Friday, 31 July 2015

Reasons for buying a house

I was talking to a friend over pizza in Kendal last night who is beginning to think of buying a house, possibly here. Asking about the factors that would influence a selection she suggested a variety. I have not tidied them up to be properties or qualities of a house but rather reasons of any sort. They included:
  • Proximity to either Kendal station 
  • A view of greenery 
  • An appropriate price 
  • Avoidance of a split level garden 
  • Fear of icy pavements 
  • Walking access to civic facilities 
  • Location outside three less salubrious areas of town 
Other factors that sometimes affect such decisions were not important including house age or style or having particular a priori room configurations.

In the UK, there is a widespread fascination, which I share, with house buying that goes beyond our eccentric habit of treating houses as primary financial investments. And so I began to wonder where in Kendal the ideal house would be and had to resist getting out my phone and searching the web there and then.

The nature of the decision has, however, a couple of interesting general features in seeming tension.

First, even given a list of factors, their combination is not transferable to someone else. The list I’ve just written down isn’t necessarily a ranking order. And some of the reasons are, as it were, enthymemes. It turns out that the desirability of avoiding a split level garden (the most left field feature on the list) was not so much aesthetic as I initially assumed (who can stand the sight of them?!) but a concern with trip hazards: a reason more familiar in those over 70 with the fear of ‘having a fall’ than younger than 40. But context and personal history is all for a reason like this (visiting relatives?). Hence perhaps a graded split level garden with grab handles on non-slip illuminated steps would be fine. And so on. But given the general Wittgensteinian idea of a symmetry of understanding explanations between speaker and audience, that suggests that the way the reasons operate for my interlocutor also awaits a context. Their valence will depend on their holistic combination in particular cases. The list doesn’t actually codify the right decision for speaker or audience.

Second, despite the uncodifiability of the reasons operating in complex decisions like this, it is still tempting – well for me at least – to think that there is a kind of unique correct outcome (in this case, relative to the houses actually for sale). (In truth, I think my wiser colleague immune to my foolish assumption.) Such a mythology also seems implicit in the presentation of house buying TV programmes – of which there are many – in the UK. Buyers are guided in a teleological quest for their ideal house, waiting somewhere out there for them. This contrasts with, say, buying a bunch of bananas where, providing they are the right degree of ripeness/unripeness, number, size and fair-trade status, any bunch satisfying those criteria will do. Ditto cars, I think. So that suggests an interesting tension between the very complexity of the case and still the thought that it is not so much aimed at satisfying criteria but rather at a correctness for which the criteria are mere epistemic guides rather than constituting a standard of correctness.

(Lurking in this area is the interesting combination in McDowell’s moral anti-anti-realism. The notion of correctness of moral judgement doesn’t rule out the possibility of difficult cases which tolerate a kind of ambiguity. The reality at which moral judgement is aimed is, if I read him right, gappy.)

Wednesday, 22 July 2015

Tâtonnement and failing to 'find' a paper

I spent yesterday trying to start a paper on John Campbell’s noughties papers [Campbell 2007, 2008, 2009] on causation in psychiatry and psychology but failed to get anywhere. Having recently read Peter Goldie’s book The Mess Inside, I wonder whether the word for the day’s activities is ‘tâtonnement’, which he suggests is a kind of feeling one’s way to a narrative: ‘a tentative, groping procedure: one might begin with an idea of how the narrative should be shaped, and, once one has developed it somewhat, one might be able to see saliences that one could not see before, and then find it appropriate to go back and reshape the narrative in this new light.' [Goldie 2012: 11]

The basic plot idea I was struggling with has the following vague elements.

1) Campbell argues that the idea of levels of explanation is the result of a pre-Humean assumption about that causation that the world must have an intelligible causal structure. (He suggests that this is a standard philosophical synthetic a priori claim.) But Hume teaches us that it need not. Causation is brute and Campbell suggests that the best approach to causation is interventionism. Whilst such ideas are sometimes fruitful we should neither assume that physical causation must be mediated by mechanisms nor that mental causation must be mediated by rational connections. It may be, for example, that all that can be said to explain a particular delusion is that intervening on whether someone is seen by the subject to be scratching his beard changes whether the subject forms and holds the delusion. There may be neither rational nor mechanical intermediaries.

2) Campbell’s illustration of how the facts about causation may eschew mechanisms resembles some unpopular remarks by Wittgenstein in Zettel. They include: ‘Why should there not be a natural law connecting a starting and a finishing state of a system, but not covering the intermediary state? (Only one must not think of causal efficacy.)’ [Wittgenstein 1981: §613] Of the underlying thought of these comments, Wittgenstein says: ‘If this upsets our concepts of causality then it is high time they were upset.’ [§610]

3) Wittgenstein’s remarks seem, however, to be aimed at removing the tension of reconciling a connection made at the mental level in mental and, according to him, non-causal terms with assumptions about underlying causal mechanisms at a physiological level. Campbell’s, by contrast, suggest that the top level is causal. This suggests that there is still a motivation (available to us, untouched by Campbell’s argument and distinct from the one Hume criticises) for adopting a particular synthetic a priori (rendering unto Caesar in accord with a distinct obligation). The claim that something is a delusion itself requires some synthetic a prioris. Campbell himself acknowledges this in a quite different seeming paper on the interpretation of Capgras [Campbell 2001]. To grasp the content of the expression of a delusion requires fitting it into a rational pattern of canonical testing.

4) So the explanation of delusions does require something more than brute interventionism. It requires the prior recognition of the effect of whatever putative causes as an instance of a delusion. That requires the kind of mental-level normative patterns that Wittgenstein stresses.

Well, as can be seen from the summary, this doesn’t really hang together. That I think it ought suggests something like the paradox of analysis for the activity of tâtonnement. The confidence that there is a narrative structure to be reached for suggests no need for tricky reaching activity. But where there is such activity, there’s no obvious goal for the reaching so how does one know where in conceptual space to look?

Whilst I can take in my stride the kind of fallible glad start of thinking one knows how to continue a series or launch a spoken sentence, it seems an odder piece of phenomenology that one can think one is not persuaded by a paper but only dimly grasp why not.

This paper may thus fall off my list of activities unless something changes on a run round Kentmere later.

Campbell, J. (2001) ‘Rationality, meaning, and the analysis of delusion’ in Philosophy Psychiatry and Psychology
Campbell, J. (2007) ‘An interventionist approach to causation in psychology’ in Gopnik, A. and Schulz, L. Causal learning: psychology, philosophy, and computation, Oxford: Oxford University Press 
Campbell, J. (2008) ‘Causation in psychiatry’ in Kendler, K.S. and Parnas, J. (eds) Philosophical Issues in Psychiatry, Baltimore: Johns Hopkins University Press 
Campbell, J. (2009) ‘What does rationality have to do with psychological causation? Propositional attitudes as mechanisms and as control variables’ in Bortolotti, L. and Broome, M. (eds) Psychiatry as Cognitive Neuroscience, Oxford: Oxford University Press 
Goldie, P. (2012) The Mess Inside: narrative, emotion, and the mind, Oxford: Oxford University Press 
Wittgenstein, L. (1981) Zettel, Oxford: Blackwells

For own housekeeping convenience, my other ongoing writing activities are as follows.

Papers / chapters under review 

‘Bootstrapping conceptual normativity?’ Foundations of Science

‘Nursing knowledge: its nature and generation’ for Chambers, M. (ed) Psychiatric & Mental Health Nursing: the craft of caring, Abingdon: CRC Press

‘Transcultural psychiatry’ for White, R., Read, U., Jain, S. and Orr, D. (eds) The Palgrave Handbook of Global Mental Health: Sociocultural Perspectives, London: Palgrave

‘Naturalism and dysfunction’ for Forest, D. and Faucher, L. (eds) Defining Mental Disorders: Jerome Wakefield and his Critics, MIT Press

 ‘Psychiatric classification, tacit knowledge and criteria’ for Keil, G., Kutschenko, L., Hauswald, R. (eds) Gradualist Approaches to Mental Health and Disease, Oxford: OUP

‘Recovery, paternalism and narrative understanding in mental healthcare’ Maria Francesca Freda, M.F. and De Luca Picione, R. (eds) Cultural Construction of Social Roles in Medicine, Information Age Publishing: Charlotte, N.C.

Papers / chapters in preparation 

‘Phenomenological implication as transcendental argument’ for van Staden, W. and Pickering, N. (eds) Wittgenstein and mental health, Oxford: OUP

‘The normativity of meaning and the constitutive ideal of rationality’ for Verheggen, C. (ed) Wittgenstein and Davidson on Thought, Language, and Action, Cambridge: Cambridge University Press

‘Philosophical understandings of mental health’ for Wright, K. and McKeown, M. (eds) Essentials of Mental Health Nursing, London: Sage

Book in preparation 

John McDowell (second edition), Abingdon: Routledge

Wednesday, 15 July 2015

Psychiatric diagnosis, tacit knowledge and criteria

I realise that these draft papers are rather a dull use of a blog but it is why I started it originally.

Abstract
The two main psychiatric taxonomies set out codifications of psychiatric diagnoses via lists of symptoms with the aim of maximising the reliability of diagnostic judgements. This approach has been criticised, however, for failing to capture the precise connection between diagnostic judgements and symptoms as detected by skilled clinicians. Assuming that this criticism is correct, this chapter offers related two accounts of why this might be so. First, skilled diagnostic judgement may be an exercise of tacit knowledge: a practical skill the exercise of which requires the presence of the patient or client. Second, the conception of criteria implicit in DSM and ICD is based on a mistaken view of how what people say and do connects to their mental states. On an alternative account, in an overall gestalt diagnostic judgement the various criteria are abstractions from a whole which directly expresses the underlying psychopathological state of patients or clients.
Introduction
For the last 50 years, both of the major psychiatric diagnostic systems – DSM and ICD – have aimed at reliability at the potential cost of validity. They have done this by codifying diagnosis in the form of criteria, influenced by operationalism from the philosophy of physics and down playing aetiological theory. It is an empirical question whether DSM-III, -IV and now -5 and the parallel ICD classifications have achieved this aim overall.
There have been criticisms, however, that the explicit criteria under-determine the diagnoses made by skilled clinicians. That is, the criteria themselves have a vagueness or indeterminacy for which experienced psychiatrists have to compensate in diagnostic judgements in response to particular patients expressing particular signs and symptoms. The overall top-down or gestalt judgement is more precise than the component criteria on which it is supposed to be based.
The aim of this chapter is not to address whether this is so but rather how it could be so. In doing so, I will make two suggestions. First, diagnosis may involve an important tacit element. As a recognitional judgement, it may share characteristics of an uncodifiable form of know-how. Second, the postulation of criteriological intermediaries between the skilled clinician and their patients’ or clients’ actual conditions may distort the recognitional process. Judgement of the underlying mental states of patients and clients may be more secure than the operationalised criteria.
The first section outlines the reasons for the emphasis, since the second half of the twentieth century, on operationalism in both the main psychiatric taxonomies. The second section sets out three similar clinically based criticisms of the resulting criteriological model of diagnosis.
The final two sections set out to shed light on how this might possible first by suggesting that diagnositic judgements are an instance of a broader class of tacit knowledge and then by suggesting that the criteriological view distorts the way that clinical signs and symptoms bespeak, to a skilled clinical, underlying pathologies directly.
Background: the rise of criteriological diagnosis
Over the last half century, there has been a concerted effort to improve the reliability of psychiatric diagnosis by pruning the two main diagnostic systems of possibly over hasty aetiological theory and stressing instead more directly observational features of presenting subjects. Two main factors explain this. (For a fuller account, see [Fulford et al 2005].)
First, on its foundation in 1945, the World Health Organisation set about establishing an International Classification of Diseases (ICD). The chapters of the classification dealing with physical illnesses were well received but the psychiatric section was not widely adopted. The British psychiatrist Erwin Stengel was asked to propose a basis for a more acceptable classification. Stengel chaired a session at an American Psychological Association conference of 1959 at which the philosopher Carl Hempel spoke. As a result of Hempel’s paper (and an intervention by the psychiatrist Sir Aubrey Lewis) Stengel proposed that attempts at a classification based on theories of the causes of mental disorder should be given up (because such theories were premature), and suggested that it should instead rely on what could be directly observed, that is, symptoms.
In fact, Hempel’s paper provided only partial support for the moral that was actually drawn for psychiatry. He argued that:
Broadly speaking, the vocabulary of science has two basic functions: first, to permit an adequate description of the things and events that are the objects of scientific investigation; second, to permit the establishment of general laws or theories by means of which particular events may be explained and predicted and thus scientifically understood; for to understand a phenomenon scientifically is to show that it occurs in accordance with general laws or theoretical principles. [Hempel 1994: 317]
These two requirements – that terms employed in classifications should have clear, public criteria of application and should lend themselves to the formulation of general laws – correspond to the aims of reliability and validity respectively. Clear public criteria promote both test-retest and inter-rater reliability whilst general laws are a step, at least, towards construct validity. But it was the former that was adopted by psychiatry as the key aim at the time. With respect to it, Hempel claims that
Science aims at knowledge that is objective in the sense of being intersubjectively certifiable, independently of individual opinion or preference, on the basis of data obtainable by suitable experiments or observations. This requires that the terms used in formulating scientific statements have clearly specified meanings and be understood in the same sense by all those who use them. [ibid: 318]
He commends the use of operational definitions (following Bridgman’s book The Logic of Modern Physics [Bridgman 1927]), although he emphasises that in psychiatry the kind of measurement operations in terms of which concepts would be defined would have to be construed loosely. This view has been influential up to the present WHO psychiatric taxonomy in ICD-10.
The second reason for the emphasis on reliability and hence operationalism was a parallel influence within American psychiatry on drafting DSM-III. Whilst DSM-I and DSM-II had drawn heavily on psychoanalytic theoretical terms, the committee charged with drawing up DSM-III drew on the work of a group of psychiatrists from Washington University of St Louis. Responding in part to research that had revealed significant differences in diagnostic practices between different psychiatrists, the ‘St Louis group’, led by John Feighner, published operationalised criteria for psychiatric diagnosis. The DSM-III task force replaced reference to Freudian aetiological theory with more observational criteria.
This stress on operationalism has had an effect on the way that criteriological diagnosis is codified in DSM and ICD manuals. Syndromes are described and characterised in terms of disjunctions and conjunctions of symptoms. The symptoms are described in ways influenced by operationalism and with as little aetiological theory as possible. (That they are neither strictly operationally defined nor strictly aetiologically theory free is not relevant here.) Thus one can think of such a manual as providing guidance for, or a justification of, a diagnosis of a specific syndrome. Presented with an individual, the diagnosis of a specific syndrome is justified because he or she has enough of the relevant symptoms, which can be, as closely as possible, ‘read off’ from their presentation. The underlying syndrome is connected to more accessible, epistemologically basic signs and symptoms.
An objection to criteriological approaches
Although the rationale for a criteriological, or bottom up, approach to diagnosis seems clear, it has not escaped criticism. The charge outlined in this section is that combining individual signs and symptoms understood initially in isolation from context and only assembled in the conjunctions that add to diagnosis is makes the signs and symptoms imprecise.
In a paper called ‘Phenomenological and criteriological diagnosis: different or complementary?’ Alfred Kraus, professor of psychiatry at Heidelberg, argues that diagnostic systems such as DSM and ICD miss out an important element of psychiatric diagnosis [Kraus 1994]. Because they assume that diagnoses are built up from a number of individual and conceptually independent symptoms they cannot capture top-down and holistic elements of diagnosis.
One key criticism that Kraus makes of what he calls this criteriological approach to diagnosis, is that rather than providing a reliable foundation, the connection between individual symptoms and conditions lacks specificity.
[S]ymptomatological/criteriological diagnosis not only makes the reality of the patient accessible in a very reduced way but also portrays the pathological phenomena in a very imprecise and broad manner The reduction of phenomena to symptoms and criteria has as its consequence a loss of specificity. [ibid: 153-4]
Taking delusions as an example of a symptom, on the criteriological model, for schizophrenia, Kraus argues that there is not a reliable connection between delusions in general and schizophrenia. ‘Delusion’ is a vague term picking out a variety of psychological states. The reliable connection is between particular kinds of delusional structure and schizophrenia. But the identification of delusions with a specific schizophrenic colouring presupposes, Kraus argues, a top down holistic model rather than a bottom up description. The assumption on the criteriological approach that symptoms can be recognised and described independently of the psychopathological diagnostic categories of which they are a part introduces vagueness to their descriptions and hence undermines the specificity of their connection to diagnostic judgements.
Kraus also argues that in the bottom-up model, symptoms can only be added together through conjunction. But no mere conjunction of individual symptoms—a ‘Chinese restaurant menu’ approach—can capture the psychological integrity up to which the individual parts add. For that, one again needs a top down holistic approach. This is not to say, however, that particular elements cannot be identified in a holistic diagnosis. It is just that the individual elements have a different logic.
One way of marking this distinction (although not Kraus’ own) is to contrast parts that are independent pieces and parts that are essential aspects. The pieces of a jigsaw add up to a whole, but each piece can exist independently of the others. By contrast a musical note has both a tone and a pitch, but neither aspect can exist independently of the other. Thus, according to a holistic approach, psychological symptoms are not independent building blocks towards diagnostic judgements but are interdependent aspects of a psychological unity.
Kraus combines with these two comments on the limits of a criteriological model of diagnosis with a further philosophical explanation of the difference in approach. This is why he contrasts the criteriological with a phenomenological rather than merely a holistic model. This concentrates not on psychiatric diseases but on the mode of being of whole persons, the ‘whole of the being in the world of schizophrenics or manics’. Thus the phenomenologically based diagnosis of schizophrenia turns on an overall assessment of the patient—a ‘praecox feeling’—as having a very different form of ‘being-in-the-world’. Whether or not that more general view is correct, Kraus’ criticism suggests that the operational structure of psychiatric manuals introduces a vagueness into the description of symptoms and hence undermines the specificity of the link between symptom, when properly understood, and diagnostic judgement.
Mario Maj makes a similar criticism. Again taking the example of schizophrenia, he argues that:
One could argue that we have come to a critical point in which it is difficult to discern whether the operational approach is disclosing the intrinsic weakness of the concept of schizophrenia (showing that the schizophrenic syndrome does not have a character and can be defined only by exclusion) or whether the case of schizophrenia is bringing to light the intrinsic limitations of the operational approach (showing that this approach is unable to convey the clinical flavour of such a complex syndrome). In other terms, there may be, beyond the individual phenomena, a ‘psychological whole’ (Jaspers, 1963) in schizophrenia, that the operational approach fails to grasp, or such a psychological whole may simply be an illusion, that the operational approach unveils. [Maj 1998: 459-60]
In fact, Maj argues that this shows the weakness of the operational approach. He argues that the DSM criteria fail to account for aspects of a proper grasp of schizophrenia: for example, the intuitive ranking of symptoms (which have equal footing in the DSM account). He suggests that there is, nevertheless, no particular danger in the use of DSM criteria by skilled, expert clinicians for whom it serves merely as a reminder of a more complex prior understanding. But there is a problem in its use to encode the diagnosis for those without such an additional underlying understanding:
If the few words composing the DSM-IV definition will probably evoke, in the mind of expert clinicians, the complex picture that they have learnt to recognise along the years, the same cannot be expected for students and residents. [ibid: 460]
Maj’s criticism that the DSM criteria do not capture a proper, expert understanding of the diagnosis of schizophrenia raises the question of how or why that could be the case. If the criticism is right, is it that the wrong criteria have been used: either the wrong symptoms and / or the wrong rules of combination? Or is there something more fundamentally wrong with the criteriological approach as applied to psychiatry?
Josef Parnas suggests the latter. In a paper describing pre-operational approaches to taxonomy and diagnosis as a ‘disappearing heritage’ he comments on an underlying difference in attitude towards signs and symptoms of schizophrenia.
When the pre-DSM-III psychopathologists emphasized this or that feature as being very characteristic of schizophrenia, they did not use the concept of a symptom/sign as it is being used today in the operational approach. This latter approach envisages the symptoms and signs as being (ideally) third person data, namely as reified (thing-like), mutually independent (atomic) entities, devoid of meaning and therefore appropriate for context-independent definitions and unproblematic assessments. It is as if the symptom/sign and its causal substrate were assumed to exhibit the same descriptive nature: both are spatio-temporally delimited objects, ie, things. In this paradigm, the symptoms and signs have no intrinsic sense or meaning. They are almost entirely referring, ie, pointing to the underlying abnormalities of anatomo-physiological substrate. This scheme of ‘symptoms = causal referents’ is automatically activated in the mind of a physician confronting a medical somatic illness. Yet the psychiatrist, who confronts his ‘psychiatric object’, finds himself in a situation without analogue in the somatic medicine. The psychiatrist does not confront a leg, an abdomen, not a thing, but a person, ie, broadly speaking, another embodied consciousness. What the patient manifests is not isolated symptoms/ signs with referring functions but rather certain wholes of mutually implicative, interpenetrating experiences, feelings, beliefs, expressions, and actions, all permeated by biographical detail. [Parnas 2011: 1126]
The claim here is that the criteriological approach has the wrong model of psychiatric symptoms and signs in two respects. Just as smoke can indicate fire or tree rings the age of a tree, the criteriological approach takes signs and symptoms to be free standing items which merely causally indicate underlying states. Furthermore, these relations are independent of one another: they are atomic. By contrast, Parnas suggests, psychiatric signs and symptoms are both essentially meaning-laden rather than brutely causal and also mutually interdependent wholes. It is the latter claim, which plays the more important role in his criticism.
One argument for their interdependence is that it is only in particular contexts that symptoms are reliable. Thus, for example, mumbling speech is comparatively widespread (Parnas estimates 5% of the population) but in – and only in – the context of other features such as ‘mannerist allure, inappropriate affect, and vagueness of thought, it acquires a psychopathological significance’ [ibid: 1126]. So the effectiveness of the sign is context-dependent. In some contexts it is indicative and in others not. Excluded from context – as it is in the criteriological context – it is vague. But it is precise in context. Parnas goes further by suggesting a more than merely additive view. Grasp of psychiatric symptoms is likened to seeing the figure of the duck-rabbit first as a rabbit and then suddenly as a duck: seeing the signs and symptoms under an overall aspect or gestalt.
A Gestalt is a salient unity or organization of phenomenal aspects. This unity emerges from the relations between component features (part-whole relations) but cannot be reduced to their simple aggregate (whole is more than the sum of its parts)... A Gestalt instantiates a certain generality of type (eg, this patient is typical of a category X), but this typicality is always modified, because it is necessarily embodied in a particular, concrete individual, thus deforming the ideal clarity of type (universal and particular). [ibid: 1126]
So the model of diagnosis is one in which the skilled clinician grasps the right diagnosis as an integrated whole in which different aspects can be seen as abstractions from that whole rather than as its basic building blocks. Such a view would accommodate Kraus’ rejection of a ‘Chinese restaurant menu’ approach and Maj’s suggestion that criteriological elements serve as reminders for already skilled clinicians. They do – on this view – in the sense that, after the fact, such articulations of the overall picture are possible, as a musical note may be divided into its pitch, tone and duration whilst it cannot be built up from those as independent building blocks. But that does not imply that the expert judgement of the whole could be built up from the individual criteria understood in isolation.
There is a further possibility hinted at in the criticism of Kraus, Maj and Parnas. On a criteriological view symptoms are not merely independent of each other (as Kraus points out) they are conceptually independent of the underlying psychopathological state that they indicate. But in the case of Kraus and Parnas, at least, there is a suggestion that the connection between symptoms (when correctly understood) and psychopathological state is more direct: the state is expressed directly in the signs and symptoms to those, at least, with the skill to see it.
Diagnosis and tacit knowledge
The criticisms of the criteriological approach set out in the preceding section prompt two further questions. The bottom up codification of diagnosis through simpler, more basic signs and symptoms suggests an explanation of how complex diagnostic judgement is possible. It is possible because it is based on simpler more epistemically accessible building blocks. The first question concerns the nature of an overall ‘gestalt’ judgement if that explanation is rejected. On what is top-down judgement based and what is its relationship to the criteriological approach? In this section, I will suggest an analogy with context-dependent tacit knowledge to try to make the rejection of the above explanation seem a less puzzling possibility [for a more detailed discussion see Thornton 2013]. But it will also help highlight how the move from context-dependent recognition to explicit criteria introduces vagueness into the description of psychiatric symptoms.
Second, if diagnostic judgement is not based on more observational features of a clinical encounter, how can it yield knowledge of underlying mental states? In the final section, I will suggest an analogy with the more general ‘problem of other minds’ and outline what may initially seem a counter-intuitive view outlined by the philosopher John McDowell which inverts the epistemic priority of judgements about behavioural signs and symptoms and judgements of underlying mental states. Again it will suggest that reliance on basic criteria comes at the cost of introducing vagueness into description of psychiatric symptoms which undermines the potential directness of psychiatric diagnosis as described by Kraus, Maj and Parnas.
I suggested at the start that the development of the theoretically minimal criteriological approach to diagnosis in psychiatry was partly influenced by operationalism in the philosophy of science in the first part of the twentieth century. The aim was to minimise uncodified elements in psychiatric diagnosis so as to maximise reliability. But there was, in the second half of the century, a contrasting view about the nature of scientific knowledge: the chemist turned philosopher Michael Polanyi’s arguments for the importance of tacit knowledge. (Polanyi himself talks of tacit knowing rather than knowledge. I will, nevertheless, use ‘knowledge’ whilst talking about his views but will return to emphasise the practical dimension to what is tacit.) Top-down or gestalt judgement in psychiatry can be thought of as an instance of tacit knowledge. I will use Polanyi to introduce this notion but will deviate from his account shortly.
Polanyi gives the following example:
We know a person’s face, and can recognize it among a thousand, indeed among a million. Yet we usually cannot tell how we recognize a face we know. So most of this knowledge cannot be put into words. [Polanyi 1967b: 4]
This is an instance of what he takes to be a general phenomenon. Indeed, he begins his book The Tacit Dimension with the following bold claim:
I shall reconsider human knowledge by starting from the fact that we can know more than we can tell. [Polanyi 1967b: 4]
The broad suggestion is that knowledge can be tacit when it is, on some understanding, ‘untellable’. ‘Tellable’ knowledge is a subset of all knowledge and excludes tacit knowledge. But the slogan is gnomic. Does it carry, for example, a sotto voce qualification ‘at any one particular time’? Or does it mean: ever?
The very idea of tacit knowledge presents a challenge: it has to be tacit and it has to be knowledge. But it is not easy to meet both conditions. Emphasising the tacit status, threatens the idea that there is something known. Articulating a knowable content, that which is known by the possessor of tacit knowledge, risks making it explicit. There is a second strand through Polanyi’s work which helps address this problem. At the start of his book Personal Knowledge in which he says:
I regard knowing as an active comprehension of things known, an action that requires skill. [Polanyi 1958: vii]
These two features suggest a way to understand tacit knowledge: it is not, or perhaps cannot be made, explicit and it is connected to action, the practical knowledge of a skilled agent. The latter connection suggests a way in which tacit knowledge can have a content: as practical knowledge of how to do something. Taking tacit knowledge to be practical suggests one way in which it is untellable. It cannot be made explicit except in context-dependent practical demonstrations. It is not that it is mysteriously ineffable but that it cannot be put into words alone.
Psychiatric diagnostic judgement can be thought of as an example of such a skill: the ability to recognise, in a particular context, the manifestation of psychiatric illness. Polanyi also compares recognition to a practical skill, likening it to bicycle riding:
I may ride a bicycle and say nothing, or pick out my macintosh among twenty others and say nothing. Though I cannot say clearly how I ride a bicycle nor how I recognise my macintosh (for I don’t know it clearly), yet this will not prevent me from saying that I know how to ride a bicycle and how to recognise my macintosh. For I know that I know how to do such things, though I know the particulars of what I know only in an instrumental manner and am focally quite ignorant of them. [ibid: 88]
In both cases, the ‘knowledge-how’ depends on something which is not explicit: the details of the act of bike riding or raincoat recognition. Whilst one can recognise one’s own macintosh one is, according to Polanyi, ignorant, in some sense, of how. Thus how one recognises it is tacit. Polanyi suggests here that explicit recognition of something as an instance of a type is based on the implicit recognition of subsidiary properties of which one is focally ignorant. He explains the distinction of focal and subsidiary awareness using the example of focusing attention on what a pointing finger points to. In looking from the finger to the object, the object is the focus of attention whilst the finger, though seen, is not attended to. It is not invisible, however, and could itself become the object of focal attention.
Polanyi seems to assume that the question of how one recognises something always has an informative answer and then to cover cases where it is not obvious what this is he suggests it can be tacit. But, firstly, whilst it sometimes may have an informative answer, there is no reason to think that it always has (cf recognising that a wall is red). Secondly, even in cases where one recognises a particular as an instance of a general kind in virtue of some further properties and cannot give an independent account of those properties, it is not clear that one need be focally ignorant of them. It may be, instead, that the awareness one has of the ‘subsidiary’ properties is simply manifested in the act of recognition. I might say, I recognise that this is a, or perhaps my, macintosh because of how it looks here with the interplay of sleeve, shoulder and colour even if I could not recognise a separated sleeve, shoulder or paint colour sample as of the same type. Whilst it seems plausible that one might not be able to say in context-independent terms just what it is about the sleeve that distinguishes a or my macintosh from any other kind of raincoat (one may, for example, lack the vocabulary of fashion or tailoring) that need not imply that one is focally ignorant of, or not attending to, just those features that make a difference. Recognition may depend on context-dependent or demonstrative elements, such as recognising shapes or colours for which one has no prior name. But if anything, that suggests one has to be focally aware, not focally ignorant, of them.
Thus Polanyi’s own account of the tacit nature of recognition faces objections. But such criticism suggests the possibility of a more minimal account of tacit knowledge. Recognition is tacit because it is a skill – for example, developed through repetition and critical practice and demonstrated in applications – and because it can thus be articulated only in context-dependent terms such as ‘like this!’. It cannot be explicated in words alone independently of additional practical demonstrations in context.
If the skilled diagnostic judgement described in the previous section by Kraus, Maj and Parnas is thought of as tacit knowledge as just explicated then it can be contrasted with criteriological diagnosis in the following way. The criteria set out in ICD and DSM are an attempt to make psychiatric diagnosis explicit, to put it into words alone. They attempt to set out context-independent descriptions of psychiatric syndromes.
Such an attempt is akin to attempting to model an ability to recognise colours and shades on general knowledge of the names for colours that ordinary people have. For most people, the ability to recognise, think about and recall (at least for some period) particular shades of colour goes beyond what they can make explicit linguistically. The ability can instead be manifested by pointing to particular instances of colour themselves. By contrast with the fine discriminations that can be made in the presence of actual colours and shades, colour vocabulary is generally vague.
Similarly, by contrast with the context depending discriminations of skilled clinicians made in the presence of their patients and clients, the criteria set out in diagnostic manuals are vague. Because they are fully linguistic, the criteria in DSM and ICD are portable. There is an advantage in communication of a linguistic codification of diagnosis that floats free of particular inter-personal relations. But it is bought at the cost of precision. By contrast, the features that play a role in the top-down diagnoses of skilled clinicians are identified in the presence of a particular patient’s or client’s psychological whole. Such recognition cannot be captured in words alone.
The analogy suggested in this section has been between clinical judgement made possible by the presence of a patient or client and recognition of a macintosh, either as an instance of a kind or as a particular one, or recognition of a colour or shade in its presence. The analogy suggests that the patient herself is passive and plays no active role. Since clinical judgement depends a great deal on what patients say and do, the general picture of tacit knowledge needs augmenting with a specific account of the recognition of mental states. That is the subject of the next section.
Criteria and other minds
In the previous section, I suggested that tacit knowledge can be used to shed light on the idea that an overall top down or gestalt diagnostic judgement could be more specific than a diagnosis based on general but vague criteria. A skilled clinician has a recognitional skill which can only be exemplified in context-dependent judgements in the presence of patients or clients. That is to approach the problem from an epistemological perspective: what it is to have knowledge in this way. In this section, I will complement that by taking an ontological view. What could the relation be between the underlying mental states and conditions amounting to mental illness or disease syndromes and the more apparently epistemically accessible criteria set out in DSM and ICD? Addressing this question will also address the active role of patients and clients raised just now.
To sketch an answer to this question I will consider a debate from the philosophy of mind about whether our knowledge of other minds in general is based on behavioural criteria. Although the argument against that view that I will outline does not directly carry over to the case of psychiatric diagnosis, it does suggest why criteriological diagnosis is vague compared to top-down or gestalt judgement.
The concept of a criterion was introduced into the philosophy of mind as a solution to the problem of other minds by followers of the philosopher Ludwig Wittgenstein. The influential Wittgenstein exegete PMS Hacker, writing in the Oxford Companion to Philosophy, defines a criterion thus:
A standard by which to judge something; a feature of a thing by which it can be judged to be thus and so. In the writings of the later Wittgenstein it is used as a quasi-technical term. Typically, something counts as a criterion for another thing if it is necessarily good evidence for it. Unlike inductive evidence, criterial support is determined by convention and is partly constitutive of the meaning of the expression for whose application it is a criterion. Unlike entailment, criterial support is characteristically defeasible. Wittgenstein argued that behavioural expressions of the ‘inner’, e.g. groaning or crying out in pain, are neither inductive evidence for the mental (Cartesianism), nor do they entail the instantiation of the relevant mental term (behaviourism), but are defeasible criteria for its application. [Honderich 1995]
Key features of this definition are that the criteria of, for example, an ‘inner’ state like pain are fixed by convention and are partly constitutive of what we mean by the word ‘pain’. Thus groaning and crying out are not mere symptoms but rather part of what we understand by ‘pain’, connected by definition not induction. At the same time, however, the criteria of pain are defeasible.
The reason for this qualification is the following intuition. Whilst, in general, pain behaviour is the expression of underlying pain, on occasion behaviour which resembles pain behaviour in every detail is not the expression of pain. It may be the result of acting or pretence. (And equally, genuine underlying pain may sometimes be stoically kept from expression.) As a result, the criterial support that apparent pain behaviour gives for a judgement that someone is in pain is taken to be defeasible. It can, on occasion, be overturned.
The idea that criteria give only defeasible support for a claim is combined with a further assumption which the philosopher John McDowell, in his criticism of this very notion, describes thus: ‘if a condition is ever a criterion for a claim, then any condition of that type constitutes a criterion for that claim, or one suitably related to it’ [McDowell 1982: 462-3]. In other words, criteria are types. Whilst on most occasions, when instances of some general type of criterion are satisfied the underlying fact for which those instances are criteria also obtains, on some occasions the type of criterion is satisfied (by some particular circumstances) but the fact does not obtain. In such cases, the criterion is satisfied but is nevertheless also defeated.
This suggests that there is an essential underdeterminination in the support that criteria, so understood, provide for judgements about mental states. In any particular case, on this picture, some expression, some sign or symptom of pain for example, may or may not actually mean that the person expressing it is actually in pain. Hence the behavioural expression is vague. Its meaning is imprecise.
This worry provides the basis for McDowell’s criticism of the use of criteria, understood in this way, to explain how knowledge of other minds is possible. On the assumption that it is sometimes, at least, possible to know someone else’s mental state, McDowell asks how such knowledge is supposed to be based ‘on an experiential intake that falls short of the fact known... in the sense [of]... being compatible with there being no such fact’ [McDowell 1982: 459].
The worry is this. If one knows something, then it cannot be the case that - ‘for all one knows’ - things may be otherwise. That possibility is ruled out precisely because one knows what is the case. But if criteria fall short of implying the fact that they are supposed to enable one to know, then they cannot themselves rule out the possibility that the fact does not obtain. So if our everyday concept of knowledge does rule this out then such knowledge cannot be based on perception that the criteria for some mental state are satisfied. A possible alternative view in which the perceived the criteria is supposed merely to be enough to satisfy linguistic conventions for the ascription of knowledge would also not address this objection, either.
If experiencing the satisfaction of ‘criteria’ does legitimise (‘criterially’) a claim to know that things are thus and so, it cannot also be legitimate to admit that the position is one in which, for all one knows, things may be otherwise. But the difficulty is to see how the fact that “criteria” are defeasible can be prevented from compelling that admission; in which case we can conclude, by contraposition, that experiencing the satisfaction of ‘criteria’ cannot legitimize a claim of knowledge. How can appeal to “convention” somehow drive a wedge between accepting that everything that one has is compatible with things not being so, on the one hand, and admitting that one does not know that things are so, on the other? [McDowell 1982: 458]
Imagine that there are two observers who both see that the behavioural criteria, so construed, for two other people being in pain are satisfied but that only one of them really is in pain: the other is pretending. If the observers’ experiences are the only grounds for them knowing the mental state of their respective subject and if their perceptions are the same in both cases (seeing that the criteria for pain are met) then how can one observer know their subject’s mental state and the other observer not? Surely, neither has knowledge even if one has, by chance, a true belief. It seems merely a matter of luck that one observers’ experience is of undefeated criteria whilst the other’s is of defeated criteria, that in one case the observed subject really is in pain and in the other merely pretending. The luckier observer has done nothing extra to earn the right to knowledge. Construing criteria as defeasible to try to accommodate the fact that we are fallible at knowing other people’s minds cannot work because it rules out that we ever have knowledge.
There is, however, an alternative view of criteria and of knowledge of other minds based on them. Rather than assuming that, in the case of pretence, the criteria for mental states are satisfied but are also defeated - by the fact that it is a case of pretence - one can instead construe it as a case of the criteria only appearing to be satisfied. This is a rejection of the idea that criteria are defeasible types of situation. Instead, McDowell presses the idea that, when criteria are satisfied, one’s experience does not fall short of the facts. So there cannot be cases where the criteria are satisfied without the fact for which they give criterial support also holding.
McDowell supports this interpretative possibility by considering a passage in which Wittgenstein discusses criteria in a non-mental context.
The fluctuation in grammar between criteria and symptoms makes it look as if there were nothing at all but symptoms. We say, for example: “Experience teaches that there is rain when the barometer falls, but it also teaches that there is rain when we have certain sensations of wet and cold, or such-and-such visual impressions.” In defence of this one says that these sense-impressions can deceive us. But here one fails to reflect that the fact that the false appearance is precisely one of rain is founded on a definition. [Wittgenstein 1953 §354]
Wittgenstein rejects the temptation to say that both the fall of a barometer and also sensations of wet and cold (or visual impressions) are mere symptoms of rain. Instead, and by contrast with the barometer fall, the connection between the sensations (or the visual impressions) and rain is definitional or criterial. They are used in an explanation of what ‘rain’ means. This thought can, however, be interpreted in two ways.
Commentators often take this to imply that when our senses deceive us, criteria for rain are satisfied, although no rain is falling. But what the passage says is surely just this: for things, say, to look a certain way to us is, as a matter of ‘definition’ (or ‘convention’... ), for it to look to us as though it is raining; it would be a mistake to suppose that the ‘sense-impressions’ yield the judgement that it is raining merely symptomatically - that arriving at the judgement is mediated by an empirical theory. That is quite compatible with this thought... when our “sense-impressions” deceive us, the fact is not that criteria for rain are satisfied but that they appear to be satisfied. [McDowell 1982:466]
Someone who steps outside their house when the lawn sprinklers are switched on may think that by having experiences of wet and cold they have experienced the criteria for rain, albeit on this occasion defeated. After all, when being taught about rain they may have been taught it through practical definitions involving experiences that felt similar. But the experiences used in the practical definition were not just any experiences of wet and cold but wet and cold experiences of rain falling. Similarly in the case of criteria for mental states, pretence can make it seem that the criteria for pain, for example, are satisfied when, in fact, they are not.
Taking the criteria to be merely any experience of wet and cold (for rain) or any experience of high pitched cries (for pain) makes them too vague to sustain knowledge. Correcting this requires rethinking the generality and the descriptive nature of criteria. If the criteria for pain are given in general and behavioural terms, they are too vague to underpin knowledge. Such ‘criteria’ do not only mean pain. So one might think of them as particular though still behavioural. If so, only particular instances of behavioural criteria (particular instances of crying out and rubbing knees etc) are valid guides to underlying pain. Such a suggestion maintains the behavioural character of criteria for mental states but denies their generality. But this threatens the idea that one can learn how to recognise pain. The alternative is to maintain (something of) their generality but deny the restriction to merely behavioural signs and symptoms. On such an account, the criteria for pain do not have in common anything that could be given in mind-free behavioural terms. Rather they share the essentially mind-involving generality of being expressions of pain.
McDowell offers a philosophical diagnosis of why such a view of criteria seems to go unnoticed which goes back to the influence of Cartesian dualism. If one starts from that basic picture then it invites a contrast between the behavioural states of other people to which one can have direct perceptual access, and mental states, which are, in some sense, hidden behind them. According to Descartes, they even exist in different kinds of space (res cogitans and res extensa). Cartesian dualism suggests an alienated picture of human behaviour in which all that anyone else can ever see is bodily movement which is only contingently associated with minds. Because perception of, and judgements about, such ‘behaviour’ is taken to be unproblematic whilst access to other people’s mental states is taken to be problematic, a route is needed from one to the other. Thus it seems plausible to think that judgements about mental states have to be grounded in independent judgements about behaviour. The alienated picture of human behaviour survives in approaches to the philosophy of mind which have long since rejected Descartes’ conception of the mind as res cogitans (or thinking stuff) existing in a different dimension to matter (res extensa).
This picture of the relation of mind and body is neither obligatory nor natural, however. One can instead think of mind and body as more closely linked. What one says and does expresses what one thinks and feels. Whilst one person’s mental states do not themselves fall within the direct experience of another their expression of their mental state does. Such expression is not one that is consistent with the absence of the inner state. So McDowell replaces an account in which all that is visible to an observer is another person’s intrinsically brute or meaningless behaviour, standing in need of further interpretation and hypothesis, with one in which that behaviour is charged with expression.
This claim addresses the worry raised at the end of the previous section that an analogy with a tacit recognitional judgement of a macintosh or a shade of colour suggests that patients and clients are passive in the face of a clinical gaze. If the analogy held closely then one person’s mental state would have to fall directly within the experience of another just as a colour can. The nuanced view is that this is not so. Patients and clients have to reveal their mental states through speech and action. But, to continue to describe the nuanced view, what they say and do makes their mental lives available to others in a way that requires no inference. This accounts adds to the more general picture of tacit knowledge in the previous section the further idea that recognitional judgement of others’ mental states requires that the other people actively express them.
By denying that our ‘access’ to the minds of others must proceed through a neutrally described behavioural intermediary (their behaviour), McDowell can offer a much less technically charged account of criteria which he summarises thus:
I think we should understand criteria to be, in the first instance, ways of telling how things are, of the sort specified by “On the basis of what he says and does” or “By how things look”; and we should take it that knowledge that a criterion for a claim is actually satisfied - if we allow ourselves to speak in those terms as well - would be an exercise of the very capacity we speak of when we say that one can tell, on the basis of such-and-such criteria, whether things are as the claim would represent them as being. [McDowell 1982: 470-1]
Knowledge of other minds depends on what people say and do. It does not require a kind of direct mind reading. The judgement is based on, emerges from, what they say and do. But the conceptualisation of what they say and do need not be couched in mind-independent neutral terms. As Dowell comments:
This flouts an idea we are prone to find natural, that a basis for a judgement must be something on which we have firmer cognitive purchase than we do on the judgement itself; but although the idea can seem natural, it is an illusion to suppose it is compulsory. [McDowell 1982: 471]
It may be easier to see patterns and generalities in behaviour construed as essentially expressive of minds than in neutrally described bodily movement. So even though judgements about others’ minds may be based on their behaviour, the description of the behaviour may be less secure than the description of what it expresses.
I have set out two contrasting accounts of criteria from the philosophical discussion of the problem of other minds to shed light on the more specific issue of mental illness diagnosis. There are, however, two related important differences between the two cases which need mention.
First, the application of the idea of criteria in the more general problem of other minds and in the case of psychiatric diagnosis differ in one clear respect. It is merely a theoretical idea in the former case but set out in practical detail in recent editions of the DSM and ICD in the latter case. Second, and related to this, is an important difference in the dialectical context of criticism of behavioural criteria in the two cases. The argument above assumes that it is possible to have knowledge of other minds. Since the standard model of criteria (as defeasible behavioural types) makes knowledge impossible, it cannot be the basis of our knowledge of other minds.
But one might object that psychiatry does not aspire to knowledge when it comes to diagnosis but some weaker state such as a belief with a particular degree of probability. And hence an argument which shows that knowledge cannot be based on criteria, so understood, need not undermine that project. Such an objection carries risk, however. Since psychiatry is a practical discipline, diagnoses form the basis for action (concerning treatment and management). Thus clinicians need more than merely having beliefs with a particular (suitably high) probability of being true, they need to know that they do.
Nevertheless, even if psychiatric diagnosis need not aspire to knowledge itself but merely to some known probability of being correct, it could be based on criteria understood as behavioural types (ie the target of the criticism of this section). Providing that there are other methods of arriving at diagnoses, such as the considered judgement of skilled clinicians or longitudinal studies, it would be possible to make an assessment of the sensitivity and specificity – in probabilistic terms – of types of behavioural criteria. The dialectical context differs for defenders of defeasible criteria for knowledge of other minds because they assume that there is no more fundamental way of having such knowledge and hence no independent test of the construct validity of the criteria.
Despite these differences, McDowell’s discussion of the two accounts of criteria and the role, in the account he defends, of the idea that behaviour can be more than mere behaviour but rather expressive mental states sheds light on the possibility, at least, of the relative vagueness of criteriological diagnosis compared to the specificity of gestalt judgement. Both the DSM and ICD stress operationalised descriptions as opposed to more essentially psychiatric descriptions couched in aetiological terms. They do this in an attempt to provide secure foundations for diagnosis. But that very strategy makes the criteria mere approximations of the underlying psychopathological states they aim to capture. As Kraus, Maj and Parnas suggest, precision requires thinking of psychiatric symptoms as abstractions from a diagnostic whole rather than built up from neutral – or more neutral – criteria whose obtaining does not strictly imply the presence of the psychiatric syndrome for which they are supposed to be signs.
An alternative view of diagnostic criteria, drawing on McDowell’s account and influenced by the empirical claims of Kraus, Maj and Parnas would stress the specific schizophrenic colouring of particular delusions, for example. It may seem that this carries the risk that identifying that a patient or client is experiencing such a delusion is riskier than the vaguer claim that they are experiencing some sort of delusion or other. But this may not be so in context. In particular cases, the justification for thinking that the delusion carries a specific schizophrenic colouring may be what warrants the more general claim that they are thus experiencing some more general category of delusion.
This view also helps address a suggestion in Kraus’ and Parnas’ description mentioned earlier: that the connection between symptoms and psychopathological state is more direct than a mere evidential or causally indicating relation. The state is expressed directly in signs and symptoms to those, at least, with the skill to see it. On the view developed above, skilled clinicians do not merely infer the diagnostic state of their patients and clients from signs and symptoms that are independent of or distinct from them. Rather, they see (or hear) in what their patients say and do the expression of a diagnostic condition.
It is natural to object to such a view (as the editors of this book did) that clinicians are fallible beings, too and so the shortcoming of the criteriological approach cannot be that criteria do not strictly imply the presence of what they are criteria for. But on the view sketched, this objection presupposes the wrong account of the fallibility of such judgements. If criteria for mental illnesses were both general and defeasible, that would explain how knowledge claims could fail but it would also fail to explain how knowledge is ever possible. On the alternative view sketched above, when all goes well a skilled clinician is able to respond to the expressions of, say, schizophrenia which do indeed necessitate that the patient has schizophrenia. Fallibilism is explained by the fact that some apparent criteria for schizophrenia are not in fact such criteria. But it is a mistake to assume that the best that even a skilled clinician can rely on is a description of the signs and symptoms that merely indicates that it is likely that someone has that syndrome. Skilled judgement is more precise than the vague descriptions of symptoms found in the DSM.
Conclusions
I have considered the charge made against criteriological models of diagnosis that, compared with the gestalt judgement of a skilled clinician, criteriological descriptions of symptoms are essentially vague. I have argued that two independently plausible considerations help explain how this could be so. Epistemologically, diagnosis based on gestalt judgement could be akin to the kind of context-dependent practical skill that underpins one model of tacit knowledge. Such skill resists codification in general context-independent terms akin to the DSM and ICD’s diagnostic criteria but is nevertheless a form of conceptually structured knowledge. Ontologically, the diagnostic criteria of the DSM and ICD may be merely more or less behavioural abstractions from underlying psychological reality. Skilled clinicians need not rely on neutral criteria but on the direct expression of complex psychological wholes.
Acknowledgement
This chapter was written whilst a fellow of the Institute for Advanced Study, University of Durham. My thanks both to the IAS, Durham and the University of Central Lancashire for granting me research leave.
References
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Friday, 10 July 2015

Recovery, paternalism and narrative understanding in mental healthcare

I have cheated and replaced the first version with a second version a week later.

Recovery, paternalism and narrative understanding in mental healthcare

Abstract
There has been a growing emphasis on the idea that recovery in mental healthcare should not be seen as a matter of getting better but instead of successfully living a flourishing life as conceived by the subject herself. Theorists of recovery also stress the importance of narrative understanding for articulating the sort of life that would count as recovery. But surely one of the threats of mental illness is that it can undermine a subject’s autonomy and hence capacity to author a suitable narrative for recovery? Addressing this worry raises the threat of paternalism. Having sketched an abstract model of recovery and compared it to the capabilities model of Sen and Nussbaum, this chapter outlines a minimal account of narrative understanding drawn from Peter Goldie’s book The Mess Inside can address the worry of paternalism.

Introduction: Recovery as the goal of mental healthcare.
In this first section, I introduce recovery as the goal of mental healthcare and sketch an abstract model for it. Recovery aims at a value-laden and person specific conception of flourishing. In the second section, I show how the capabilities approach of Amartya Sen and Martha Nussbaum fits this abstract model but that the difference between Nussbaum’s and Sen’s versions reflects a corresponding difference between substantive and procedural accounts of personal autonomy. This difference is also present in Davidson and Hopper’s more specific claims about the possibilities for recovery from mental illness and leads to a challenge to the recovery model. If mental illness can compromise autonomy and calls for sensitive clinical intervention to recover it, does this not risk the paternalist imposition of others’ values? In the final two sections I argue that a narrative view of a sense of self can address this on either opposed broad view of recovery and autonomy.
Recovery has come to be promoted as a novel and desirable target for mental healthcare. It has become a proud boast that mental healthcare is recovery orientated. Nevertheless, whilst there is agreement that in this context, it does not mean merely getting better or returning to a previous state of health, there remains disagreement as to what recovery is.
There is an increasing global commitment to recovery as the expectation for people with mental illness. There remains, however, little consensus on what recovery means in relation to mental illness. [Davidson and Roe 2007: 450]
The term ‘recovery’ appears to have a simple and self-evident meaning, but within the recovery literature it has been variously used to mean an approach, a model, a philosophy, a paradigm, a movement, a vision and, sceptically, a myth. [Roberts and Wolfson 2004: 38]
In the UK, a policy paper published by the Sainsbury Centre for Mental Health, titled ‘Making recovery a reality’, begins by summarising some key points of emphasis which, it is suggested, characterise any broadly conceived recovery-based approach. These points include:
Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems.
Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness.
Hope is central to recovery and can be enhanced by each person seeing how they can have more active control over their lives (‘agency’) and by seeing how others have found a way forward.
Self-management is encouraged and facilitated. The processes of self-management are similar, but what works may be very different for each individual. No ‘one size fits all’.
The helping relationship between clinicians and patients moves away from being expert / patient to being ‘coaches’ or ‘partners’ on a journey of discovery. Clinicians are there to be “on tap, not on top”.
People do not recover in isolation. Recovery is closely associated with social inclusion and being able to take on meaningful and satisfying social roles within local communities, rather than in segregated services.
Recovery is about discovering – or re-discovering – a sense of personal identity, separate from illness or disability. [Shepherd, Boardman and Slade 2008: 0]
The Scottish Recovery Network summarises its views of recovery in similar terms:
Recovery is about living a satisfying and fulfilling life.
Recovery is about more than the absence of the symptoms of illness. Some people describe themselves as being in recovery whilst still experiencing symptoms.
There can be lots of ups and downs during the recovery process – some people describe it as a journey.
For this reason people often talk about being in recovery rather than recovered.
Some people consider recovery as being ‘back to the way things were’ or back to ‘normal’ but for others recovery is more about discovering a new life or a new way of being. [Brown and Kandirikirira 2007: 3]
These lists provide a starting point for setting out a theoretical model of recovery. But there is a further structural constraint. To articulate a recovery model which is distinct from or contrasts with, for example, a bio-medical model of mental healthcare, it is not enough to say that recovery (construed in some broad way) is a desirable aim of mental health care. One could hold that whilst holding a broadly bio-medical view of health and illness: for example, as pertaining to biological function versus dysfunction. To count as a distinct model of healthcare, it must offer more than just a broad aim but rather a theoretical conception of what illness, or health, or something like health is. (In the UK, the rise of the recovery movement coincided with both greater optimism within biological psychiatry of the efficacy of medicines but also the kind of theoretical articulation of a novel view of recovery with which I am here concerned. Both elements played a role, complicating the historical story.)
The characterisations of recovery above suggest the importance of two distinctions. First, there is a distinction of focus between pathology and whatever is its relevant contrast, perhaps health. Second, there is the distinction between what is evaluative or normative and what is merely plainly factual. Together these can be used to sketch a distinct although abstract conception of recovery. I will take each in turn.
The philosophy of psychiatry, and more generally the philosophy of medicine, has tended to focus on the illness end of a spectrum between health and illness. The key concern has been with the notion of illness (or disease or disorder). One reason for that has been the origin of the debate, at least within the philosophy of psychiatry, in the response to Thomas Szasz’ argument that mental illness is a myth [Szasz 1972]. Szasz’ claim that mental illness is an oxymoron prompted responses by biologically minded psychiatrists and researchers who attempted to devise models of illness (or disease or disorder) which accommodated not only physical but also mental illness [Kendell 1975, Boorse 1975]. That in turn has led to an ongoing debate focusing squarely on ill health [Fulford 1989, Pickering 2006, Wakefield 1999]. There was no equivalent Szaszian argument for the mythic status of mental health and hence no incentive for a philosophical defence of that notion.
Against a background focus on the nature of illness, recovery can seem to be simply a return from, or a removal of, that status. Whatever illness or disease is, recovery is its negation. By contrast, concentration first on the health end of the spectrum is at the heart of the recovery approach. This accords with the claim quoted from the document ‘Making recovery a reality’ above that ‘Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness’. A recovery model has to do more than just take the aim of healthcare to be the removal of illness.
The second distinction is between views of mental illness in particular, or illness more generally, as necessarily evaluative or merely descriptive. Does the analysis of mental illness contain reference to values or not? Some philosophers and psychiatrists argue that at the heart of the idea of illness is something that is either bad or wrong for a sufferer or is a deviation from a social or moral norm. Both of these are evaluative or normative notions and hence both are views of illness as value-laden.
Others argue that illness is a plainly factual matter. Typically, they argue that illness involves a failure of a biological function and that function – and hence deviation from, or failure of, function – is a plainly factual, biological (and/or psychological) term couched in evolutionary theory.
Having sketched the two distinctions, I suggest that a clue to articulating a recovery model which genuinely contrasts with a medical model is to locate it on the health-focused rather than pathology-focused side of the first distinction and on the values-laden or normative side of the second.
That remains just a clue: more conceptual work has to be done. But it might be objected that the first of these two distinctions is unnecessary; we can articulate a genuine contrast to a bio-medical model simply by using the second distinction.
The idea is that a bio-medical model construes mental illness as value-free, as reducible to plain facts about biological (and/or psychological) function. Adopting the opposite view – that illness is a necessarily evaluative notion – stands in genuine contrast. And a conception of recovery in relation to illness, so construed, might be enough to count as a recovery model because of that genuine, substantive contrast.
Whilst such a position is a genuine contrast to a plausible candidate for a bio-medical model of illness, it does not seem to capture an important element of the recovery approach: a particular goal or aim of therapy which is not defined merely as the absence of illness. It is instead captured in specific terms such as a hope, autonomy and social inclusion.
One specific problem is that even if one thinks of illness as a necessarily evaluative notion, this is not a sufficient reason to think that health is. It might be the mere absence of an evaluatively identified illness state. Health might be conceptualized in merely statistically normal (rather than normative or evaluative) terms, perhaps as the state of most people, or, alternatively, the state one was previously in. If so, whilst the states that individuals have an interest in recovering from are those with particular normative or evaluative properties (whatever those are), recovery itself might be characterized in non-normative non-evaluative terms. And that does not seem to fit the way the recovery approach is characterized by its supporters.
What of the other distinction? Could a recovery model be defined simply as one which focuses on a positive conception of health, or something like it, rather than merely the absence of pathology, however construed? Again, no. As the authors of ‘Making recovery a reality’ make plain, they have a very particular conception of the aim of recovery tied to a conception of hoped for and autonomous life connected to social inclusion. That specific content is not captured merely by a focus on health which, as I have just argued, might be thought of in statistical normal terms.
To capture what is characteristic of a recovery approach in order to frame a recovery model, it seems that both aspects are needed: a) a focus on a conception of health, or something like it, and b) in normative or evaluative terms. A recovery model is thus one which construes the positive aim of mental healthcare to be a state of health or something like it, necessarily characterised in normative or evaluative terms.

The capabilities approach to recovery
The model sketched above abstracts from typical comments made about the nature of recovery in mental healthcare in practical policy documents. The idea that recovery aims at a value-laden conception of a flourishing life, which is tailored to the individual concerned, fits such documents. But that is not to say that that is the most that might be offered by way of theoretical articulation of recovery. More can, and has been, said which is, nevertheless, consistent with the abstract model just sketched. In this section, I will outline an influential theoretical framework for thinking about recovery: the capabilities approach. I will use this to extract a potential tension in thinking about the value-ladenness and person-centeredness of recovery and thus flag the role, in the next section for narrative.
The capabilities approach to recovery in mental healthcare is based on Amartya Sen’s model for welfare economics developed in the 1980s. Rather than focusing on the fair distribution of resources or primary goods, Sen proposes that the focus of welfare economics should be on a fair distribution of the capacity to lead a flourishing life. In this context, capability is a measure of the ability to do the things and to be the ways that amount to a flourishing form of life. Sen uses the word ‘functionings’ for this latter idea.
The expression [‘capability’] was picked to represent the alternative combinations of things a person is able to do or be-the various ‘functionings’ he or she can achieve. The capability approach to a person’s advantage is concerned with evaluating it in terms of his or her actual ability to achieve various valuable functionings as a part of living… Functionings represent parts of the state of a person-in particular the various things that he or she manages to do or be in leading a life. The capability of a person reflects the alternative combinations of functionings the person can achieve, and from which he or she can choose one collection… Some functionings are very elementary, such as being adequately nourished, being in good health, etc., and these may be strongly valued by all, for obvious reasons. Others may be more complex, but still widely valued, such as achieving self-respect or being socially integrated. Individuals may, however, differ a good deal from each other in the weights they attach to these different functionings-valuable though they may all be-and the assessment of individual and social advantages must be alive to these variations. [Sen 1993 :31]
Applied to welfare economics, the approach takes account of the fact that people can differ in the resources they need to achieve valuable ways of being and acting. Hence it delivers different results from simply advocating equal distributions of resources or primary goods.
In characterising capability, Sen stresses the role of freedom. The freedom to live different kinds of life is reflected in a person’s set of capabilities. Freedom itself adds value to a life. Even the existence of possibilities not adopted or embraced add, via a sense of freedom, to the value of a life. But the relevant sense of freedom does not range over just any possible life. Having the option to live kinds of life that an individual would never consider is not freedom in Sen’s sense. Genuine freedom has to be assessed relative to what a subject values. Further, what is valued changes what counts as ‘functioning’. Fasting and starving both involve the deprivation of food but because the former is chosen it counts as functioning.
This sensitivity of what counts as capability fits the value-ladenness and person-centredness of the abstract model of recovery outlined in the previous section of this chapter. It also fits the focus not on pathology but on health or flourishing. The aim of recovery, on such an understanding, is to maximise the capability of a person to achieve various valuable functionings as a part of their life. It thus connects the abstract requirements on a recovery model to some pre-existing philosophical and economic thinking. But this connection also highlights a tension in, or challenge for, the recovery model which, in the next two sections, will be connected to the role of narrative.
Despite the importance of freedom there is an important tension in thinking about capability because of a second influence on its initial articulation: the Aristotelian philosopher Martha Nussbaum. Nussbaum draws on Aristotle’s account of flourishing to argue that there is a list of basic human functions that applies to all human beings [Nussbaum 1988: 176]. Not just anything could count as human functioning. Thus drawing on Aristotle, Nussbaum argues for universal standards for assessing human capability. This contrasts with Sen’s liberal or relativist view that with freedom comes proper diversity of choice. This forms the basis in the The Tanner Lectures on Human Values of one of his criticisms of traditional welfare economics based on the fair distribution of resources or primary goods [Sen 1980].
In the co-authored introduction to a collection of papers on the capabilities approach, Nussbaum and Sen jointly set out the difficulties that apply to the choice between pressing a universal or a culturally relative view of human capabilities. It is worth quoting this passage at length.
Should we, for example, look to the local traditions of the country or region with which we are concerned, asking what these traditions have regarded as most essential to thriving, or should we, instead, seek some more universal account of good human living, assessing the various local traditions against it? This question needs to be approached with considerable sensitivity, and there appear to be serious problems whichever route we take. If we stick to local traditions, this seems to have the advantage of giving us something definite to point to and a clear way of knowing what we want to know... It seems, as well, to promise the advantage of respect for difference: instead of telling people in distant parts of the world what they ought to do and to be, the choice is left to them. On the other hand, most traditions contain elements of injustice and oppression, often deeply rooted; and it is frequently hard to find a basis for criticism of these inequities without thinking about human functioning in a more critical and universal way…The search for a universally applicable account of the quality of human life has, on its side, the promise of a greater power to stand up for the lives of those whom tradition has oppressed or marginalized. But it faces the epistemological difficulty of grounding such an account in an adequate way, saying where the norms come from and how they can be known to be the best. It faces, too, the ethical danger of paternalism, for it is obvious that all too often such accounts have been insensitive to much that is of worth and value in the lives of people in other parts of the world and have served as an excuse for not looking very deeply into these lives. [Nussbaum and Sen 1993: 4]
Uncritical relativism versus paternalism is an apparent rather than actual dilemma, however. Each is the criticism that someone taking the corresponding opposed view might make. Universalists fear uncritical relativism but are in turn accused of paternalism by their opponents who emphasise diversity. To see this it is worth flagging corresponding opposed views of autonomy since paternalism is the trumping of another's autonomy.
The idea that universal standards of human flourishing necessarily threatens paternalism presupposes that autonomy really is autonomous of external standards. One such view is proceduralism equates base autonomy with the capacity of a subject to reflect on and endorse, at a second order level, their first order actions and values [eg Frankfurt 1971]. But it remains neutral as to what those first order actions and values are. Substantive approaches, by contrast, argue that the notion of autonomy involves an ability to be guided by the good and the true. And hence a specification of what it is to be autonomous cannot avoid substantive claims about human flourishing [eg Wolf 1990].
Clearly if the very idea of autonomy presupposes tracking some universal standards, then the mere existence of such standards cannot threaten the ethical danger of paternalism, the unwarranted undermining of autonomy. If, on the other hand, one thinks that autonomy is merely a matter of reflective coherence, then the absence of universal standards is not a threat of uncritical relativism, it is just that criticism is a matter of local coherence.
This opposition within accounts of autonomy and versions of a capabilities approach to welfare economics also has an echo in its application to the recovery model in mental healthcare. In their paper ‘A Capabilities Approach to Mental Health Transformation: A Conceptual Framework for the Recovery Era’, Larry Davidson and colleagues follow Sen in stressing the connection between a capabilities approach to recovery and the proper diversity of choices that will be made:
It is in the very nature of choice to result in variability, otherwise choice would not really be free but would refer only to changes in the quantity of some basic universal. While smoked salmon and french fries are, in fact, both foods, to say that a person who prefers smoked salmon to french fries has no real preference because they are both foods is to miss the point of having preferences to begin with. It is to gloss over the issue of choice, but this is precisely where our primary interest lies. Without choice there is no freedom, and therefore no justice; with choice there inevitably will be differences and diversity. [Davidson et al 2009: 42]
The view could be described as ‘liberal’ or ‘procedural’. It stresses the role of freedom and the proper diversity of responses to its exercise. By contrast, Kim Hopper argues in his paper ‘Rethinking social recovery in schizophrenia: what a capabilities approach might offer’ that:
Any application of capabilities must therefore first define/defend a (full or partial) list of valued functionings... [Hopper 2007: 876]
Hopper follows Nussbaum following Aristotle in assuming some objective and universally applicable limits to the proper exercise of choice and freedom. An objective and substantive list of valued functionings would be an objective standard independent of individual choices and that might, in principle at least serves as standards of correctness for them. That is, it makes sense on Hopper’s view to think that someone might be in error about the nature of their own flourishing. They might be able to follow the correct procedures of second order reflection on first order values but be in error about objective values at both levels. That possibility is ruled out on a liberal or procedural view.
A similar contrast is also evident concerning the authenticity of choice. Davidson et al claim that mental illness does not affect the status as an agent of individuals.
There can be no recovery without self-determination… Mental illness may pose an obstacle to the person’s achievement of the kind of life he or she wishes to have, may make it more difficult to live that life, and, at its most extreme, may even deprive the person of life altogether. In none of these cases, though, does mental illness fundamentally alter the basic nature of human beings, which is that of being self-determined agents, free to choose and pursue the kind of life they as individuals value. Mental illness does not rob people of their agency, nor does it deprive them of their fundamental civil rights. [Davidson 2009: 4-1 italics added]
By contrast Hopper warns that the choices made people with mental illnesses may lack authenticity. Their choices may be affected or distorted as a consequence of illness itself or their treatment as a result of that illness.
Deprivation and disgrace can so corrode one’s self worth that aspiration can be distorted, initiative undercut and preferences deformed. Sensitive work will be needed to recover that suppressed sense of injustice and reclaim lost possibility. [Hopper 2007: 877]
Whichever view one takes of the local and diverse or universal view of capabilities and the corresponding opposition between procedural versus substantive view of autonomy, Hopper’s point is surely empirically correct. The stigma of carrying a mental illness diagnosis is often reported to be as disabling as the mental itself [Corrigan and Watson 2002]. That raises the possibility of an indirect connection – mediated by medical and broader societal treatment – between illness and aspiration. But there are also direct connections. In his study of the phenomenology of depression, Matthew Ratcliffe reports that in severe depression not only is motivation undermined but awareness of the very possibilities for action diminish. Objects are no longer imbued with the possibilities for action. So it is not just that there are possible actions which the sufferer feels incapable of taking up. Rather, the sense of such possibilities also vanishes. In extreme cases, this undermines an understanding of other people’s purposive actions.
[M]ore profound losses involve an inability to comprehend the possibility of anything being practically significant for anyone:
But in among the bad and worse times, there were also moments when I felt, if not hope, then at least the glimmerings of possibility… It was like starting from the beginning. It took me a long time, for example, to understand, or to re-understand, why people do things. Why, in fact, they do anything at all. What is it that occupies their time? What is the point of doing? During my long morning walks, I watched people hurrying along in suits and trainers. Where was it they were going, and why were they in such haste? I simply couldn’t imagine feeling such urgency. I watched others throwing a ball for a dog, picking it up, and throwing it again. Why? Where was the sense in such pointless repetition? [Brampton, 2008, p.249]
This description of the ‘return of possibility’ serves to make salient what was previously diminished or lost: a sense of what it is for someone to act purposively, to find things significant and respond to them accordingly. Activities such as playing with a ball or hurrying to a destination had become strange, unfamiliar, bereft of meaning. The depressed person therefore experiences her situation as something she cannot act upon. [Ratcliffe 2015: 167]
The examples Ratcliffe describes suggest that Davidson et al are wrong to deny that mental illnesses can rob people of their agency. Such a connection to agency seems, to the contrary, to be a key element in the way that mental illnesses cause harm. This may not be so obvious in in schizophrenia, for example, but it is still plausible to think that delusions disrupt the formation of intentions for action [Fulford 1989]. Perhaps the reason Davidson makes that claim is a confusion with, or assimilation to, the claim that follows: ‘nor does it deprive them of their fundamental civil rights’. This claim might express the following warning. One should not assume that just because someone has a mental illness that they therefore forfeit fundamental civil rights premised on the idea of being an autonomous human agents. But even this claim has to accommodate the complication of legal detention and compulsory treatment under mental health legislation. Such a widely held legal principle suggests that mental illness can, in a limited and nuanced way, even alter fundamental civic rights.
Hopper’s comment that reclaiming a lost sense of possibility will require ‘sensitive work’ suggests, however, the danger that Nussbaum and Sen flag concerning an objective view of human flourishing: the danger of paternalism. If the central aim of the recovery model is to articulate a conception of a life worth living which fits the values of the person concerned, but if mental illness can corrode their sense of possibility and undermine their agency, how can the right endpoint for healthcare for them be selected without external imposition? Although highlighted within conceptions of recovery drawn from a capabilities approach, this general problem seems also to affect the more abstract account of recovery developed in the previous section. If recovery is aimed at a conception of flourishing articulated by the mentally ill patient or client him or herself, and if mental illness can affect his or her ability authentically to choose, what should guide the right conception of recovery?
In the final two sections of this chapter, I will suggest a role for narrative in addressing this problem. In the next section I will highlight the connection between recovery and narrative and draw on one particular view of narrative for a narrative sense of self. In the final section I will argue that this helps address the risk of paternalism whichever view of capabilities and whichever view of autonomy is adopted.

The link to narrative
To begin the section, I will first motivate the idea that narrative is a helpful place to address the tension between two different versions of the capabilities-based approach to recovery. There have been a number of claims that there is a close direct connection between recovery and narrative understanding. One indication of this is the proliferation of ‘recovery stories’ as part of the promotion of the recovery approach. These explore:
the personal and existential dimensions of recovery, taking the form of subjective and self-evaluated accounts of how an individual has learned to accommodate to an illness. These accounts have become the founding stories of the recovery movement [e.g. Chamberlin, 1978; Lovejoy, 1984; Deegan, 1988, 1996; Leete, 1989; Unzicker, 1989; Clay, 1994; Coleman, 1999; Ridgeway, 2000], and anthologies of these personal stories have been used by governments and professions as a means of combating stigma and reasserting a focus on personal perspectives [Leibrich, 1999; Lapsley et al, 2002; Ramsay et al, 2002]. [Roberts and Wolfson 2004: 38-9]
More generally it is claimed that people who have suffered mental illness can be helped towards recovery through a narrative based theory. Pat Bracken and Phil Thomas, for example, cite both Larry Davidson and Glen Roberts.
In their work on recovery, both Davidson and Roberts choose not to use an approach grounded in traditional descriptive psychopathology, but turn instead to narrative theory and methods, seeing this as providing a rigorous empirical and clinical methodology in helping people suffering from chronic psychosis to move to recovery. [Bracken and Thomas 2009: 245]
On Bracken and Thomas’ view, clinical work is informed by narrative theory which is distinct from traditional Jasperian descriptive psychopathology. Roberts himself makes the connection between recovery and narrative even closer (or at least even more explicit). By contrast with Bracken and Thomas, he sees a narrative view as consistent with Jaspers’ view of understanding (by contrast with explanation).
A narrative view values content, and in seeking to understand delusions and hallucinations, as opposed to explaining them [Jaspers 1974], one is engaged in re-contextualising the illness in the life experience of the individual. This in turn may inform the rehabilitation process and give insight into the complexities of recovery, which for some will include the loss of the compensations of delusional beliefs and re-engagement with the implications of having a severe mental illness and what preceded it [Roberts 1999]. [Roberts 2000: 436]
But he goes on to suggest (or at least to make explicit the idea) that subjects or patients – rather than only clinicians – possess a narrative understanding and it is this which can help or hinder them in recovery.
Patients with self-sufficient, unelaborated, dismissive narratives need to be encouraged to break open their defensive stories and consider other possibilities. Conversely, those who seem unable to find a narrative thread and to be drowning in the chaos of their experience need help to find a shape and pattern that enables them to fit things into place [Holmes, 1999]. In therapy, patients learn to build up their storytelling capacity, their “autobiographical competence” [Holmes, 1993]. [Roberts 2000: 436]
Across the literature there is evidence of an idea that narratives structure subjects’ lives in such a way that partially determines what seems possible to them. Therapists can propose new life ‘plots’ and help map out new possibilities in the face of mental illness and hence new possibilities for recovery. To take a non-mental health example, therapists can propose new plotlines to spinal cord injured patients for whom there is, sadly, no going back to their past able-bodied plots. They have suffered a kind of ‘narrative wreckage’ from which they need rescuing in a dialogue with therapists [Frank 1997: 53-56].
Whilst that direct connection between narrative understanding and recovery is potentially an important clinical one, it is not a necessary connection. Exploring the options for a flourishing life through the idea of stories may in itself be directly therapeutic for many people, but it is possible that such an approach might fail because, for example, it may remind people of what they cannot do anymore.
What is the conceptual or logical connection between a recovery model and narrative understanding? Narrative theorists who apply the idea of narrative to social phenomena face a strategic choice. Either, they offer a specific detailed account of narrative in which case it narrows the range of application of narrative theory since few social phenomena will fit all the characteristics of narrative so defined. Or, they stress the universal application of narrative theory and hence are forced to offer a more general, thinner characterisation of narrative.
In the former approach, they may, for example, divide narratives into: abstract, orientation, complicating action, evaluation, resolution and coda [Labov and Waletsky, 1967]. Or, alternatively: temporality, people, action, certainty (or not) and context [Clandinin and Connelly 2000]. In practice there is a great deal of overlap between the accounts. Nevertheless, there is no obvious necessary connection between a recovery model and narrative understood in this detailed concrete way. Whilst narratives may often have the elements narrative theorists favour, and whilst this may contingently be true of the kind of ‘recovery stories’ often published in support of the recovery approach, there is no need to link the very idea of recovery in mental healthcare to the provision of a narrative with all of the parts of a favoured detailed theory of narrative.
But if not, what is the role of narrative understanding and recovery? A more plausible approach to answer this question is to take a more modest view of the necessary and sufficient elements of narrative understanding. The philosopher Peter Goldie articulates just such a minimal account in his last book The Mess Inside [Goldie 2012]. His account of narrative starts with the general claim that:
A narrative is a representation of events which is shaped, organized, and coloured, presenting those events, and the people involved in them, from a certain perspective or perspectives, and thereby giving narrative structure – coherence, meaningfulness, and evaluative and emotional import – to what is narrated. [Goldie 2012: 8]
This definition emphasises that a narrative is a representation. It is constructed from the perspective of a narrator even when the narrative is not actually written or told and is merely an exercise of thought by a subject. Thus the narrative is fundamentally distinct from what it represents: the events or, for example, the life of a subject being narrated. The three characteristics of the structure of the narrative thus pertain to the narrative and not to what is narrated.
The first characteristic feature of a narrative is that it has coherence, in the sense that it reveals, through the process of emplotment, connections between the related events, and it does so in a way that a mere list, or annal, or chronicle, does not. [ibid: 14]
In fact, Goldie does not attempt to say very much about the nature of narrative coherence. Surprisingly, given that narrative structure might be thought to be distinct from the nomological or lawlike structure of the physical sciences, he uses a comparison with causal explanation. Such explanations cite factors that are typically neither necessary nor sufficient for the explanans [Mackie 1993]. But they are selected from the total set of causal factors for an event on the basis of the interests of the author and audience of the account. Although he denies that there is a simple relation between causal explanation and narrative understanding, Goldie suggests that this is common with narrative accounts.
A further clue to the nature of narrative coherence comes from a remark on the epistemological of narrative construction. Borrowing and modifying Paul Ricoeur’s notion of ‘emplotment’ itself based on Aristotle’s Poetics, Goldie suggests that it involves shaping, organizing, and colouring events, the raw material of the narrative, itself always already described in significant ways. Arriving at this is a matter of tâtonnement or trial and error, feeling one’s way to the real significance of what is narrated.
The process of emplotment is often a tâtonnement, a tentative, groping procedure: one might begin with an idea of how the narrative should be shaped, and, once one has developed it somewhat, one might be able to see saliences that one could not see before, and then find it appropriate to go back and reshape the narrative in this new light. More than that, the tâtonnement typically involves a groping search for the appropriate evaluative and emotional import of what is narrated. [ibid: 11]
The second general characteristic set out is meaningfulness. Goldie suggests that there are two aspects to the meaning of narratives.
First, a narrative can be meaningful by revealing how the thoughts, feelings, and actions of those people who are internal to the narrative could have made sense of them from their perspective at the time—that is, from their internal perspective. And, secondly, a narrative can be meaningful by revealing the narrator’s external perspective: his or her thoughts and feelings that throw light on why the narrative was related (or just thought through) in that particular way. Bound up with these two kinds of meaningfulness are the two ways in which a narrative can have evaluative and emotional import. [ibid: 17]
This connects to the third key element: the evaluative and emotional import of narratives. In a nutshell.
Things matter to people, and a narrative involving people can capture the way things matter to them. [ibid: 23]
These characteristics are supposed to apply across the board to narratives. Goldie has, however, a particular focus: autobiographical narrative thinking. In particular, he discusses in depth autobiographical thinking about one’s past and one’s future. Both illustrate the claim that an autobiographical narrative sense of self is an essential aspect of human subjectivity.
In the case of narrative thinking about the past, the difference between internal and external perspective on both meaning and evaluative and emotional import plays a role. In thinking, now, about one’s past, an autobiographical narrative presents a view of the meaning and significance of past events and actions through the emotional lens of the present. A mismatch between past and present perspectives can take the form of regret in cases where one realises that had one not acted in such and such a way, such an effect would not have occurred.
In narrative thinking about the future, imagination plays a role analogous to memory in thinking about the past. Goldie suggests that it plays a key role in thinking through the ‘branching possibilities’ of different ways in which events may come to pass. In future directed thinking, there is again a difference between internal and external perspective on both meaning and evaluative and emotional import. One can imagine not only different future actions but also their emotional effects. The emotion imagined for the future can have an emotional effect in the present. Goldie suggests that narrative thinking is also involved in developing virtues. One connection is through fictional narratives. An emotional response to the lives and actions of fictional characters enables an understanding goes had in hand with an imagined response to other possibilities. But the same applies to future planning for one’s own life based on responses of shame and guilt to mistakes made in the past and hence the adoption of counter-factual and causal thinking about how to act in the future.

Narrative, paternalism and Hopper’s ‘sensitive wok’
Kim Hopper’s mention (above) of the ‘sensitive work’ needed to recover a suppressed sense of injustice and reclaim lost possibility reflects the dual dilemma for a clinician of either paternalistically imposing an entirely external view of what someone in recovery from mental illness ought to want or failing to challenge a view which may be impoverished by mental illness, stigma and even, in some cases, experience of psychiatric treatment. If the central aim of the recovery model is to articulate a conception of a life worth living which fits the values of the person concerned, but if mental illness can corrode their sense of possibility and undermine their agency, how can the right endpoint for healthcare for them be selected?
Although it does not offer a way out of the fundamental tension articulated by Nussbaum and Sen, a narrative sense of self offers some practical help. Narrative, understood along the lines that Goldie suggests, has a balance of subjectivity and objectivity. The objectivity lies in the need for narrative coherence and structure and in the implicit contrast between internal and external perspectives in narratives. The subjectivity lies in the essentially perspectival nature of the narratives. Autobiographical narratives are both narrated from a particular perspective but also concern the life of the very same person as the narrator. These come together in the tâtonnement, the tentative, reaching for the right narrative structure of events.
On a broadly procedural view of autonomy, any intervention to impose values on a subject who already enjoys a reflective balance between first and second order values and policies is a form of paternalism. But there may still be a need for what Hopper calls ‘sensitive work’ is a subject’s self narrative is incoherent. For example, is there is a lack of coherence between past regret and suitable future directed policies to avoid similar errors in the future. Clinical narrative-based intervention could take the form of working with a client to enable their understanding of their past and plans for the future to fit their current conception of themselves. Narrative self-understanding introduces a temporal dimension and the explicit possibility of divergence of value between what one valued in the past, values now and may come to value in the future. Narrative coherence provides a standard by which present values and habits can be subject to criticism by the subject her or himself. In the initial apparent dilemma, an extreme of relativism is avoided insofar as a conception of flourishing and hence recovery will have to have a form of narrative coherence for the subject. Whilst the notion of objectivity within narrative understanding is not one of external
On a substantive view of autonomy, answering to external, universal standards for human flourishing need not involve paternalism. Hence a clinician’s ‘sensitive work’ may involve persuasion that some forms of life are more valuable than others and their neglect by a subject is the result of his or her illness. Whilst external standards need not seem to a substantivist to threaten paternalism they could. Given the connection, to which both sides of the debate about capabilities agree, between flourishing and freedom a brute imposition of an external view of flourishing could be paternalistic. But if externally proffered conceptions of the good life are suggested and adopted as part of a narratively structured set of policies and plans for future life reconciled with the subject’s narrative account of their past and present too then that is not a brute imposition. Even if a clinician has to work to introduce neglected values, if they are adopted they will have to made to cohere by the subject him or herself with a narrative account. This avoids the charge of crude paternalism.
Emphasising the normative standards implicit in the idea of narrative coherence is not a quick fix for a balanced conception of recovery. The severely depressed person quoted by Ratcliffe (above) was, at the time of the experiences described, incapable of the kind of narrative understanding just outlined. In such cases, a recovery model can neither be adopted nor can it coherently be imposed. But a narrative sense of self suggests a rationale for a middle way between paternalism and uncritical relativism whichever broad view of recovery and of autonomy is adopted.

Conclusion
In this chapter I have attempted to shed light on three related issues. First, in the light of its recent popularity and promotion as the goal of mental healthcare, what is meant by 'recovery'? Second, how can the harm that mental illness can do to people's autonomy be reconciled with a recovery approach which is based on patient or client choice? Third, does the existing connection between recovery and narrative shed light on the first two issues?
Drawing on typical statements of the aims of the recovery movement in mental healthcare, I have articulated an abstract specification for a recovery model. It is health rather than illness based and it is essentially value laden. Recovery aims towards the goal of a conception of flourishing tailor-made to individual patients and clients. This is consistent with one elaboration of a theory of recovery based on Sen's capabilities approach to welfare economics. On that model, the valued 'functionings' that underpin capability are person-specific. But as two of the key architects of that policy suggest, there is a tension between two rival versions of it. On one (Nussbaum's), there are universal standards for human flourishing. On the other (Sen's), the emphasis on freedom as a key aspect of capability implies diversity. These two views give rise to two opposing perceived dangers: uncritical relativism versus paternalism.
Paternalism is a threat to human autonomy and the two approaches to capabilities correspond to two broad approaches to it. On a proceduralist account, autonomy is a form of internal coherence of beliefs and values. On a substantivist account, the idea of autonomy presupposes successfully tracking some particular conception of the good and the true.
The two view find expression within recovery on a stress on human diversity (Davidson) versus the idea of some universal standards coupled with the idea that mental illness may cloud people's judgements of flourishing so understood or otherwise undermine their agency (Hopper). This raises a threat, however, that in responding to this clinicians will inevitably be paternalist.
On the assumption that mental illness can indeed distort people's views of their own flourishing, the final section has suggested that a narrative sense of self can play a role in undermining the threat of paternalism. On a proceduralist view of autonomy, and Sen's version of capabilities, a clouding of judgement is a lack of coherence in a narrative sense of self and hence the sensitive work to correct this involves helping the patient or client to repair their own narrative. On a substantive view of autonomy, which corresponds to Nussbaum's view of capabilities, a clouding of judgement may also involve failing to observe universal forms of human flourishing. And hence the sensitive work to correct this involves enabling a patient to see the rightness of these universal forms. But the role of narrative ensures that this is not a brute imposition from without. Only if the subject can integrate the universal values into his or her own narrative will the work have been successful.

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