© 2009 by The Johns Hopkins University Press

More Aristotle, Less DSM

The Ontology of Mental Disorders in Constructivist

Perspective Marino Pérez-Álvarez, Louis A. Sass, and José M. García-Montes

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

Both 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

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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 TerrainIn 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)

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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

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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 FollowAn 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 DisordersPrior 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

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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 CauseThe 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,

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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 CauseThe 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).

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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)

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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 CauseThe 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

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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

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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 CauseAristotle’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

ConclusionsThis 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

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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).

AcknowledgmentsThis 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.

Notes1. 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

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