Schizophrenia as a Transformative Evaluative Concept: Perspectives on the Psychiatric Significance of the Personal Self in the Ethics of Recognition

Psychiatric diagnosis serves many functions in the struggle for recognition, such as access to public mental health systems and legal compensation, but it is not necessarily well-equipped for the task of self-understanding (Tekin, 2019) and reconfiguration of personal values in the recovery process – and the likelihood of optimal outcome that is geared to the individual person's quality of life (see Maj et al., 2020). Call this the transformative dimension of recognition in the complex journey from diagnosis to therapeutic empathy in the doctor–patient relationship.

Patients who are diagnosed with a serious and enduring mental health condition often find it difficult to make sense of themselves in relation to their psychiatric diagnosis. Specifically, they have problems with distinguishing their "self," or "who they are," from their mental disorder or diagnosis (Dings & Glas, 2020; Radden, 1996; Sadler, 2007). I argue that what marks out an "owned" and, conversely, "disowned" experience (and behavior) as such is the wider context of the subject seeing themselves as a whole person as characterized by a sense of their own agency (Marcel, 2003). A variety of phenomenological and theoretical considerations strongly suggest that the psychiatric significance of the concept of selfhood is helpfully understood holistically by the five aspects of agency, identity, trajectory, history and perspective that give us the sense of unity and control that generates the subjective sense of self (Neisser, 1988; Sadler, 2007). Although there are proposals in the psychological literature about therapeutic integration that resemble this claim (Freud, 1914; Radden, 1996; Tekin, 2016), few have made a general case in philosophy of psychiatry for thinking about values in understanding the psychiatric significance of the personal self in this way. This commentary is intended as a first step in that direction.

The contribution of Gilardi and Stanghellini is particularly illuminating in demonstrating the significance of the personal self and the role of narrative identity in coming to terms with medication and related personal values in the therapeutic process. Consider the dynamic reflection on recognition and therapeutic empathy in the philosophical dialogue at play:

Drugs don't cure. Meaningful relationships do. The recognition I got was instrumental in my own taking possession of my condition, and in delivering the same recognition for the people around me, starting from my mother and then everyone else.

(p. 7–8)

In what follows, I set to one side the complex question of cure in schizophrenia to allow better focus on the interplay of values and relational agency in examining the implicit task of self-ownership in psychiatry. When Gilardi tries to make sense of his experiences he seems to be examining the relationship between his diagnosis and who he is. How should we understand this? Gilardi and Stanghellini argue that optimal treatment outcome in psychotherapy "cannot simply be measured as a diminishing of diagnostically significant symptomatology assessed by some rating scale" (p. 5). The simple reason for assenting to this claim is the recognition that therapeutic success also involves complex existential issues surrounding self-ownership, personal identity and responsibility in the recovery process, where the notion of self-ownership is framed relationally as an ongoing mirroring process between self and others (Bergqvist, 2018; Jopling, 2000; Tekin, 2011).

So far, so uncontroversial. The harder question that remains is how to balance patient values and those of the social context of their environment in assessing diagnostic treatment goals; as the authors put it, "should we declare victory upon schizophrenia when a patient is fully integrated [in society] and his symptoms under (drug?) control, never mind his underlying grief?" (p. 8). Gilardi and Stanghellini's central question as to whether the clinician must always follow through on the idiosyncratic value of the patient in the move from diagnosis to therapeutic empathy invites further reflection on the role played by narrative identity and the concept of self in recovery (see Goldie, 2012; Schechtman, 1996; Zahavi, 2014). I have argued elsewhere (Bergqvist, 2020) that we rethink the idea of the "point of view" of the individual patient and the wider context of...