See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/236777176

More Aristotle, Less DSM: The Ontology of Mental

Disorders in Constructivist Perspective

Article in Philosophy, Psychiatry & Psychology · January 2009

DOI: 10.1353/ppp.0.0192

CITATIONS READS

18 271

3 authors, including:

Pérez-Álvarez, Marino José Manuel García-Montes

University of Oviedo Universidad de Almería
138 PUBLICATIONS 1,328 CITATIONS 84 PUBLICATIONS 1,118 CITATIONS

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Influencia de la metáfora View project

All content following this page was uploaded by Pérez-Álvarez, Marino on 19 January 2015.

The user has requested enhancement of the downloaded file.

 More Aristotle,
Less DSM
The Ontology of
Mental Disorders
in Constructivist
Perspective
Abstract: This work begins by proposing the need
for exploring the mode of being of mental disorders. It
is a philosophical study in an Aristotelian perspective,
with special emphasis on the anthropological–cultural
dimension. It is difficult for such an inquiry to be car-
ried out from within psychiatry or clinical psychology,
committed as these fields are to their own logic and
practical conditions. The issues are, in any case, more
ontological than strictly clinical in nature. We there-
fore turn to Aristotle, and specifically his doctrine of
the four “causes,” to flesh out the social and cultural
dimensions of mental disorders. In accordance with the
present analysis, the material cause of disorders would
be found in the contingencies of life; the formal cause
would pertain primarily to the way clinical conditions
themselves can serve as models of ‘being ill’ in our
society; the efficient cause would correspond to the pa-
tients themselves, understood as active (albeit less than
fully conscious) agents as well as to the pharmaceutical
industry and the mass media; the final cause would be
found in different adaptive functions served by the dis-
order. We conclude that the “mode of being” of most
(if not all) mental disorders—in particular, their status
as mental disorders—can often have more to do with
cultural forms than with biological factors.
Keywords: Efficient cause, final cause, formal cause,
material cause, social drama, Charcot effect, clinical
psychology, psychiatry
© 2009 by The Johns Hopkins University Press
Marino Pérez-Álvarez, Louis
A. Sass, and José M. García-
Montes
B
oth psychiatry and clinical psychology
have developed rapidly in the last half
century or more, at scientific and technical
levels, and also in terms of social prestige and
services provided to society. Neither field seems,
however, to have developed a very clear position
on the nature of the mental disorders that they
study and treat. Generally, mental disorders have
been assumed to be natural formations, objective
entities that exist “out there,” independent of the
clinical practices that study them. In this line, men-
tal disorders, like physical illnesses, are typically
understood to derive from dysfunctions of one or
another kind of internal mechanism.
The supposed internal dysfunction is, however,
conceived rather differently depending on the prac-
titioner’s clinical approach or overall theoretical
perspective. In contrast with other mainstream
medical and health specialties, psychiatry and clini-
cal psychology contain a variety of highly diverse
approaches, including some that reject the “internal
dysfunction” assumption mentioned. This plurality
of approaches does not seem to be a consequence of
the scientific immaturity of psychiatry and clinical
psychology but, rather, of the open or ambiguous
212  ■  PPP / Vol. 15, No. 3 / September 2008
character of mental disorders themselves, which
are inherently susceptible to various reconstruc-
tions and interventions. One question concerns the
extent to which mental disorders might, in fact, be
constructed entities of a historical–social nature,
cultural forms that provide models of ‘being ill’
for persons who are experiencing crises, conflict,
or dramatic situations of various kinds. Such a
suggestion would not deny the reality of mental
disorders, but poses the question as to the genesis
and nature of these realities.
Clarification of this issue is not likely to come
from within psychiatry or clinical psychology,
committed as these fields are to their own logic and
perspective. The issue is, in any case, more philo-
sophical than scientific or technical in nature—it is
one of many examples of the need for philosophi-
cal thinking within the mental health professions.
Indeed, the key question here is ontological: It
concerns the type of reality or “way of being” of
mental disorders. The sort of ontological inquiry
we propose in this article may help to unsettle the
often taken-for-granted view of mental disorders
as deriving primarily from interior dysfunctions,
whether neurobiological or psychological in na-
ture. Such an inquiry can reveal certain blind spots
of clinical know how, in particular, a tendency to
“discover” what clinical practices themselves may,
in fact, have brought into play.
In this essay, we proceed as follows. First, we
attempt to illuminate the general terrain—to open
a clearing in the jungle of psychiatric and clinical–
psychological theory and practice, with a view to
identifying the problems faced and the path to be
followed. Second, we introduce Aristotle’s concept
of the four causes: material, formal, efficient, and
final. This serves as a critical instrument for the
ontological inquiry we propose. In the end, we
draw some conclusions about the mode of being
of mental disorders. Although our ontological in-
quiry is intended to apply (at least to some extent)
to all forms of mental or emotional disorder, we
nevertheless focus on certain disorders that we
consider exemplary, particularly schizophrenia.
Clearing the Terrain
In this introductory section, we consider why
one should not expect clarification of the (above-
mentioned) ontological issues to come from the
clinical disciplines themselves. Then we indicate
the path to be followed in the rest of this paper.
Exposing the ‘Charcot Effect’
An exploration of the ontological status of
mental disorders requires a “critique of clinical
reason.” A key reason why such a critique is not
likely to emerge from the disciplines of psychiatry
or clinical psychology concerns what might be
termed the ‘Charcot effect’ (Pérez-Álvarez and
García-Montes 2007).
It is widely recognized that J.-M. Charcot
(1825–1893), the eminent French neuropatholo-
gist of the late nineteenth century, was responsible
for inducing attacks of hysteria under the assump-
tion that he was merely describing them. To the
extent that Charcot’s clinical expectations actually
functioned as prescriptions of what was to be
observed, Charcot was himself immersed in a self-
confirmatory system, with the admiration of the
audience who attended his lectures serving mainly
to support this effect. But the ‘Charcot effect’ is
not merely a particular historical occurrence. The
phrase refers not only to Charcot’s work at the
Salpêtrière hospital in Paris, where he described
the grand attaque de l’hystérie in the 1890s
(Shorter 1992), but also to a far more general
clinical phenomenon that may occur, to a greater
or lesser extent, in virtually all psychodiagnostic
and psychotherapeutic processes (Berkenkotter
and Ravotas 2002; Borges and Waitzkin 1995).
An important current instance of what might
be termed the Charcot effect is the tendency,
common in both research and clinical practice in
contemporary psychiatry, to define or diagnose a
disorder by its response to medication. This is the
strategy that Peter Kramer (1993), in Listening to
Prozac, called ‘listening to the drug.’ In clinical
practice, the medication actually serves to specify
the diagnosis. Thus,
if a supposed manic-depressive does not respond to
lithium or to another of the mood stabilizers, a psychia-
trist will wonder whether after all he’s schizophrenic.
If a supposed schizophrenic is managed effectively
on anti-anxiety agents or even without medication, a
psychiatrist will question whether she is, in fact, schizo-
phrenic. (Luhrmann 2000, 49)
 Pérez-Álvarez, Sass & García-Montes / More Aristotle, Less DSM  ■  213
As David Healy has pointed out, pharmacologi-
cal companies engaged in psychiatric research can
now “not only set out to find the key to the lock
but can dictate a great deal of the shape of the lock
to which a key must fit” (1997, 212). Certain dis-
orders seem, in fact, to owe their existence to their
status as targets for medications that companies
wish to market: for example, panic disorder in re-
lationship to alprazolam (Xanax; Valenstein 1998)
and social phobia in relation to paroxetine (Paxil;
Moynihan and Cassels 2005). In similar fashion,
the proliferation and popularization of a variety
of medications seem to be converting depression
into a supposed “epidemic” (Pignarre 2001).
This new drug “cartography,” as Radden
(2003) terms it, seems to be at the root of a grow-
ing discrepancy between diagnostic proliferation,
on one hand, and etiological knowledge, on the
other. Diagnoses proliferate and become estab-
lished even though (despite mountains of biologi-
cal data) very little has actually been established
regarding the actual causes of many disorders. It
is true that, in medicine, diagnosis has typically
preceded the discovery of causes. The reality is,
however, that many contemporary psychiatric
diagnoses do not fulfill (nor is there much prospect
of their fulfilling) the requirements of biologically
oriented psychiatric research, either in the sense
of being precisely defined or of taking underlying
psychopathological processes into account (van
Pragg 1997).
In view of these developments, it should come
as no surprise that the traditional interest in
psychopathology—in studying the nature and
etiology of mental disorders as distinct from their
treatment—seems practically absent from much
contemporary research and clinical practice, as
several recent psychiatric editorials have lamented
(e. g., Andreasen 1998, 2007; Maj 1998; Tucker
1998). Indeed, if viewed from a psychopatho-
logical standpoint, much of the research enterprise
seems to be bogged down in clinical trials of treat-
ment response, without much promise of leading
to deeper knowledge of underlying pathologies
(Pignarre 2004). Psychiatric practice has been
largely reduced to the dispensing of drugs, often
not even by psychiatrists, but by general practi-
tioners equipped with questionnaires for making
rapid diagnoses.
The now-prominent strategy of defining the dis-
order by the medication can be seen as a case of the
‘Charcot effect.’ In a certain sense, disorders found
in clinical practice are propagated by the research
strategy itself, in conjunction with pharmaceutical
marketing. It is doubtful that such conditions are
optimal for exploring the understanding of the
true status of mental disorders.
The ‘Charcot effect’ is also quite prominent in
clinical psychology, where disorders also tend to be
defined according to the procedures used to treat
them. We know, of course, that Oedipal complexes
tend to present themselves to psychoanalysts,
depressive schemas to cognitive therapists, and
inappropriate behavioral repertoires to behav-
ior therapists. A patient may adopt not merely
the vocabulary of the therapist, but an entire
configuration—including forms of experience and
expression as well as of self-understanding—that
derives, at least in part, from the way the problem
is clinically viewed. The point is that each psy-
chiatric or psychological system and associated
ideology creates its own universe of discourse,
within which a patient’s problems are interpreted
and modeled. In this sense, we are indeed faced
with a kind of ‘Charcot effect,’ an effect that is
mirrored in the finding of apparently similar ef-
fectiveness of different psychological treatments
(Huble, Duncan, and Miller 1999). There seems
little doubt, then, that psychiatric expectations
and diagnostic trends do influence the presenta-
tion of symptoms and the nature of the disorders
that manifest themselves. The question remains
as to just how these expectations and trends have
their effect, and also how much of the domain of
mental or emotional disorder can be understood
in this way.
In any case, the ‘Charcot effect’ makes it
highly unlikely that any ontological clarifica-
tion will come from mainstream psychiatry or
clinical psychology. And this is so, not because
of any supposed conflict of interests, but because
of epistemological obstacles arising from clinical
practices and conceptions themselves. Each clinical
conception involves a specialized mode of ‘seeing,’
‘talking,’ and ‘writing’ that ends up constructing
its objects, as Byron J. Good (1994, ch. 3) has
shown in relation to the medicine taught at Har-
vard Medical School. Therefore, it is unlikely that
214  ■  PPP / Vol. 15, No. 3 / September 2008
those adopting these clinical conceptions will be
aware of their participation in the production of
the objects they study, especially when they see
themselves as reaffirmed in what they do. The
scientific attitude of contemporary psychiatry
and clinical psychology is to take for granted that
mental disorders are “out there” to be discovered,
described, and treated. However, such an attitude
can be simplistic and misleading as the basis of
ontological inquiry.
The Road to Follow
An ontological inquiry such as that proposed
here must take as the object of analysis the real-
ity that constitutes the clinical field. That reality
includes both patients with their problems and
clinicians themselves, with their theories and
procedures. Such an inquiry demands a global
view that can encompass all the different actors
(including patients and clinical professionals)
and place them within the cultural and scientific
context. Such a view is comparable to that of
an anthropologist doing a field study, where the
“natives” are patients and clinicians. Analogies
from the world of theater are also relevant, for the
development of mental disorders can be fruitfully
viewed as the unfolding of a drama, taking into
account the reciprocal role of the different actors.
Here we might employ the notion of ‘social drama’
proposed in Victor W. Turner’s anthropology of
experience and performance (Turner 1982, 1986;
Turner and Bruner 1986). Clinical professionals do
not, after all, actually see ‘cerebral disturbances’ or
‘mental processes’; these are their assumptions (hy-
potheses, explanations). The ‘things themselves’
that are faced by clinical professionals would be,
above all, social dramas, dramas in which the
clinicians themselves also play their role.
The notion of social drama can be applied to
diverse situations and in different cultures. Turner
(1982) defines social dramas as units of aharmonic
or disharmonic process that arise in conflict situ-
ations. Typically they have four phases: breach,
crisis, redressive action, and reintegration; and
these can be neatly applied to the psychological
and sociocultural trajectory followed by mental
disorders. The question, then, is to see how certain
social dramas, involving breach and crisis, come to
be converted into mental disorders—that is, how
they become the clinical phenomena they are.
We do not deny, of course, that mental disorders
typically involve biological factors. But, often,
what matters most is how the person responds
to or deals with the factor or its effects. The way
in which one manages one’s biological alteration
is what usually gives the alteration its specifi-
cally psychiatric meaning. In the case of hearing
voices, for instance, it seems to be not the voices
themselves, but the person’s beliefs about hearing
voices, and also the social consequences of these
beliefs and attitudes, that actually determine
whether or not they come to constitute a disorder
(Romme and Escher 1993). This is but one of the
ways in which, as Sass and Parnas (2007) note,
“subjective experience can play an important
causal role in the progressive experiential trans-
formations of a developing schizophrenic illness”
(p. 86). We propose that Aristotle and his theory
of the four causes offer a useful way of approach-
ing the processes at issue. Our application of the
four causes should be viewed as an exploratory
attempt, a way of calling attention to some gener-
ally neglected ways in which the realm of so-called
mental disorders may be understood.
The Four Causes of Mental
Disorders
Prior Considerations
Aristotle presents the theory of the four causes
in his works Physics and Metaphysics (Aristotle
1999, 1994/2000). The four causes refer us to
aspects of explanation that are necessary for a full
understanding of things and events, both natural
and artificial. The four causes (perhaps better de-
scribed as four fashions in which we cite the cause
[Lear 1988, 27]) refer us to aspects of explana-
tion that are necessary for a full understanding of
things and events, both natural and artificial. They
are what allow us to grasp what might be called
“the why” of something (van Fraassen 1980, 26),
the “reason why it is so” (van Fraassen 1980,
25). Aristotle begins with the material element
of which something is made, the material cause;
then turns to what constitutes the element as a
particular something, which is the form it takes
 Pérez-Álvarez, Sass & García-Montes / More Aristotle, Less DSM  ■  215
or model it follows, in other words, its essence or
formal cause. The efficient cause is what brings
about the change from the previous condition,
namely, the agent, constructor, or architect. The
final cause constitutes the function for which a
thing was created.1
It should be borne in mind that the terms Ar-
istotle uses (aition, aitia) actually have a broader
meaning than our own word ‘cause.’ Although
some scholars, such as Guthrie (1981), argue
that the English term “cause” is the best term for
capturing Aristotle’s intended meaning, others
seem to prefer the phrase “explanatory factor”
(Falcon 2006; van Fraassen 1980, 32, 34, 43).
Aristotle’s “causes” refer, in any case, to explana-
tory factors that address “why-questions” (van
Fraassen 1980, 42), that is, that help to explain
why something exists, and in the way that it does.
They concern a fundamental kind of knowledge
that has a metaphysical or ontological rather than
purely empirical status. To focus on the four causes
is not, of course, to deny the crucial relevance of
empirical knowledge, but rather to consider the
diverse frameworks within which such knowledge
can be considered and integrated.
Although we assume that our application of the
four causes covers all disorders, we recognize that
it is easier to see in disorders where the cultural
dependence is more clear. Our application does
not rule out possible neurobiological factors, but
nor does it give them pride of place. (And we note,
in passing, that surprisingly few, if any, neurobio-
logical factors have been reliably established in
psychiatry and clinical psychology, either as etio-
logical factors or even as predictive or diagnostic
markers ([Scott 2006; Valenstein 1998]).
Let us turn, then, to the first of Aristotle’s four
causes.
Material Cause
The material cause relates to the material of
which a thing is made.2 Aristotle often uses the
example of a statue, which can be made of bronze
or another substance. But mental disorders have to
do, of course, not with physical objects but with
people, who feel and act in relation to one another.
In this sense, mental disorders are more akin, for
example, to tragedy than to sculpture. The mate-
rial of tragedy consists in human conflicts and the
general vicissitudes of life—disappointments, frus-
trations, existential conditions, personal dramas,
and the like. We suggest that the nature of mental
disorders derives, in large measure, from the way
this sort of “material” comes to be moulded by
various cultural forms or ‘cultural idioms’ (e.g.,
by the notions of folk psychiatry described be-
low, in the section on formal causes).3 Thus, for
example, people learn to frame certain conflicts
and vicissitudes—sadness, poverty, misfortune,
suffering—in terms of “depression,” thereby giv-
ing rise to the era or “epidemic” of depression
that emerges after the late 1980s (Dworkin 2001;
Healy 1997; Pignarre 2001).
Other life problems and circumstances, such as
certain fears, conflicts, tensions, or interpersonal
difficulties, would constitute the material that is
manifest as panic disorder or social phobia, to
mention two recently created disorders (Pérez-
Álvarez and García-Montes 2007). It is consistent
with Aristotle’s view to recognize that there are
constraints on what kind of material can be used
to form a particular kind of entity. More or less
specific materials would therefore be at the basis
of particular disorders; for example, sadness
with respect to depression, or fear with respect to
anxiety or phobia. Here, however, these specific
material causes, such as sadness and fear, are
considered more as conditions of human existence
or ways of being-in-the-world than as explana-
tory biological mechanisms. Our starting point
for the understanding of mental disorders is not
biological substrates (although without denying
their implication in all human activity), but rather
the vicissitudes of life. This would also apply to
the case of schizophrenia.
Of what material would schizophrenia be
made? According to our perspective, the material
of schizophrenia could be largely found in the
crisis of common sense and the allied social dis-
location this involves (Blankenburg 1971, 2001;
Stanghellini 2001, 2004). It would therefore be
necessary to study the reality of the life-world
(Schutz 1962) to study schizophrenic crises. The
reality of the world of life or of common sense, as
Schutz (1962) points out, includes, among other
elements, the experience of the self, life projects,
216  ■  PPP / Vol. 15, No. 3 / September 2008
sociability, and belief in the world as it appears. In
an anthropological–cultural perspective, it would
be necessary to study the way the self is constituted
in a particular society. As Fábrega (1989) argues,
the self is the key to the mediation of cultural
factors in the experience, course, and duration
of the crisis called ‘schizophrenia.’ As a crisis,
schizophrenia represents both a difficult situation
(the collapse of the taken-for-granted world) and a
possible adaptive reorganization or reconstructive
effort on the part of the person who undergoes
it (e.g., formation of delusions). On the basis of
these materials, which, as pointed out, already
involve a certain form, schizophrenia will take its
course, which may involve only a single psychotic
episode or, alternatively, may involve the process
of chronification necessary for the current DSM
diagnosis to be applied. Which of these alternatives
(among others) actually occurs, can itself depend
on various cultural factors that we discuss in rela-
tion to other Aristotelian ‘causes.’
Given our perspective, it is noteworthy that
Aristotle (in De anima) laid down the bases for
studying common sense (koiné aisthesis). Recently,
Stanghellini (2004, 2007), following Blankenburg
(1971, 2001), has argued that the theory of koiné
aisthesis provides a solid philosophical basis for
understanding schizophrenic psychopathology.
In turn, schizophrenia would indeed shed light
on common sense or koiné aesthesis, insofar as it
highlights structures of common sense understand-
ing that are otherwise difficult to perceive.4
In sum, the materials of which mental disorders
are made are to be found in the challenges and
vicissitudes of life. There is, of course, never any
lack of life problems. It is, however, only in mod-
ern society that these problems of life are turned
into psychological or psychiatric problems. What
previously was likely to be perceived as a chal-
lenge, attributed to luck or destiny, or conceived
in religious, moral, or ethical terms, comes in our
era to be characterized as a dysfunction resulting
from some supposed cognitive, emotional, or
behavioral process, and whose solution must lie
in some technical procedure. This leads us to the
issue of formal cause.
Formal Cause
The formal cause concerns the form or pattern
adopted by mental disorders, the overall pattern
of being ill.5 These patterns can be established in
cultural practices in ways that are informal or
formal, implicit or explicit, with such nosological
systems as the DSM (American Psychiatric Asso-
ciation, 1994) being the principal formal source
in contemporary Western society.
The sociologist Alan Horwitz offers a useful
description of a key difference between physical
and mental illnesses:
Unlike physical illness, where symptoms are usually
indicators of underlying disorders, the symptoms of
mental disorders are symbolic representations of
underlying vulnerabilities that are structured to fit
dominant cultural models of ‘appropriate’ disorders in
particular times and places. In this sense, the symptoms
of mental disorders are part of ‘cultural tool kits’ no
less than language, fashion, and musical or culinary
tastes. (2002, 268)
In our view, the “dominant cultural model” for
mental illnesses, at least in contemporary Western
society, is largely provided by such systems as
the DSM itself. In this sense, clinical labeling can
be understood as playing a role that is perhaps
less descriptive than prescriptive—that is, not so
much a matter of capturing prior phenomena as
of trimming and shaping their form. This process
occurs not only in the course of clinical practice
but also in the extra-clinical contexts of everyday
psychological culture, as we shall also see presently
in relation to the efficient cause (Pérez-Álvarez and
García-Montes 2007).
According to our perspective, the role of
cultural forms in mental disorders is not merely
expressive, but constitutive. In this regard, it
should be said that our perspective is philosophical
rather than simply cultural. Our starting point is
a philosophical anthropology according to which
the fundamental mode of human existence is en-
gaged activity. We are referring to a philosophical
anthropology based on Heidegger (being-in-the-
world) and also on Ortega y Gasset (“I am myself
and my circumstances”; see in this same issue [van
Fraassen 1980, 26]), and developed in line with
an ontological hermeneutics following Gadamer
and Ricoeur (Sass 1988).
 Pérez-Álvarez, Sass & García-Montes / More Aristotle, Less DSM  ■  217
Within this sort of philosophical anthropology,
what should be stressed is the horizonal nature and
the linguisticality of the human being. Horizonal
nature means that the human being is always in
some circumstance and within some horizon,
which constitutes the context in which all human
activity occurs, including mental disorders. Given
the public nature of the horizon—because it is a
socially shared context—our self-interpretations
or self-understandings are broadly determined by
the possibilities given in culture. As for linguisti-
cality, such a perspective assumes that language is
not merely a part of man’s equipment for dealing
with the world, but indeed is—to a significant
extent—what permits us to have a world, because
it provides the principal source of our interpreta-
tions and understanding of both the world and
oneself. Thus, the function of language in relation
to experience would be not expressive but, rather,
constitutive (Sass 1988, 246). In sum, culture
would be the condition of possibility of the hu-
man being, including the possibility of mental
disorders.
On this philosophical view, the cultural perspec-
tive takes on a transcendental and fundamental
dimension. This goes beyond traditional tran-
scultural psychiatry, which covered only general
categories (e.g., developed versus developing coun-
tries), and at best, particular aspects (e.g., exotic
beliefs and rituals). We would be talking here
about a cultural perspective that puts meaning
back into the center of psychiatric research and
practice, and that studies how culture comes to
constitute the experiences, actions, and reactions
of mental disorders (Fábrega 1989; Good 1994,
1997; Jenkins and Barrett 2004; Kleinman 1988;
Vanthuyne 2003).
In this perspective, Western culture itself is the
object of study. The question would be to adopt
an anthropological or dramaturgical point of view,
as indicated, which provides a global picture that
includes patients with their problems and clinical
professionals themselves with their theories and
procedures. Important in this regard would be the
‘cultural idioms’ in the articulation of the experi-
ence of mental disorders. A “cultural idiom” is
made up of value systems, forms of interpretation,
and epistemological assumptions, all of which
structure the form in which people experience,
give meaning to, and react to the situations they
face (Vanthuyne 2003). Likewise, we would high-
light medicalizing and psychologizing practices as
the most well-established forms of pathologizing
(more so, for example, than moralizing) in folk
psychiatry (Haslam 2005).
Given this clinical culture, it should come as
no surprise that the DSM can be considered as a
source of ways of ‘being ill’ in Western society, as
suggested at the beginning of this paper. It is not
that people actually read the DSM or similar noso-
graphic systems, but its ‘idiom’ ends up shaping
the experience of ‘everyday nerves’ (Healy 2004).
We might say that, in practice, folk psychiatry and
formal psychiatry are intimately allied factors, rel-
evant to ‘formal cause’ (the latter to be discussed
below). Examples of this intimate alliance, studied
by Healy (2004), are the prevalence of anxiety in
times of diazepam (Valium), the transformation of
cases of anxiety into depression in times of fluox-
etine (Prozac), and the emergence of panic disorder
and social phobia in relation to the correspond-
ing new drugs (see also Horwitz 2002; Medawar
and Hardon 2004; Moynihan and Cassels 2005).
This consideration of the social shaping of the
experience of ‘everyday nerves’ and the like does
not deny the reality of the disorders presented by
patients—in this case anxiety, depression, panic
disorder, and social phobia—but rather attempts
to clarify some of the factors whereby this reality
comes to be made real.
Cultural forms are also critical in schizophre-
nia. Jenkins and Barrett (2004) make this point
forcefully:
[W]hat we know about culture and schizophrenia at the
outset of the twenty-first century is the following: Cul-
ture is critical in nearly every aspect of the schizophrenia
illness experience: the identification, definition and
meaning of the illness during the prodromal, acute and
residual phases; the timing and type of onset; symptom
formation in terms of content, form and constellation;
clinical diagnosis; gender and ethnic differences; the
personal experiences of schizophrenic illness: social
response, support and stigma; and, perhaps most
important, the course and outcome of disorders with
respect to symptomatology, work and social function-
ing. (pp. 6–7)
218  ■  PPP / Vol. 15, No. 3 / September 2008
More specifically, the crisis of common sense in
which schizophrenia consists (in terms of its ma-
terial cause) would be molded, first of all, by the
forms of selfhood or self-experience that are cur-
rent in the culture of reference (Fábrega 1989), and
also by prevailing conceptions of mental disorders
in particular. In this regard, we might propose
the schizoid personality, characteristic of modern
society (Devereux 1970; Pérez-Álvarez 2003; Sass
1992), as a model for schizophrenia (Pérez-Álvarez
2006). The fact that the crisis of common sense in
‘schizophrenia’ involves certain alterations of self-
awareness, with a marked solipsistic and autistic
character (Parnas and Sass 2001), is related to the
prominence of schizoid tendencies or, in Foucault’s
terms, with that ‘strange empirico-transcendental
doublet’ that would be modern man (see Sass
1992, 1994). This means that disorders in some
ways akin to ‘schizophrenia’ would adopt other
forms, relatively distinct from the Western form,
in different cultures, according in this case both
to the mode of selfhood characteristic of the con-
text and also to prevalent models of ‘being mad.’
Thus, for example, one might speak of the ‘Asian
model’ of psychosis (Corin, Thara and Padmavati
2004; Good and Subandi 2004; Wilce 2004), in
which both the experience of the disorder and the
associated behavior seem more interpersonal than
intrapsychic in nature. For example, in such cases
the characteristic ‘withdrawal’ is not so much so-
lipsistic and autistic as social in nature: wandering
around outside the village, ‘talking bad.’ behaving
rudely, and so on.
In our perspective, clinical practices themselves
(nosographic systems and the like) also contribute
to the molding of schizophrenia. Thus, for exam-
ple, diagnosis based on a series of symptoms and
use of ‘antipsychotic’ medication as the preferred
treatment contribute to conceiving disorders as
illnesses of the brain. As Horwitz (2002) says:
“The view that real illness must have biological
causes is, paradoxically, a cultural construction”
(p. 156). The point is that this consideration as an
illness of the brain forms part of folk psychiatry
or cultural idioms, so that it ends up giving form
to the disorder presented. But things do not neces-
sarily have to be this way. First of all, there are,
in fact, no firmly established bases for considering
schizophrenia as an illness of the brain, as there
are for, say, Alzheimer’s disease (even though we
are not clear on its etiology). To borrow a contrast
framed by Kleinman (1999), it is crucial to view
schizophrenia not as a “disordered modulation”
of a universal “human nature,” but, rather, as a
particular configuration of a diversity of “human
conditions” which, of course, include biological
aspects (Jenkins and Barrett 2004, 10).
Efficient Cause
The efficient cause relates to the issue of who or
what force makes it that, or brings it about that,
something comes to be as it is—in this case, who
or what brings it about that life problems take
the form of ‘mental disorders.’6 Obviously, people
do not just have mental disorders in the way that
they have, say, hepatitis; nor do mental disorders
emerge in the same way as, say, teeth. Nor is it
the case, obviously, that mental disorders are the
products of deliberate steps taken to achieve a de-
sired outcome. Still, what we call mental disorders
always do involve, at some level, active (although
not necessarily fully conscious) responses to the
problems that life puts in a person’s way. After
all, even passivity is an “action” in the sense that
it nearly always involves at least some degree of
choice among alternative possibilities or ways
of being. And this active element means that a
given disorder is always subject to, or bound up
with, various kinds of psychosocial and cultural
forces.
Patients typically present their problems to
clinical professionals, in whose presence the prob-
lems undergo a kind of ‘secondary elaboration.’ To
begin with, the prevailing clinical perspective will
shape the “material” by giving special weight to
some aspects or features of the patient’s experience
and behavior rather than others (Berkenkotter and
Ravotas 2002), thereby molding symptoms that
may previously have had a more undefined form.
That the problem presented typically takes the
form of a diagnostic condition, which from that
point on structures the original problem, is, in part,
a response to a practical need for the problem to
take some recognizable, quasi-medicalized form,
with treatment-oriented implications (Neimeyer
and Raskin 2000). In this sense, the issue is the
 Pérez-Álvarez, Sass & García-Montes / More Aristotle, Less DSM  ■  219
selection not so much of a ‘natural kind’ as of a
‘practical kind,’ that is, of a category that responds
primarily to functional and practical demands, for
example, by serving to simplify understanding and
guide action toward solution of a problem.7 Thus,
for example, a problem of “everyday nerves,” to
re-employ the expression used previously, could
be conceived of as ‘stress’ or as ‘depression,’
depending on which was more practical with a
view to helping the client, without either choice
being a diagnostic error. (By contrast, it would be
a monumental error for a doctor to confuse, say,
pneumonia with tuberculosis; see Haslam [2002a]
and Zachar [2000, 2002]).
Patients and clinical professionals are, of
course, both embedded in a cultural context. The
psychological and biomedical culture of contem-
porary society encourages people to present as
mental problems what might otherwise be seen
as merely problems in living, or even, perhaps,
not as problems at all (they might, for example,
experience themselves as sad, perhaps appropri-
ately so, rather than as depressed). Thus, patients
may already arrive at the clinician’s office with a
more or less sophisticated, ‘primary elaboration’ of
their problems as, for instance, ‘panic disorder’ or
‘depression.’ And because patients (like clinicians)
are targets of marketing by the pharmaceutical
industry, they may end up having the disorders that
the drugs treat. This cultural framing of experience
can have various problematic consequences for the
individual. One Moroccan psychoanalyst makes
this very point when he describes the consequences
of establishing the first psychiatric institutions
during the colonial period. “The symptom,” he
writes, “has been increasingly addressed to the
representatives of modern science, while people are
increasingly alone with their suffering” (Pandolfo
2000, 117, citing Bennani 1995, 113).
The pharmaceutical industry is not, of course,
the only promoter of new disorders. Here an
interesting example is the case of posttraumatic
stress disorder (PTSD). PTSD entered into the
DSM III (American Psychiatric Association 1980)
in the context of the moral and political but also
economic claims of Vietnam War veterans who
needed a diagnostic concept that could include
and, in some sense, ‘objectivize’ a diffuse set of
difficulties by construing them as direct conse-
quences of traumas experienced in war (Young
1995). The re-structuring of ‘clinical reality’ by
diagnostic categories is apparent in the rapidity
with which a wide range of problems—from psy-
chosomatic problems to problems related to social
adjustment—were woven into ‘PTSD.’
Even schizophrenia is affected by the kind of
‘efficient causality’ conceptualized here. In Creat-
ing Mental Illness, the sociologist Alan Horwitz
(2002) excludes schizophrenia, together with
bipolar disorder and the psychotic forms of depres-
sion, from what he terms the “creation” of mental
disorders on the grounds that the etiology is so
largely biological.8 There is, however, consider-
able evidence that sociocultural factors do have a
significant role in the course of schizophrenia as a
chronic, debilitating illness. The well-established
finding of poorer prognosis of schizophrenia in
developed countries compared with developing
countries (Warner 2004) may well be due, at least
in part, to the reifying propensities of Western
conceptions of mental illness and the pathologizing
impact of diagnosis, medication, hospitalization,
and other clinical practices that can steer people
with life crises toward a veritable ‘psychiatric ca-
reer.’ It is worth noting, for example, that patients
with schizophrenia in the psychotropic era seem
to spend on average more time in the course of
a psychiatric career in a hospital than they did
before modern drugs came ‘on stream’ (Healy
2004, 236).
Fortunately, the Western health care framework
does offer some alternative ways of approaching
schizophrenia that tend to normalize the crises
rather than fostering the kind of ‘psychiatric
career’ referred to above. Some examples are
Open Dialogue (Seikkula and Olson 2003), where
clinical professionals deal with the psychotic crisis
within the family context (visiting homes); Making
Sense of Voices (Romme and Escher 2000), which
involves understanding voice hearing in biographi-
cal context and normalizing these experiences; and
Acceptance and Commitment Therapy (Bach and
Hayes 2002; Veiga-Martínez, Pérez-Álvarez, and
García-Montes 2008), which proposes the ac-
ceptance of symptoms and fosters an orientation
to values. All three approaches seek to avoid or
220  ■  PPP / Vol. 15, No. 3 / September 2008
minimize both medication and hospitalization.
We see, then, that the efficient cause in the cul-
tural construction of mental disorder can involve
various actors. Both patient and clinicians play
their role, and they do so in a context that includes
the psychological culture, the biomedical research
industry, marketing by pharmaceutical companies,
and also advocacy by nonprofit groups that may
have their own private interests and agendas, in
particular, an interest in defining disorders as
brain-based diseases. These latter include the Na-
tional Alliance for the Mentally Ill (McLean 1990)
and Children and Adults with Attention-Deficit/
Hyperactivity Disorder (Fukuyama 2002, ch. 3).
Final Cause
Aristotle’s notion of final cause, applied to men-
tal disorders, refers to the purposes these disorders
may serve, and the meanings associated with these
purposes.9 It is important to recall that what we
conceptualize as a mental disorder represents,
at the same time, a problem and an attempt at a
solution—a point that has, in various ways, been
recognized by practically all psychotherapeutic
approaches. If the dysfunctional (or purposeless)
aspect is often the most obvious or prominent,
this is, at least in part, the result of viewing these
“disorders” in a biomedical or psychiatric con-
text. One must recognize as well a set of possible
functions that conditions of mental or emotional
disorder can serve. One such function is that of
alarm, indicating that something is wrong in the
life system—as may be the case with anxiety in
relation to a relationship crisis, or depression in
relation to coping with a life change. Another
such function is that of creating a haven, a kind
of truce in the vicissitudes of life that permits one
to reorganize energies and readjust one’s course.
Another might be that of a cry for help or recogni-
tion that is directed at the social environment. And
indeed, it is also conceivable for the disorder to
represent a way or a style of sorting out problem-
atic situations, or even an actual way of life. In this
perspective, particular symptoms or signs would
be viewed as environmentally directed actions or
signals, rather than primarily as indications of an
underlying or internal condition, whether neuro-
biological or psychological.
Within these general functions (alarm, truce,
cry for help, way of life), each symptom would
have its specific functions. Thus, for example, one
function that the sadness of depression probably
fulfils is that of not wasting effort on lost causes.
But as Sartre (1948) has pointed out, sadness also
involves what he terms ‘turning the world back
to zero,’ an experience of being equidistant from
everything, which can have the effect of opening
one up to becoming interested in new projects
that were unthinkable when one was interested
in what turned out to be a lost cause. As far as
psychotic symptoms (hallucinations, delusions)
are concerned, these may imply adaptive efforts
of self-maintenance in the face of the crisis that
is occurring or has occurred in the patient’s life.
Thus, for example, auditory hallucinations can
have pragmatic functions, such as providing ad-
vice, warning, or criticism, and may even simply
be a source of company (Leudar et al. 1997). The
point is that hallucinated voices may have their
biographical–personal sense—which is the aspect
focused on in the above-mentioned Making Sense
of Voices approach (see also Open Dialogue). In
the case of delusions, we might speak of existen-
tial meanings that these symptoms may have for
the patient, even to the point of representing a
preferred reality (Roberts 1991).
The final cause or adaptive function of symp-
toms may also have a phylogenetic origin, ac-
cording to evolutionary psychiatry. Evolutionary
psychiatry provides examples of the possible
adaptive value, during evolution, of traits and
states that we view today as pathological, because
the cultural context is now very different (Fábrega
2002). In this regard, it might be said that culture
can channel and modulate these functions on a
historical scale.
We see, then, that diagnostic categories provide
the patterns of being ill in modern society—which
accords with the idea that each society tends to
have its own preferred patterns, as Devereux
(1970) argued. In this way, mental disorders, as
practical kinds rather than natural kinds, would
be socially instituted ways of channeling ‘social
dramas’ and ‘everyday nerves’ or other forms of
malaise. The personal problem or crisis is socially
‘processed’ through the forms instituted in each
society for that purpose.
 Pérez-Álvarez, Sass & García-Montes / More Aristotle, Less DSM  ■  221
Conclusions
This work has set out to explore the ‘mode
of being’ of mental disorders in an ontological
perspective, with special emphasis on the anthro-
pological–cultural dimension. In doing so, we
have applied Aristotle’s theory of the four causes.
This application calls attention to some generally
neglected ways in which the realm of so-called
mental disorders can be understood.
Specifically, the material cause concerns the
problems of life (conflicts, vicissitudes, crises) that
can be understood as the starting point of mental
disorders. The formal cause concerns the role of
cultural forms (cultural idioms, folk psychiatry,
clinical theories and procedures) in the shaping
of life problems into the mental disorders they
eventually become. The efficient cause concerns
the role of diverse actors (patients, professionals,
the pharmaceutical industry) in fashioning life
problems into these mental disorders. The final
cause concerns the adaptive function the symp-
toms may have. The Aristotelian perspective has
the advantage of integrating these four aspects
into a unified theory, which we propose as an
ontology of mental disorders, at least in their
anthropological and cultural dimensions. In any
case, our approach is not merely social construc-
tivist or cultural–constructivist, but rather, as we
have pointed out, philosophical–anthropological
in nature. In this perspective, mental disorders
have more to do with the human condition, with
its social, cultural, and linguistic aspects, than with
human nature understood in biological terms. Two
implications, one conceptual the other practical,
arise from our approach.
As regards the conceptual implication, our
approach can be offered as an alternative to the
pathogenicity/pathoplasticity model, according
to which it is assumed that biology ‘determines’
the cause and structures the form of the mental
illness, while culture and social factors ‘shape’ and
‘influence’ only the content of the disorder. This
model, as Kleinman argues, is a “stratigraphic
version of the mind/body dichotomy, [where] biol-
ogy is bedrock (the source of pathogenesis), and
psychological and especially social and cultural
layers of reality are held to be epiphenomenal
(i.e., they are said to exert ‘merely’ pathogenic
effects)” (Kleinman 1988, 25; see Sass [1994,
98–9]). In contrast with this mechanistic model,
whose root metaphor is the machine, we propose
a contextual, anthropological–cultural model,
whose root metaphor is the historical event (fol-
lowing Stephen C. Pepper’s classic distinction in
his book World Hypotheses [1942]). According
to the contextual model, mental disorders would
not be something one has but, rather, something
one becomes; something that cannot be properly
understood outside a biographical, historical, and
cultural context. As Sass and Parnas note with
regard to schizophrenia:
[symptoms] cannot be considered to be mere epiphe-
nomena of neurophysiological changes. Indeed, they can
be neither understood nor explained without making
reference to the subjective or phenomenological dimen-
sion. This is not to deny the key role of neurobiologi-
cal abnormalities. Indeed, these latter may well have
ultimate causal primacy—as the main source of the
early experiential abnormalities. . . . Once the field of
experience is transformed, however, this gives rise to
forms of attention and modes of experience involving
developments-from or reactions-to subjectively experi-
enced aspects of both self and world. (2007, 86)
As far as practical implications are concerned,
our approach questions the traditionally assumed
separation of medication on the one hand and
psychological therapy on the other. According
to this traditional model, medication is typically
seen as the first line of action and psychological
therapy as a secondary complement. A particular
aspect of this model is its focus on elimination of
the symptoms (e.g., sadness in depression, voices in
schizophrenia) as a principal objective, and often
as a first step before psychotherapy or psychosocial
rehabilitation.
In opposition to this therapeutic dichotomy, our
approach would propose ‘psychosocial rehabili-
tation’ as a framework in which to combine the
different possible forms of help, including medica-
tion. Thus, the elimination of symptoms would not
have to be the prime therapeutic objective, or even
an objective at all; the principal aim would in this
case be reconstruction of the world of life (projects,
values, personal empowerment). In this line would
be current therapies such as Behavioral Activation
222  ■  PPP / Vol. 15, No. 3 / September 2008
as well as Acceptance and Commitment Therapy.
Behavioral Activation has shown, in depression,
that the activation of behaviors aimed at modify-
ing one’s environment can offer an alternative to
medication and to cognitive therapy (Dimidjian et
al. 2006). It is relevant to underline that Behav-
ioral Activation is not based on the assumption
of a neurochemical or cognitive deficit that needs
to be ‘treated’ as a condition for improvement;
nor does it approach symptoms (such as sadness
and depressogenic thoughts) directly. For its part,
Acceptance and Commitment Therapy consists
basically in promoting the acceptance of symptoms
that tend to be exacerbated by attempts to control
them, and also in helping the client recover a sense
of meaningful living that is consistent with his or
her values. Acceptance and Commitment Therapy
has demonstrated its effectiveness for a range of
mental disorders, including psychotic symptoms
(Bach and Hayes 2002; Gaudiano and Herbert
2006; Veiga-Martínez et al. 2008).
Acknowledgments
This work was financed with a research project
from the Spanish Ministry of Science and Tech-
nology (ref. SEJ2005-24699-E/PSIC) awarded to
the first author.
Notes
1. As Lear (1988, 27) notes, although Aristotle
identified four ways in which cause can be cited, there
are, in a certain sense, only two causes for him: form
and matter. This is because Aristotle considered “the
so-called formal, efficient, and final causes [to be] three
different aspects of form itself.”
2. The material cause, as an explicit concept, does not
figure in the history of psychiatry. The notion of material
cause can, however, be considered equivalent to the clas-
sic psychological/philosophical notions of both “object
of experience” and “sensory input.” In accord with this
distinction (which presumes the modern subject–object
separation), the perceiving subject would be understood
to provide the form, and the external object or sensory
input would provide the material.
3. It should be borne in mind here, as is made clear in
Aristotle, that all material, however elementary, involves
a certain form, because otherwise it would not even
be recognizable. For example, bricks are the material
of which a house is made, but they themselves have a
certain form, whose material would be the compounds
of which they are composed, and so on. However, Ar-
istotle’s proposal does not require a process of infinite
reduction. The point is to identify the elements or level
at which to establish knowledge about something. As far
as mental disorders are concerned, and at least accord-
ing to our perspective, the appropriate level at which
we should understand them would be the molar level
given by experiences and actions, and not the molecular
one given by biological substrates (see the discussion in
Changeaux and Ricoeur 1998).
4. Schizophrenia, leaving aside the disorder and suf-
fering it involves, can provide us with an understanding
of human functioning (Jenkins 2004) and of culture,
particularly of modern culture, given the affinity be-
tween madness and modernism (Sass 1992, 1994).
5. The words ‘formal cause’ were used in the his-
tory of psychiatry, in the early nineteenth century, as
equivalent to ‘proximal cause’ and in reference to a
supposed ‘internal mechanism’ (Berrios 2000). Here we
understand the words ‘formal cause’ to refer to a model
in the Aristotelian sense (see Lear 1988).
6. The ‘efficient cause’ figured in the history of psy-
chiatry, in the early nineteenth century, as ‘distant cause,’
in reference to the biographical and cultural antecedents,
which today would be called ‘risk factors’ (Berrios
2000). However, the sense of efficient cause here relates
rather to ‘actors’ than to ‘factors.’ According to Lear
(1988), the notion of antecedent event does not capture
the importance of Aristotle’s insistence that what con-
stitutes the real cause is the builder who builds.
7. In the perspective of the present work, as has been
noted, “mental illnesses” would be seen as “practical
kinds” in Zachar’s (2000, 2002) pragmatic and func-
tional sense, rather than as “natural kinds” in Wake-
field’s (2002) essentialistic sense. Even if one adopted
the taxonomy proposed in Haslam (2002a)—where
Zachar’s distinction is refined and the possibility of
“natural kinds” of mental illness is defended—it remains
clear that (as Haslam [2002b_ notes), natural kinds “are
plausible, but probably vanishingly rare, inhabitants of
the psychiatric domain” (240). It is noteworthy that,
as a possible instance of a natural kind, Haslam sug-
gests Williams syndrome, an entity with known physi-
ological and anatomical markers and not, for example,
schizophrenia.
8. Horwitz (2002) himself does, however, stress the
decisive role of context in the final determination of
the ‘illness.’
9. The final cause has not been prominent in the
history of psychiatry. But in recent years it has been
receiving considerable attention, as evolutionary psy-
chiatry use evolutionary biology and psychology to seek
the adaptive purposes that mental illness and symptoms
may serve or may have served in the Environment of
Evolutionary Adaptedness (Stevens and Price 2001).
 Pérez-Álvarez, Sass & García-Montes / More Aristotle, Less DSM  ■  223

References Corin, E., R. Thara, and R. Padmavati. 2004. Living

through a staggering world: The play of signifiers
Andreasen, N. C. 1998. Understanding schizophrenia:
in early psychosis in South India. In Schizophrenia,
A silent spring? American Journal of Psychiatry
culture, and subjectivity. The edge of experience, ed.
155:1657–9.
J. H. Jenkins and R. J. Barrett, 110–45. Cambridge:
———. 2007. DSM and the death of phenomenology in
Cambridge University Press.
America. Schizophrenia Bulletin 33:108–12.
Devereux, G. 1970. Essais d’ethnopsychiatrie generale
American Psychiatric Association. 1980. Diagnostic and
[Essays of general ethnopsychiatry]. París: Gal-
statistical manual of mental disorders, 3rd ed. Wash-
limard.
ington, DC: American Psychiatric Association.
Dimidjian, S., S. D. Hollon, K. S. Dobson, K.B. Sch-
———. 1994. Diagnostic and statistical manual of
maling, R. J. Kohlenberg, M. E. Addis, R. Gallop,
mental disorders, 4th ed. Washington, DC: American
J. B. McGlinchey, D. K. Markley, J. K. Gollan, D.
Psychiatric Association.
C. Atkins, D. L. Dunner, and N. S. Jacobson. 2006.
Aristotle. 1994/2000. Physics, trans. R. P. Hardie, and
Randomized trial of behavioral activation, cognitive
R. K. Gaye. The Internet Classics Archive, ed. D.
therapy, and antidepressant medication in the acute
C. Stevenson. Available online at http://classics.mit.
treatment of adults with major depression. Journal of
edu//Aristotle/physics.html.
Consulting and Clinical Psychology 74:658–70.
———. 1999. Metaphysics, trans. H. Lawson-Tancred.
Dworkin, R. W. 2001. The medicalization of unhappi-
New York: Penguin Books.
ness. The Public Interest Summer:85–99.
Bach, P., and S. C. Hayes. 2002. The use of acceptance
Fábrega, H. 1989. The self and schizophrenia: A cultural
and commitment therapy to prevent the rehos-
perspective. Schizophrenia Bulletin 15:277–89.
pitalization of psychotic patients: A randomized
———. 2002. Origins of psychopathology. The phy-
controlled trial. Journal of Consulting and Clinical
logenetic and cultural basis of mental illness. New
Psychology 70:1129–39.
Brunswick, NJ: Rutgers University Press.
Bennani, J. 1995. La psychanalyse au pays des saints.
Falcon, A. 2006. Aristotle on causality. Stanford En-
Casablanca: Le Fennee.
cyclopedia of Philosophy. Available from http://
Berkenkotter, C., and D. J. Ravotas, D. J. 2002. Psy-
plato.stanford.edu/entries/aristotle-causality/; IN-
chotherapists as authors: Microlevel analysis of
TERNET.
therapists’ written reports. In Descriptions and pre-
Fukuyama, F. 2002. Posthuman society. New York:
scriptions. Values, mental disorders, and the DSMs,
Farrar, Strauss & Giroux.
ed. J. Z. Sadler, 251–68. Baltimore, MD: The Johns
Gaudiano, B. A., and J. D. Herbert. 2006. Acute treat-
Hopkins University Press.
ment of inpatients with psychotic symptoms using
Berrios, G. E. 2000. La etiología en psiquiatría: Aspectos
Acceptance and Commitment Therapy: Pilot results.
conceptuales e históricos [Etiology in psychiatry:
Behaviour Research and Therapy 44:415–37.
Conceptual and historical aspects]. In Psicopa-
Good, B. J. 1994. Medicine, rationality, and experience.
tología descriptiva: Nuevas tendencias [Descriptive
New York: Cambridge University Press.
psychopathology: New trends], ed. R. Luque and J.
———. 1997. Studying mental illness in context: Local,
M. Villagrán, 539–78. Madrid: Trotta.
global, or universal? Ethos 25:230–48.
Blankenburg, W. 1971. Der Verlust der Naturlichen
Good, B. J., and M. A. Subandi. 2004. Experiences of
Selbstverstandlichkeit: Ein Beitrag zur Psycho-
psychosis in Japanese culture: Reflections on a case
pathologie Symptomarmer Schizophrenien. Stut-
of acute, recurrent psychosis in contemporary Yo-
tgart: Ferdinand Enke Verlag. French translation:
gyakarta, Indonesia. In Schizophrenia, culture, and
Blankenburg, W. 1991. La Perte de L’Evidence
subjectivity. The edge of experience, ed. J. H. Jenkins
Naturelle: Une Contribution a la Psychopathologie
and R. J. Barrett, 167–95. Cambridge: Cambridge
des Schizophrenies Pauci-Symptomatiques, trans. J.
University Press.
M. Azorin and Y. Totoyan. Paris: Presses Universi-
Guthrie, W. C. G. 1981. A history of Greek philosophy.
taires de France.
Volume VI. Aristotle. An encounter. Cambridge:
———. 2001. First steps toward a psychopathology of
Cambridge University Press.
‘common sense’. Philosophy, Psychiatry, & Psychol-
Haslam, N. 2002a. Kinds of kinds: A conceptual
ogy 8:303–15.
taxonomy of psychiatric categories. Philosophy,
Borges, S., and H. Waitzkin. 1995. Women’s narra-
Psychiatry, & Psychology 9, no. 3:203–17.
tives in primary care medical encounters. Women
———. 2002b. Practical, functional, and natural
& Health 23:29–56.
kinds. Philosophy, Psychiatry, & Psychology 9, no.
Changeux, J. P., and P. Ricoeur. 1998. Ce qui nous fait
3:237–41.
penser: La nature et la règle. Paris: Editions Odile
———. 2005. Dimensions of folk psychiatry. Review
Jacob.
of General Psychology 9:35–47.
224  ■  PPP / Vol. 15, No. 3 / September 2008
Healy, D. 1997. The antidepressant era. Cambridge:
Harvard University Press.
———. 2004. Shaping the intimate: Influences on the
experience of everyday nerves. Social Studies of Sci-
ence 34:219–45.
Horwitz, A. V. 2002. Creating mental illness. Chicago:
University Chicago Press.
Huble, M. A., B. L. Duncan, and S. D. Miller, ed. 1999.
The hearth and soul of change. Washington, DC:
American Psychiatric Association.
Jenkins, J. H. 2004. Schizophrenia as a paradigm case
for understanding fundamental human processes. In
Schizophrenia, culture, and subjectivity. The edge
of experience, ed. J. H. Jenkins, and R. J. Barrett,
29–61. Cambridge: Cambridge University Press.
Jenkins, J. H., and R. J. Barrett, ed. 2004. Schizophrenia,
culture, and subjectivity. The edge of experience.
Cambridge: Cambridge University Press.
Kleinman, A. 1988. Rethinking psychiatry. From cul-
tural category to personal experience. New York:
The Free Press.
———. 1999. Experience and its moral modes: Culture,
human conditions, and disorder. In The Tanner Lec-
tures on human values, ed. G. B. Peterson, 357–420.
Salt Lake City: University of Utah Press.
Kramer, P. D. 1993. Listening to Prozac. New York:
Viking.
Lear, J. 1988. Aristotle. The desire to understand. Cam-
bridge: Cambridge University Press.
Leudar, I., P. Thomas, D. McNally, and A. Glinski.
1997. What voices can do with words: Pragmatics
of verbal hallucinations. Psychological Medicine
27:887–98.
Luhrmann, T. M. 2000. Of two minds: The growing
disorder in American psychiatry. New York: A. A.
Knopf.
Maj, M. 1998. Critique of the DSM-IV operational
diagnostic criteria for schizophrenia. British Journal
of Psychiatry 172:458–60.
McLean, A. 1990. Contradictions in the social produc-
tion of clinical knowledge: The case of schizophrenia.
Social Science and Medicine 30:969–85.
Medawar, C., and A. Hardon. 2004. Medicines out
of control? Antidepressants and the conspiracy of
goodwill. The Netherlands: Aksant.
Moynihan, R., and A. Cassels. 2005. Selling sickness.
How the world’s biggest pharmaceutical companies
are turning us all into patients. New York: Nation
Books.
Neimeyer, R. A., and J. D. Raskin, eds. 2002. Construc-
tions of disorder: Meaning-making frameworks for
psychotherapy. Washington, DC: American Psycho-
logical Association.
Pandolfo, S. 2000. The thin line of modernity: Some
Moroccan debates on subjectivity. In Questions of
Modernity, Vol. 11, ed. T. Mitchel, 115–47. Min-
neapolis: University of Minnesota Press.
Parnas, J., and L. Sass. 2001. Self, solipsism, and
schizophrenic delusions. Philosophy, Psychiatry, &
Psychology 8, no. 2/3:101–20.
Pepper, S. C. 1942. World hypotheses. A study in evi-
dence. Berkeley: University of California Press.
Pérez-Álvarez, M. 2003. The schizoid personality of
our time. International Review of Psychology and
Psychological Therapy 3:181–94.
———. 2006. La personalidad esquizoide como modelo
de la esquizofrenia. In Esquizofrenia. Nuevas per-
spectivas en la investigación, ed. A. J. Cangas, J. Gil,
and V. Peralta. Bogotá: Psicom Editores.
Pérez-Álvarez, M., and J. M. García-Montes. 2007.
The Charcot Effect: The invention of mental illness.
Journal of Constructivist Psychology 20:309–36.
Pignarre, Ph. 2001. Comment la depression est devenue
une épidémie. Paris: La Découverte.
———. 2004. Le grand secret de l’industrie pharma-
ceutique. Paris: La Découverte.
Radden, J. 2003. Is this dame melancholy? Equating
today’s depression and past melancholia. Philosophy,
Psychiatry, & Psychology 10, no. 1:37–52.
Roberts, G. 1991. Delusional belief systems and mean-
ing in life: A preferred reality? British Journal of
Psychiatry 159:19–28.
Romme, M., and S. Escher, ed. 1993. Accepting voices.
London: Mind.
———. 2000. Making sense of voices. The mental
health professional’s guide to working with voice-
hearers. London: Mind.
Sartre, J. P. 1948. The emotions: Outline of a theory,
trans. B. Frechtman. New York: Philosophical
Library.
Sass, L. A. 1988. Humanism, hermeneutics, and the
concept of human subject. In Hermeneutics and
psychological theory. Interpretive perspectives on
personality, psychotherapy, and psychopathology,
ed. S. B. Messer, L. A. Sass, and R. L. Woolfolk,
222–71. New Brunswick, NJ: Rutgers University
Press.
———. 1992. Madness and modernism. Insanity in
the light of modern art, literature, and thought.
Cambridge: Harvard University Press.
———. 1994. Civilized madness: Schizophrenia, self-
consciousness and the modern mind. History of
Human Sciences 7:83–120.
Sass, L. A., and J. Parnas. 2007. Explaining schizophre-
nia: The relevance of phenomenology. In Recovering
schizophrenia, ed. M. C. Chung, K. W. M. Fulford,
and G. Graham, 63–95. New York: Oxford Uni-
versity Press.
Schutz, A. 1962. On multiple realities. In Collected
papers: I. The problem of social reality, ed. M. Na-
tanson, 207–59. The Hague: Martinus Nijhoff.
 Pérez-Álvarez, Sass & García-Montes / More Aristotle, Less DSM  ■  225
Scott, T. 2006 America fooled. Victoria: Argo Publish-
ing.
Seikkula, J., and M. E. Olson. 2003. The open dialogue
approach to acute psychosis: Its poetics and micropo-
litics. Family Process 42:403–18.
Shorter, E. 1992. From paralysis to fatigue. A history
of psychosomatic illness in the Modern Era. New
York: The Free Press.
Stanghellini, G. 2001. Psychopathology of common
sense. Philosophy, Psychiatry, & Psychology 8, no.
2/3:201–11.
———. 2004. Disembodied spirits and deanimated bod-
ies. The psychopathology of common sense. Oxford:
Oxford University Press.
———. 2007. Schizophrenia and the sixth sense. In
Recovering schizophrenia, ed. M. C. Chung, K. W.
M. Fulford, and G. Graham, 129–49. New York:
Oxford University Press.
Stevens, A., and J. Price. 2001. Evolutionary psychiatry:
A new beginning, 2nd ed. New York: Routledge.
Tucker, G. J. 1998. Putting DSM IV in perspective [edito-
rial]. American Journal of Psychiatry 15:159–61.
Turner, V. 1982. From ritual to theatre. The human
seriousness of play. New York: PAJ Books.
———. 1986. The anthropology of performance. New
York: PAJ Books.
Turner, V., and E. M. Bruner, ed. 1986. The anthropol-
ogy of experience. Urbana: University of Illinois
Press.
Valenstein, E. S. 1998. Blaming the brain: The truth
about drugs and mental health. New York: The
Free Press.
Van Fraassen, B. C. 1980. A re-examination of Aristo-
tle’s philosophy of science. Dialogue XIX:20–45.
View publication stats
Van Pragg, H. M. 1997. Over the mainstream: Diagnos-
tic requirements for biological psychiatric research.
Psychiatry Research 72:201–12.
Vanthuyne, K. 2003. Searching for the words to say
it: The importance of cultural idioms in the ar-
ticulation of the experience of mental illness. Ethos
31:412–33.
Veiga-Martínez, C., M. Pérez-Álvarez, and J. M. García-
Montes. 2008. Acceptance and commitment therapy
applied to treatment of auditory hallucinations.
Clinical Case Studies 7:118–35.
Wakefield, J. C. 2002. Fixing a Foucault sandwich:
Cognitive universals and cultural particulars in the
concept of mental disorder. In Toward a sociology
of culture and cognition, ed. K. A. Cerulo, 245-266.
New York: Routledge.
Warner, R. 2004. Recovery from schizophrenia. Psy-
chiatry and political economy, 3rd ed. New York:
Bruner-Routledge.
Wilce, J. M. 2004. To ‘speak beautifully’ in Bangladesh:
Subjectivity as Pagalami. In Schizophrenia, culture,
and subjectivity. The edge of experience, ed. J. H.
Jenkins and R. J. Barrett, 196–218. Cambridge:
Cambridge University Press.
Young, A. 1995. The harmony of illusions. Inventing
post-traumatic stress disorder. Princeton, NJ: Princ-
eton University Press.
Zachar, P. 2000. Psychiatric disorders are not natural
kinds. Philosophy, Psychiatry, & Psychology 7, no.
3:167–82.
———. 2002. The practical kinds model as a pragmatist
theory of classification. Philosophy, Psychiatry, &
Psychology 9, no. 3:219–27.