Monday, 1 September 2014

Oxford Summer Schools and Conferences: Mind, Value and Mental Health: Philosophy and Psychiatry Summer School and Conference

Oxford Summer Schools and Conferences: Mind, Value and Mental Health: Philosophy and Psychiatry Summer School and Conference
23–25 July 2015

Applications are now open for these two linked events exploring areas in which the philosophy of mind and ethics or the philosophy of value make contact with issues about mental health.

Summer School
23–24 July 2015
Highlights include:
Other Minds: Anita Avramides, Joel Kruegar and Vasu Reddy
Hallucination/Psychosis : Matthew Broome, Matthew Parrott and Owen Earnshaw
Embodiment: Katherine Morris
Mental Health and Human Flourishing:Edward Harcourt and Jeremy Holmes
Ancients and Mental Health: Karen Margarethe Nielsen

25 July 2015
Speakers include:
Owen Flanagan (James B Duke Professor and Professor of Neurobiology, Duke University, USA)
Gerritt Glass (Professor of Philosophy and Psychiatry, VU University, Netherlands)
Rachel Cooper (Senior lecturer, Lancaster University, UK)

Quick thoughts on contesting Jaspers and ununderstandability

Aline M.P., who is working on a PhD on delusion, and I had one of those interesting PhD supervisions today which made me regret the lack of time to go very carefully over some key texts. In this case, Jaspers’ General Psychopathology. And thus my summary of our rather swift conversation may reveal some key ignorance on my part but I found it really helpful to talk through the strategic issues even if they refer as much to a logically possible Jaspers rather than the actual one (so what follows is an alloy of Aline’s and my thinking today although blindspots reflect badly only on me, as supervisor).

The irony of recent debate about the definition of delusion is, familiarly, that the standard definition varying a little across versions of the DSM has long been thought inadequate. That is, it isn’t news to argue against it. In fact, the main elements can be found in Jaspers who both puts it forward as a preliminary way to direct attention in the right general direction but also dismisses it with the comment:

To say simply that a delusion is a mistaken idea which is firmly held by the patient and which cannot be corrected gives only a superficial and incorrect answer to the problem. Definition will not dispose of the matter. [Jaspers: 93]

In its place, he emphasises instead ununderstandability as the criterion of primary delusions. If anything is, this is the definition of primary delusion in General Psychopathology. So if we are reading Jaspers critically, this might be a focus for assessment. But it faces a problem. If Jaspers uses ununderstandability to define primary delusions then contesting that status is not denying an empirical, synthetic claim but contesting an analytic claim.

So one possible response Jaspers could offer any critic is this: for any experience which is understandable, he can deny that it is a primary delusion and claim that his opponents are talking about the wrong experiences precisely because delusions are defined to be ununderstandable. (Cf trying to falsify ‘bachelors are unmarried’ by looking for married bachelors would suggest merely that one did not know what a bachelor was. Of course this may not be a useful word / concept) This begins to suggest that the claim is not falsifiable.

This thought raises a question or two. Why does it seem as though Jaspers is saying something interesting and contentious in that claim? And what are philosophers such as Sass doing when he seems to be trying to refute/falsify Jaspers?

Our first thought today: Jaspers starts by using the DSM style criteria and then goes on to say that the real criterion is ununderstandability. Thus it is tempting to hear him to be saying: ‘of the things picked out by the DSM criteria, actually they are ununderstandable’. Now that is substantial, empirical, falsifiable, synthetic etc etc. If so having both of these potential definitions of delusion is, despite appearances, important even if illicit. It gives the illusion that Jaspers is making a bold claim about the world rather than telling us of a terminological decision he has adopted. (Note that his official position is that delusions are those mental states that are ununderstandable and, further, that such states do not fit the DSM criteria.)

That also suggests one way one might interpret Sass and other philosophers who aim to make delusions intelligible etc. They also may be relying on the DSM criteria and saying, of what satisfies them, that they can be understood. If so, they are not strictly disagreeing with Jaspers but suggesting a different meaning for the word ‘delusion’ than his official position allows and then showing how such delusions can be understood.

In fact it seems that Sass does something slightly different. He assumes that everyone will agree that what Schreber experiences really are delusions however delusions should be defined. (In effect, this is an ostensive definition of delusions: the sort of thing Schreber writes about.) He then argues that we can understand them.
In the face of Sass (or, say, a two factor theorist) Jaspers might concede that he does succeed in shedding light on delusions in some way but that he does not provide proper understanding of, say, an empathic form and that that is what he was ruling out.

The problem with this move is that the more concrete he is about empathy, ie the more specific his views about what it is are, the more likely critics (eg Sass) are to reply: “Well who cares about empathic understanding? We have given a more general way of getting understanding.” But the more general Jaspers’ view of understanding (whether or not he uses the word empathy), the less likely he is to be able to make this initial reply to his critics.

A more likely response Jaspers could make to such critics is to argue that they have not, in fact, demonstrated understanding on any plausible view of it. This allows him to agree that they are discussing primary delusions (however they conceptualise them*) but for him to defend his main claim of ununderstandability against them. The main backing for this is that in Sass’ case, we do not understand the nonsensical solipsism after all (it being nonsensical). (And for two factor theorists, we really don’t understand the move from a lack of a sense of familiarity to a claim about robotic replacement even given the idea that delusional people are a bit quick with inferences. Adding these two factors together still provides no understanding of someone holding the delusion.)

(*Typing this now, I’m less happy about it. The question of under what Fregean sense they do think of delusions seems significant/substantial. A descriptive sense milked from the DSM would inherit its flaws, though it would be difficult to think that it is flawed: to think of delusions identified via the DSM criteria that they somehow did not instance the criteria that specified them in the first place. A demonstrative would still need a sortal which, in this case, will introduce difficulties: eg. that paradoxical mental state which does not fit the constitutive ideal of rationality.)


I hope that I am beginning to emerge from what has seemed the carcrash of 2014 and looking at the articles I have in draft at the moment. They include:

‘Is there such a thing as nursing knowledge?’ for Chambers, M. (ed) Psychiatric & Mental Health Nursing: the craft of caring
Is there such a thing as ‘nursing knowledge’? What do and should we mean by that phrase? And does it help define nursing itself? It may seem that denying that there is such a thing, or unified kind, as nursing knowledge risks undermining the profession of nursing and runs counter to its new graduate status in the UK. But I will argue that on one understanding of the question, at least, it is correct to answer ‘no’ but that this is no threat to a picture of nursing as richly knowledge-based.
To do this, I will consider three important distinctions of kind which divide up forms of knowledge and argue that, in each case, nursing knowledge is distributed across both sides. This suggests that it is implausible to think that nursing knowledge is unified. At the same time, however, I will suggest that in each case there is reason to think that what is involved is, indeed, a form of knowledge. Finally, I will suggest that there is a key form of knowledgeable judgement at the heart of nursing but that this takes the form of an art rather than a science.

‘Naturalism and dysfunction’ for an MIT collection on Harmful Dysfunction edited by Denis Forest (Philosophie, Histoire et Sociologie de la M├ędecine Mentale (PHS2M) programme University of Paris Descartes)
The harmful dysfunction account of disorder separates an explicitly normative or evaluative notion of harm from the idea of dysfunction which is subject to a reductionist naturalistic account. Dysfunction is analysed as a failure of function which is itself reduced via evolutionary biology. In this paper, I question this latter aspect of the account. Light can be shed on the prospect of reducing the apparently normative notion of dysfunction by comparing it with two distinct reductionist projects in the philosophy of content which stand to each other as do the contrasting options in the euthyphro dilemma. A more modest project takes for granted the structure of normative relations between concepts and attempts to solve an engineering problem of how human thought can fit that structure. A more ambitious project aims to explain that structure itself in naturalistic terms. The ambitious project, however, is undermined by an argument from Wittgenstein. I argue that the harmful dysfunction analysis of disorder has to be interpreted as isomorphous with the latter project and is thus subject to the same objection.

‘The normativity of meaning and the constitutive ideal of rationality’ for Verheggen, C. (ed) Wittgenstein and Davidson on Thought, Language, and Action CUP
The normativity of meaning and the constitutive ideal of rationality. One legacy of the later Wittgenstein is the view that both meaning and mental content is normative. This is suggested by two distinct threads in the Philosophical Investigations. There is the idea that word use can be compared to rule governed games. And there is the idea that propositional attitudes prescribe satisfaction conditions likened to a ‘despotic demand’. But both elements have come under recent fire by philosophers who grant that meaning may be governed by constitutive rules but that these need not be thought of as having any prescriptive force and, further, there are no plausible articulations of any relevant prescriptive norms. Light can be shed on what has become a rather sterile debate, however, by comparing parallel views of the role of normativity arising from Davidson’s constitutive ideal of rationality which has been criticised as descriptively inadequate in the face of widespread empirical irrationality. But it also suggests a way in which the norms of meaning can be both constitutive and prescriptive.

‘Psychiatric classification, vagueness and tacit knowledge’ for Keil, G., Kutschenko, L., Hauswald, R. (eds) Gradualist Approaches to Mental Health and Disease
DSM III aimed to improve the reliability of psychiatric diagnosis via an operationalist emphasis on ‘observable’ signs and symptoms and the initial downplaying of aetiological theory. Signs and symptoms are first elicited and then syndromes derived through diagnostic algorithms. Whilst this has prompted the charge that reliability has improved only at the cost of validity, there has also been a criticism, from European psychiatrists, that the signs and symptoms articulated within DSM III and IV are vague by contrast with the specification provided by explicitly phenomenological psychiatry. Rather than providing a reliable foundation, the connection between individual symptoms and conditions in the DSM lacks specificity. By contrast, phenomenological psychiatry can chart a correlation between schizophrenia, for example, and particular kinds of catatonia or delusional structure. Correlations are not between schizophrenia and delusions in general but delusions with a specific schizophrenic colouring.
In this chapter, I attempt to shed light on these claims without presupposing the phenomenological tradition but instead by forging a connection between diagnosis and tacit knowledge. In The Tacit Dimension, Michael Polanyi introduces the idea of such knowledge with the phrase ‘we can know more than we can tell’ but that leaves the nature of the knowledge underdetermined. I suggest, first, that it is a context-dependent but conceptually structured practical skill and, second, that the top-down approach to psychiatric symptoms compensates for the vagueness of DSM descriptions of symptoms through an exercise of recognitional tacit knowledge. This connection is not, however, unique to psychiatry. Although linguistic classification is the first step to making knowledge explicit it is itself an exercise of tacit skill, referred to by Polanyi as the ‘art of denotation’.

Bootstrapping conceptual normativity?
Both anti-reductionist and reductionist accounts of linguistic meaning and mental content face challenges accounting for learning a first language. Anti-reductionists cannot account for a transition from the pre-conceptual to conceptual without threatening to reduce the latter to the former. Reductionists of a representationalist variety face the challenge of Fodor’s argument that language learning is impossible.
This paper examines whether Ginsborg’s account of primitive normativity might provide some resources for addressing these issues. Rejecting her ‘no conception’ account of normativity in favour of a demonstrative, local conception provides one response to Fodor’s argument which is available to an anti-reductionist and at least a further hint as to how context-independent linguistic concepts can be developed from context-dependent local conceptions of how to go on.

‘Phenomenological implication as transcendental argument’ for Pickering, N. and van Staden, W. (eds) Wittgenstein and mental health for submission to the OUP International Perspectives in Philosophy and Psychiatry (IPPP) series
In their paper ‘Explaining schizophrenia: the relevance of phenomenology’, Sass and Parnas argue that phenomenological psychopathology can be explanatory rather than merely descriptive because it articulates the way in which mental symptoms are understandably connected by relations of ‘phenomenological implication’. They illustrate this claim through an account of schizophrenia as a disorder of a sense of ipseity from which two aspects seem to follow as a matter of phenomenological implication: the characteristic hyper-reflexivity of subjects with schizophrenia and what Sass and Parnas call ‘diminished self-affection’ which is a diminished sense of existing as a subject of awareness or agent of action. Both would follow if schizophrenia were at root a problem with ipseity. They further argue that these connections cannot be captured using the conceptual resources of Anglo-American philosophy.
In this chapter, I argue that the last claim is not true. Light can be shed on phenomenological implication by examining the nature of the synchronic and diachronic relations Sass and Parnas describe. I argue that their apparent intelligibility stems from their resemblance to expressive reactions, to rational action explanation and to the kind of transcendental argument one finds in the Kantian-Wittgensteinian tradition exemplified by analytic philosophers such as David Pears and Peter Strawson. In the last case, Sass and Parnas’ connections can be seen as mirroring such attempts within broadly Wittgenstein-influenced analytic philosophy to articulate the conditions of possibility of experience such as the connection between embodiment and judgement suggested by interpretations of Wittgenstein’s ‘private language argument’. But, I argue, there is a key disanalogy between such analytic investigations of the conditions of possibility of normal experience and a phenomenological investigation of psychopathology. In the former case, the connections are articulated from within a familiar and shared form of mindedness. Aspects of that are abstracted from the whole. By contrast, Sass and Parnas chart – partial, at least – failures of the conditions of possibility of normal mindedness. Given this contrast, it is less clear that phenomenological implication can successfully shed light on psychopathology.

‘Transcultural psychiatry’ for White, R. (ed) The Palgrave Handbook of Global Mental Health: Sociocultural Perspectives

‘Non-rational understanding? Feelings and the Beltane Fire Festival’ 


Thursday, 7 August 2014

Draft abstract for Amsterdam workshop this month

Draft abstract for Amsterdam workshop this month

Title: Anti-reductionist normativism: a price worth paying.

Key words: Causal explanation, intelligibility, normativity and reductionism

Abstract: There is momentum in the philosophy of psychiatry away from a picture of reductionism based on a well ordered hierarchy of levels of explanation and towards either cross level interaction or scepticism about the very idea of levels of explanation. This is a move towards explanatory pluralism and pragmatism and away from a metaphysical picture that can seem to be the unjustified imposition a priori claims about how the world must be. In this presentation, however, I will argue that the resultant austere picture carries two significant costs. First, it undermines our right to characterise states as mental states. That is, it shed no light on the intelligibility of states as mental. Second, it undermines our grasp of the pathological status of the conditions that form of the subject matter of psychiatry. Normativism offers a distinct, full blooded contrast to a reductionism of levels. Whilst it faces significant challenges, it promises to address these potential gaps in the intelligibility of the subjects of psychiatry and is thus a price worth paying.

Wednesday, 9 July 2014

On failing to read Lee Braver's Groundless Grounds

I hope that this will not seem like much of a criticism of Lee Braver's Groundless Grounds. I cannot offer a philosophical engagement with it because, although I have turned every page and, as much as ever, read every word (with the usual re-reading of particularly tricky, pithy passages) I don't think that I have actually read it.

So first a rough sketch of that thought and then, second, a brief suggestion as to why.

What do I think when I think that I have read a book in the, I guess, normatively charged sense of the word I am trying to deploy? Something like this: I have grasped sufficient of the surface meaning which amounts to grasping the way in which the author wants me to understand the ideas she is sketching. That isn't a very good way of putting the point and I do not mean to hint at acts of philosophy by pointing (contra Jonathan Lear on Wittgenstein). But much philosophy isn't entirely pellucid. Often I can give an account of the surface of a piece of philosophy without being yet in a position to assess it.

At the moment I am reading a 2009 paper by Alex Byrne criticising Travis's criticism of 'content' views of experience. I could describe the general argumentative structure and point to where the key terms of art are introduced and sketch their broad role. But right now I could not explain to someone else what Byrne means by 'non-comparative looks'. When, shortly (tomorrow?) I can then I will have read the paper. And only then will I be able to think (next week, after further intuition or judgement) about whether I am persuaded by the argument so constructed. There is a point at which, poor memory aside, I don't think I need to read the paper any more, I have reached a kind of data saturation, but I have not done with it. The further stage, however, calls for imagination on my part which may never come. But the paper itself has done its work.

I don't seem to be able to reach even that initial stage with Lee Braver's book, however. This seems odd because he writes well, with flair, and deploys a series of metaphors and similes to helpful effect. I bet some of his phrases make their way into my ways of explaining Wittgenstein (for which apologies to him in advance). But I think I know the problem.

Some years ago I had a frosty reception at a conference from a famous American philosopher of mind. After I had given my paper, he warmed and in conversation I realised that he'd assumed that I subscribed to a principle, which really irritated him:

W: Wittgenstein says that p, therefore p.

Although I do indeed assume a kind of hermeneutic principle of charity, and so use something like W as a regulative principle, working out what it is that Wittgenstein says, in the sense of means, takes some effort which turns on working out what it would be justified, perhaps for him but via for us, to say. So W ends up guiding an argument to establish the truth of p rather than being a naked appeal to authority. In the works on Wittgenstein that I am able to read (on this rather arch understanding), there is a similar method. By contrast, this book is closer to the locution: Wittgenstein insists... Thus even though the views ascribed do indeed hang together, they are not bound together in the surface presentation by an explicit structure of reasons. The surface form is more history of ideas than an attempt to inhabit an argumentative position and work out its rational connections. The net result is that I cannot get a hold on it, grasp a surveyable whole. The links which would help form the scaffolding of my understanding of it are hidden beneath the surface of the text.

It is a pity because although a book on Wittgenstein and Heidegger would not be the first of its kind nor one which deploys a contrast with the earlier Wittgenstein to illustrate the later (in truth best not to read this book at the same time as Marie McGinn's book on the Tractatus) still putting Heiddegger and Wittgenstein in my more explicit contrast to the Tractatus might help go further than Rorty's brisk comments on this thirty years ago.

PS: my thoughtful correspondent DY suggests, in a response by email, that he has/is never finished with a text: 'Subsequent reading illuminates things, and these things always need checking against previous materials. I reread and reread all the time!' I have to say that this rings rather truer than my own description above. But I guess, in a spirit vaguely influenced by the arguments between McDowell and Travis on perception, I want to confine these subsequent discoveries to acts of judgement after the fact of reading (akin to a Travisian move) whilst thinking that the reading mentioned here involves a lesser conceptual grasp (a McDowellian move). Indulge me!

Tuesday, 8 July 2014

Rough airport thoughts on craft versus science

In the last presentation of the conference I've been to, Tom Burns, Oxford Psychiatry, put forward a distinction to help to ward off anti-psychiatric criticism of psychiatric diagnosis. He suggested that anti-psychiatric commentators often helped themselves to an unfair characterisation of psychiatry in order to help support their own comments. But, he suggested, it was unfair to claim that psychiatric diagnosis failed tests of good science (one such accusation) because psychiatry was a craft not a science. Evidence for this was the very length of medical education, its connection to education by eminence, and it's practical focus. Merely learning the necessary DSM categories, for example, would take an ordinarily clever young person weeks rather than years.

As a fan of craft knowledge, I think that there is both something in the evidence for the craft status of medicine and that nothing negative follows for its status. But I am not sure of the dialectical purpose of the craft versus science distinction as applied here.

One might argue that psychiatry is not reducible to science alone but involves skills that can only be characterised as craft skills. One way to put that would be to say that it irreducibly involves know-how as well as knowledge that. But if so, how does offering both these elements protect diagnosis from criticism? Won't diagnosis naturally count as part of what Jennifer Aniston would perhaps describe as the 'science bit'?

One way to bring the craft to bear conceptually on the diagnosis element itself might be to stress the latter's status as Kantian reflective rather than determinate judgement. Again, I like this idea. But the conceptual package brought to bear on an individual - the combination of concepts and laws - is again surely a science, or at least a science in aspiration, in the case of psychiatry? To deny that would be to concede diagnosis to anti-psychiatry not to defend it.

So might one think that not only is the subsumption of an individual (person, case, event, experience) under a concept a skill (reflective judgement, again) but that the derivation of inferential consequences of that subsumption is also a skill, something, eg., that resists codification? Perhaps. If so, it might be akin to making a moral judgement on Dancy's view. Nothing generally follows. What follows depends only on the particular circumstances. But not merely in the way that the application of codified Newtonian physics to a particular object depends on its context but rather in a way that resists any general codification (akin to Newtonian laws). Now that would be radical. Psychiatry as moral advice, as it were, though not only concerned with what is Good. Can this really be Tom's view?

Monday, 7 July 2014

DSM-5 and the future of psychiatric diagnosis

I am in Geneva at a Brocher Symposium on DSM-5 organised by Matthew Smith. It is an interdisciplinary session with philosophers, historians, anthropologists and clinicians. My own contribution was to be a discussant for a paper by Vicky Long on the history of the the diagnosis of occupationally caused mental illnesses. Playing that role reminded me of the difficulty of commenting on one discipline from within another: the worry that one is simply missing the point. For example, if a paper charts the history of actual happenings, is it at all relevant to ask normative questions about whether something else would be or have been better? At its best, I guess that philosophy might be able to tease out some of the concepts both as deployed by historical 'actors' but also by historian analysts. (I lingered on the difference between work's tedium and the ennui and alienation it rationally prompts, on the one hand, and, on the other, it causing illness and then further how stable that distinction was.)

So far I am mainly chewing over a paper by Rachel Cooper, a precursor to which I heard last year. What was familiar was the idea that, just as the qwerty keyboard has become stuck because of the inertia of its beurocratic connections long after its initial rationale has ceased to apply, so the multiple uses of the DSM means that it is practically impossible to change (I can imagine Bruno Latour providing actual economic costings for changing it). That thought connected into a comment about the continuity, despite earlier talk of paradigm changes, of the actual content, the categories etc, of DSM-IV and DSM-5. What was new, however, was the fact that some framing comments about DSM have changed. The concept of disorder is no longer necessarily value-laden (it just usually is). DSM-5 is no longer supposed to be atheoretical but is grouped with the hope of spotting underlying theoretical uniformities. And... From this, Rachel drew two conclusions: there is no close connection between the theoretical frame of DSM and its content. And second, there is no reason to assume that the DSM has any single underlying broader conception of illness and healthcare. Afterall, it is written by several quasi autonomous subgroups and is read selectively and differently by its different readers. So the frame serves a less than obvious purpose. This prompted Gavin Miller to suggest, among other things, a kind of religious text analogy for the rhetorical purpose of the frame.

I am not sure about that. But there does seem to me to be an interesting question what the purpose of general definitions of disorder, or general comments on culture (discussed later by Stefan Ecks), is. Surely not, for example, to offer genuine guidance on whether a particular condition is a disorder (for the sorts of reasons Neil Pickering stresses). But to address that question would require some decision about the ground rules for answering it, for example, the role of the authors' intentions.