Review of "Cognitive Theories of Mental Illness"

By Joelle Proust (Special Editor)
Hegeler Institute, 1999
Review by George Graham, Ph.D. on Nov 19th 2000
Cognitive Theories of Mental Illness

No doubt at least some mental illnesses can be understood in psychological terms.  When I say that some mental illnesses can be understood in psychological terms what I mean is this.  The onset, variation, persistence and consequences of such illnesses can be explained, in significant if perhaps not exclusive measure, by using the language, broadly defined, of cognitive psychology.  Cognitive psychological language makes reference to the cognitive or conceptual content properties of activities or events in a person.  So, if a mental illness can be understood in psychological terms, this means that cognitive or conceptual content properties, which philosophers also refer to as intentional properties and which include both conscious and non-conscious content, are among the causal constituents of the illness.  They are part of what may be called ‘the causal explanatory texture’ of the illness.

In multiple personality or dissociative identity disorder, for example, some activity within a person is said to possess the complex conceptual content alternate personality, or to have the meaning alter, and therein to figure in the disorder’s onset, variation, persistence, and behavioral effects.  Suppose you and I thirst for water.  Will we both seek water when thirsty?  If I am your alter, in the sense relevant to MPD, and I am present (active), and you are not (perhaps you are ‘out’), I may seek water and you may not.  Such is the texture of MPD.  If I am your alter, given the content of being an alter, although we may share the same body/brain, we may not behave in the same manner.  Such is the purported behavioral impact of being an alter.

The Monist is a distinguished philosophy journal with more than an eighty year history.  Each issue is organized around a specific philosophic theme or cluster of concerns.  Issues may have special issue editors.  Professor Joelle Proust of Paris has edited this issue devoted to the cognitive psychological understanding of mental illness.  The issue is similar in scope to a recent issue of Mind and Language (February 2000), which has been republished as Pathologies of Belief (Blackwell 2000), and which I have reviewed in these electronic pages.  Two authors (Young and Gerrans) appear in both issues with different contributions.

Proust’s issue contains essays by philosophers (Gerrans, Campbell, Hardcastle, Flanagan, and Woolfolk), psychologists (Maher and Young) and one psychiatrist (Vogeley).  In keeping with the practice of The Monist, it does not contain an editorial introduction.  Proust’s editorial judgment is displayed in the selection and placement of papers.

The issue begins with an essay by Brendan Maher, which outlines and refines a thesis for which Maher is widely known among students of delusions of bizarre sorts, rationality, and mental illness.  This is that boundary between delusional and non-delusional beliefs cannot be drawn by appealing to reasoning deficits of deluded believers.  Delusions reflect normal reasoning (inference types similar to that of non-deluded believers) in response to abnormal perceptual experiences.  Deluded believers suffer from bizarre experiences – experiences with bizarre perceptual contents -- and not from delusion specific and faulty inferential powers.

Young’s essay counters, with special attention to Capgras and Cotard delusions, that deluded believers actually do seem to suffer from reasoning deficits or at least from attributional biases of a sort which cause them to make, in bizarre cases, incredibly unwise inferences (e.g. “I am dead”).  Both Maher’s and Young’s essays contain a wealth of material concerning how best to understand delusions.  There is helpful dialectical interface between them, which may explain why Proust opens the issue with this pair.   At the end of Maher’s essay, for example, he sketches responses to criticisms of the sort voiced by Young.

Gerrans shares Young’s willingness to consider abnormalities other than perceptual abnormalities in the explanation of delusion.  Some of these abnormalities, argues Gerrans, are sub-personal and include a phenomenon to which he refers as failures of affective programs.  Affective programs are cognitive neuropsychological processes, which implement feelings and emotions.  If you believe, for example, that you are dead, this may because affective programs, which underlie the feeling of being alive or of taking pleasure in life, are amiss.  Affective programs contribute to a person’s inferential responses to her own states or conditions.  They keep inferences about oneself or one’s condition on proper track.  When programs are lesioned or disordered, the inferences themselves become amiss.

Campbell and Vogeley are attracted to an idea, introduced in Christopher Frith’s work on schizophrenia (see The Cognitive Neuropsychology of Schizophrenia [Hillsdale, NJ: Earlbaum 1992]), that some symptoms of scizophrenia, such as thought-insertion and verbal auditory hallucinations, represent failures to self-monitor one’s own thinking or conscious mental activity.  The notion of failure of self-monitoring relevant to schizophrenia is tricky.   It’s explanatorily fertile but descriptively elusive.

Prompted by our own reading of Frith, my colleague G. Lynn Stephens and I deploy the notion in When Self-Consciousness Breaks: Alien Voices and Ineserted Thoughts (Cambridge, MA: MIT Press, 2000), which focuses on thought insertion and verbal auditory hallucinations.  Stephens and my view, somewhat like Frith’s, Campbell’s, and (as best I can determine) Vogeley’s is that a failure to properly monitor or (better) experience one’s own causal role in thinking helps to explain some bizarre elements in thought insertion and verbal auditory hallucinations.  There are differences, however, in the manner in which each of us (Frith, Campbell, Vogeley, and Stephens and Graham) describes the relevant monitoring failure and its explanatory role.  Campbell, for example, claims that something akin to motor instructions accompanies thinking and that part of what should be monitored by a person, or in a person, since monitoring as well as instructing thought normally are non-conscious sub-personal processes, is whether her thoughts reflect those instructions.  Absent proper monitoring, thinking which otherwise meets instructions may be experienced as alien or as the mental activity of another person.

Stephens and I find the notion of instructions to think unhelpful for understanding the psychology of experiencing oneself as thinking.  Campbell appreciates problems with the notion but ultimately does not depart from using it.  One difficulty is that persons usually don’t as such instruct themselves to think.  Campbell’s solution to this difficulty is to identify instructions to think not with instructions per se but with instruction analogues in the long-standing attitudes (such as beliefs) of a person.  His idea seems to be this, put simply.  If I believe, say, that snow is white, I may think ‘snow is white’.   The connection between belief and thought is something like the connection between an instruction to think that snow is white and thereupon or thereby thinking ‘snow is white’.  The monitoring picture he tries to paint is of a thought’s being directed by an attitude and the person somehow noticing, sub-personally, whether the directive is satisfied by thoughts that occur.   Directed but poorly monitored thoughts might be experienced as alien.

As suggested, I tend to doubt whether Campbell’s picture is the proper portrait of monitoring or experiencing one’s own thoughts.   My own and Stephens’ view is that experiencing thoughts as your own requires having a sense of what you are like as person or thinker.  This requires having beliefs about your long standing attitudes and realizing that these attitudes should contribute to what you think, but it does not involve attitudes (beliefs) functioning, in any robust sense, as instructions.  Having thoughts, which fail to concord with this sense of self, combined with other factors, which we discuss in the book, contribute to thought insertion and auditory verbal hallucination.

Frith’s notion of self-monitoring is utilized by some contributors to the special issue of Mind and Language, above mentioned, as well as by other philosophers (such as Shaun Gallagher), who are not represented in either issue.   Whole or partial followers of Frith are growing, though as yet there has been little if any mutual awareness or cross talk between us.  Hopefully with the publication of the special issues of the two journals, my book with Stephens, and the appearance of work of Gallagher and others, this will change.  Each of us is trying to construct a conception of self-monitoring useful for explaining the sense of ownership of mental activity which is missing in various thought disorders.  Campbell’s contribution is a welcome addition to the effort.

Back to Proust.  The chapter by Hardcastle and Flanagan explores whether dissociative disorders can be arrayed along a continuum, whose zones are distinguished by the degree to which dissociation splits a person into multiple selves or reveals (mere) multiplexity in a person.  Hardcastle and Flanagan are skeptical about whether the notion of self is sufficiently well behaved in metaphysical theory and clinical practice to make sense of selves in strictly realist terms.  Are selves real?  Hardcastle and Flanagan’s answer is a mix of yes and no.  Their scruples about the nature and existence of selfhood prompt them to develop a notion of self as narrative construct, which constitutes the conceptual framework for the distinction between multiplex and multiple selves.  The self as construct does not exist independent of the construction.  One should coordinate the construction to biographical facts about the person or human being – who has the self or selves -- but these facts seriously underdetermine just what sort of self or selves should be constructed.  Theirs is realism about the self but with a license for creative invention.  I am tempted to call it inventive realism about the self.  It permits Hardcastle and Flanagan to speak of multiplex selves as dissociated but not fully determinate precursors to multiple selves.

To the frustration of anyone who believes that mental illnesses are malfunctions, malfunctions (and functions) must be contextualized to social or historical (e.g. stone age versus post-modern) circumstance.  In the last essay in the issue, Woolfolk offers valuable reflections on the contextualization of malfunction.

Prospects for a cognitive psychology of mental illness brighten when a collection of such high quality papers as this issue of The Monist appears.  Thanks to Professor Proust for assembling the collection.  It is well worth a trip to your local college or university library to give the issue a careful read.



George Graham, Ph.D., is Chair and Professor, Department of Philosophy, Professor of Psychology, and Associate Director of Cognitive Science, University of Alabama at Birmingham.  Graham is the co-author with G. Lynn Stephens of When Self-Consciousness Breaks: Alien Voices and Inserted Thoughts (MIT Press, 2000).  He is the co-editor with William Bechtel of A Companion to Cognitive Science (Blackwell 1998, 1999pb). 




1. ``Anomalous``Experience in Everyday Life: Its Significance for Psychopathology, Brendan A. Maher


2. ``Delusions,``Andrew W. Young


3. ``Delusional``Misidentification as Subpersonal Disintegration, Philip Gerrans


4. ``Schizophrenia,``the Space of Reasons, and Thinking as a Motor Process, John Campbell


5. ``Hallucinations``Emerge from an Imbalance of Self-Monitoring and Reality Monitoring, Kai Vogeley


6. ``Multiplex``versus Multiple Selves: Distinguishing Dissociative Disorders, Valerie Gray Hardcastle and Owen Flanagan


7. ``Malfunction``and Mental Illness, Robert L. Woolfolk



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