationale forconceptual vagueness is largely empirical, Graham's reasons forconceptual vagueness are both empirical and philosophical: Wecannot hive off  “ order ”  from  “ disorder ”  at some fixed point, and sowe are dealing with a concept that is not amenable to treatment interms of necessary and sufficient conditions.As an alternative, Graham outlines a concept of mental disorder as “ prototypically understood ” : A mental disorder is a disability or inca-pacity in the rational and reason ‐ responsive exercise of one or morebasic psychological capacities, which harms (or has the potential toharm) the disordered subject and which is brought about by a mixtureof mental and neural causes. These first three elements combine tosupport the fourth: an understanding of mental disorder as having “ some preservation of rationality. ”  As Graham puts it, a mental disor-der has  “ a truncated  ‘ logic ’  or compromised rationale of its own. ” 13 While both concepts are intentionally vague, Graham's is muchmore closely tied to standards for rational functioning. He combineshis concept of disorder with a list of basic psychological capacities,impairment of which make a person worse off — either positivelyharmed or liable to be harmed as a consequence of her disorder. Suchcapacities include bodily and spatial self ‐ location; historical andtemporal self ‐ location; general self and world comprehension; commu-nication; care, commitment, and emotional engagement; responsibilityfor self; and recognizing and acting on opportunities. 13 Crucially, the way in which Graham generates this list of basiccapacities is  less  metaphysically weighted than Aristotle's ownaccount. Graham makes use of a Rawlsian ‐ style overlapping consen-sus argument, where the question at issue is not  what essential onto-logical feature must be perfected , but rather  what can we all agree thatwe rely on rationality for  ? 13 We may think of this as putting weighton how rational creatures value their own rationality — so that rational-ity is a constitutive norm for our life form by our own lights.Fundamental psychological capacities are  “ fundamental ”  because oftheir importance to us in our lives as lived. This still tells a story of HENEY   1109  human nature, but it is of human nature in action, rather than asdistilled down its ontological essence. This is in contrast withAristotle's more robust srcinal accounting, which focuses on theperfection of our nature — of achieving not just a satisfactory but anideal functional arrangement. 1 This revisionary approach to Aristotelian metaphysics to preserveAristotelian ethics may seem like it comes close to the second avoid-ance ‐ route I gestured at in the previous section: Keep the virtues, losethe constitutivism. But that is not quite right. Rather, I am locatingwhatever intuitive force constitutivism has in our  endorsement  ofrationality as a norm under which we place ourselves. Thus, one wayto frame the argument of this paper could be as follows: One can keepthe virtues and keep the constitutivism, but lose the perfectionism.This may be an unwelcome suggestion for those who are attractedto the ideal of  ho phronimos — the practically wise person who exem-plifies rationality perfected — as the pinnacle of human achievement.But it will be a welcome one for those who are attracted to the ideathat rationality admits of degrees and thus that being over a certainthreshold in respect of one's basic rational capacities is sufficient forliving a life high in well ‐ being.The important upshot is that Graham's concept of mental disordersupports regarding a person with mental disorder as not arational, butimperfectly rational — impaired in respect of some fundamentalpsychological capacities, but not utterly without such capacities. It alsoaccounts for the harm (or possibility of) that drives the intuitive judge-ment that experiencing disorder is bad in a way that could not beconsistent with flourishing. Let us now consider two ways ofresponding to the srcinal point of contention: that a person with amental disorder cannot flourish. 4  |  TRUNCATED RATIONALITY AND THEPERFORMANCE OF RECOVERY  Crucially, that a disorder produces truncated rationality within aperson does not mean that she cannot come to identify the truncationin question. Since there is residual or wider rationality present, sheherself can be brought to recognize the ways in which her disorderis undermining her own flourishing. A disordered person can be quitewell aware of the costs of irrationality and seek to find ways to avoidpaying them. Indeed, doing so is frequently a step on the path toeffective treatment, for identification of a problem in one's ownfundamental psychological capacities is liable to come packaged witha recognition of harm (or the threat of harm), which the person seeksto avoid.Because a person's background or residual rationality can bebrought to bear on her own experience of her disorder,  “ pass ‐ through ‐ reason ”  therapies are possible. As Graham puts it,  “ Pass ‐ through ‐ reason treatments share one common goal: to redirect andimprove a person's self ‐ knowledge and understanding or comprehen-sion of their current situation. ” 13 The paradigm example is cognitivebehavioural therapy, along with other forms of talk therapy.Of course, such therapies may not always be the best option — invery severe cases, the challenge of appealing to background or resid-ual rationality may be too steep for pursuing it to be the best reliefof the suffering being experienced in connection with the disorder.In such cases,  “ bypass ‐ reason ”  therapies may be preferable. Suchtreatments  “ try to reduce or suppress the symptoms of a disorder ” ; “ the assumption [ … ] is that a patient may be better able to manageor understand their own behaviour and ultimately to respond topass ‐ through ‐ reason therapy. ”  Given the prevalence of prescriptionof psychotropic medications, it may be that some people who couldbe aided by pass ‐ through ‐ reason therapies nonetheless prefer abypass ‐ reason route. 13 What the very practice of  treatment  suggests is that reason isredeemable in a person with mental disorder. This redemption ofreason is what underlies much of the recovery movement in mentalhealth care. As Swarbrick says,  “ Recovery is a deeply personal, uniqueprocess of regaining physical, spiritual, mental, and emotional balancewhen one has experienced illness, crisis, or trauma. ”  This process hasbecome  “ a vision, outcome, and framework for transforming livesand the mental health care  …  system. ” 14 What does it mean to say, as Swarbrick does, that recovery is per-sonal? James articulates the individuality of struggling and learningthrough struggle beautifully:  “ No two of us have identical difficulties,nor should we be expected to work out identical solutions. Each, fromhis peculiar angle of observation, takes in a certain sphere of fact andtrouble, which each must deal with in unique manner. ” 15 On anyversion of a constitutivist account, thinking about how well we areliving up to a standard of rationality is as against a standard properto our kind; in recovery, we also need self ‐ knowledge. Coming toknow one's  “ sphere of fact and trouble ”  can help one to come togreater self ‐ understanding and to take responsibility for the  “ uniquemanner ”  in which one can deal with one's own struggles. Grahamhas also argued for this point, stating that an illness that producesself ‐ knowledge helps us to see how we can hope for recovery withoutbeing delusional or deliberately self ‐ deceptive: The kind of epistemicaccess opened up to what makes one suffer in an illness can also pro-vide insight into what it takes for one to be well. 16 One can imagine a sceptical response to the claim that recoverycan be instantiated in the life of a person who had previously beenseverely disordered. Sure, such a response might go, a person with amild set of symptoms, or a singular episode of disorder, can enterrecovery — but a deeply disordered person? We can respond to suchscepticism via the consideration of patient narratives, which are apowerful resource in understanding the possibility of regaining groundwith respect to previously impaired fundamental psychological capac-ities. Such accounts also help us to see that just as flourishing is anactivity, and not a state, so too is recovery.Boevink offers a highly compelling narrative of recovery, detailingher transition from being a psychiatric inpatient to a recovering personintegrated into her community and pursuing many of the activitiesassociated with a flourishing human life. There can be no doubt thather illness, at its most incapacitating, was very severe. She reports thatduring a psychotic episode,  “ I saw bad signs everywhere. For instance,there were a lot of birds in my garden. I thought they had come to getmy soul. I was guilty. For all their baby birds that had not made it, theycame to get my soul. ” 17 In the face of such severe disruptions, Boevinkarticulates a felt  “ need to regain, maintain, and cherish my strength. ” At the time of her narrative presentation, she is  “ ten years further 1110  HENEY   on, and [has] discovered that regaining strength and self ‐ confidencerequires endless patience. ”  She describes recovery as  “ what weourselves must do. ” 17 Like flourishing on the Aristotelian model, thedeliberate adoption of the work of recovery invokes agency and acapacity for rationality.By appealing to Graham's concept of mental disorder as charac-terized by truncated (rather than absent) rationality, we have seen thatone response to the worry that a person with a mental disordercannot flourish is to consider how truncated rationality can besupported in acute phases of the disturbance of rationality character-istic of disorder and buttressed (if not fully repaired) for the long haulof a recovering life. 5  |  DEATH BEFORE DIAGNOSTIC One other way to respond is to invoke an insight of Aristotle's own:To assess flourishing, we must have the whole shape of the life inview. Death before diagnostic. Because flourishing happens over time,assessment of whether or not a person has flourished can only beaccurate after her death:  “ let us grant that we must wait to see theend, and must then count someone blessed, not as being blessed[during the time he is dead] but because he previously was blessed. ” 1 There is something compelling to this idea. We cannot considerthe shape of a life until we have the whole of it in view, and judge-ments on some piece of the whole will be highly fallible. I can enterno further here into the debate about  which  life shapes are prefera-ble 18-20 — but whatever final accounting that question receives, weshould not close the door on the possibility that someone can live awell ‐ shaped life on the grounds that she has a mental disorder.In fact, Boevink articulates a stance very like Aristotle's view inher narrative of recovery, stating that  “ It is important that our profes-sional helpers do not take away our hope of recovery. After all, no onecan predict the course that our lives will take. ” 17 We are in a positionof poor epistemic access in assessing the success of any human lifewhile it is being lived (including our own). It is clear that Aristotle holdsthat a life in progress is not an adequate evidential base for a judgement of whether a person has succeeded in fulfilling her humanfunction. On the modestly revised norm ‐ focused constitutivistaccount sketched above, it really is  fulfilling the function , and notperfecting the capacity to the highest degree, that is at issue.Inconsideringthepotentialflourishingofapersonwithmentaldis-order, we must appreciate that responding to challenges in a virtuousway is an important aspect of a life narrative. 9,10,21-23 The potentialfor recovery from, through, or alongside a condition characterized bytruncated rationality allows us to hold open the space, on aconstitutivist view, that a person with mental disorder can live a goodhuman life. Just as we cannot assess flourishing without the wholeshape of a life in view because flourishing is an activity, the same holdsfor the activity of recovery. Recovery cannot be assessed at a singlemoment, but requires a wider lens — perhaps even the widest lens: thewhole life. Because the rationality norm associated with Graham's con-ceptallowsustoconsidersatisfying,ratherthanperfecting,ourrationalcapacities,wecanappreciatethatapersoncanbe “ inrecovery ” withoutthis meaning that every vestige of disorder is forever vanquished. 6  |  CARING CONSTITUTIVISM This leads me to a consideration of implications. By this I do not meansimply implications for clinicians; rather, I mean implications for ourcommunal understanding of the clinical context of mental health care.The reason to draw this distinction is to stress that we all have inter-ests, moral and practical, in understanding the context in which anyperson vulnerable to mental illness may at some point find themselves.To say that we have a moral interest here is a point that could beeasily argued from within a broad spectrum of normative ethical theo-ries, those driven by guiding normative notions of duty, of virtue, ofconsequence, or of care. But perhaps no more sophisticated argumentis needed than to point out that if anything is true of humans as atype, it is that we are — as Aristotle noted — of a  polis . We are in andof communities. And when suffering is present in our communities,which we can prevent or ameliorate, we have a moral interest in doingso. What this means in the context of mental health is acknowledgingthe suffering that untreated and stigmatized mental illness can causeand educating ourselves about what is effective in preventing orameliorating it.To say that we have a practical interest is just to reiterate thepoint that mental illness is something to which we are all vulnerable.In ordering and planning our lives, knowing something about mentalhealth and hygiene — including how the medical contexts which seeto it operate — is a practical necessity. If education cannot quite beinoculation, at least forewarned is forearmed.Much of what I go on to say here may seem merely like an artic-ulation of best practices, with which clinicians are intimately familiar.Still, there is value in articulating best practices, especially when it iscommonplace to say that in resource ‐ starved health care systems,the standards of those practices are not always met. In 2015, an initialwhite paper concerning the state of mental health in New York Citymapped out many deficits facing the city, which clearly show that poormental health outcomes are a consequence of complex economic,environmental, and social factors. 24 TheThrive NYC report also drawson sources to suggest that many of those deficits can be generalizedto broader contexts — for example,  “ approximately half of all treatmentfor major depressive illness in the U.S. does not follow expert ‐ recom-mended best practices. ” 24-27 There is clearly a lot at stake in discussing care practices. What Inow argue is that the earlier discussion of constitutivism has put usin the position to see that practicing mental health care informed bya normative ideal of human flourishing need not imply hard ‐ heartedness (or hard ‐ headedness) on the part of the practitioner.Rather, constitutivism can be taken as a basis from which ideals ofrationality and recovery can be empathetically developed and anattitude of hope can be sincerely adopted alongside those notions ofrationality and recovery. Rethinking that way in which rationalitycontinues to be present, though truncated, in a person living withmental disorder supports hope as a fitting attitude to have both forthat person and for her support network. The hypothesized presenceof a degree of rationality is important for several reasons.First, it supports taking the narratives of the disordered veryseriously, for the author of that narrative is not completely irrationalor arational, but imperfectly rational. Since all humans are imperfectly HENEY   1111
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