Monday, 20 October 2014

Abstract on transcultural psychiatry

For personal reasons, my mind is fogged at the moment and whole draft papers, approaching completion, seem to be stuttering towards their ends. And hence I think I need to write a series of fresh abstracts to help me tighten and commit to them. So here is the first for a chapter on transcultural psychiatry.

DSM-5 introduces an emphasis on non-Western cultural idioms of mental distress but without making explicit the relation between these and the psychiatric scientific aspirations, such as for their reliability and validity, of the rest of the taxonomy. This paper outlines three possible views of the nature of transcultural psychiatric taxonomic concepts which would render them different from but not incompatible with the rest of the taxonomy. But I argue in the second section that establishing the correctness of any one is none too easy. Two influential approaches to the nature of the concept of disorder – Wakefield’s harmful dysfunction analysis and Fulford’s failure of ordinary doing – can be pressed, with merely minor tweaking, to support any of the a priori models of transcultural concepts. In the final section I examine one such idiom: khyal attacks or khyal cap or wind attacks, a syndrome found among Cambodians. I argue that this does not fit any of the ways of ‘domesticating’ variation from standard DSM-5 categories and that this suggests that the very idea of transcultural psychiatric diagnostic concepts fits uneasily with the rest of DSM-5.

Thursday, 16 October 2014

Causality, Teleology and Explanation in Social Sciences

I came across a seminar given by Prof Ricardo Crespo (IAE Universidad Austral) in the IAS building last night organised by the Centre for Humanities Engaging Science and Society (CHESS) on Causality, Teleology and Explanation in Social Sciences.

The abstract ran:

This paper argues that four analytical levels may be found in social sciences, including economics –namely, a) a statistical descriptive level, b) a causal explanatory level, c) a teleological explicative level and d) a prescriptive teleological level. Typically, social sciences only consider levels a) and b). The exclusion of level c) may lead to viewing behaviors that do not respect theories such as the rational choice theory or the expected utility theory –theories which adopt “instrumental rationality”—as “anomalies”. Including level c) entails considering “practical rationality” and makes those anomalies reasonable. The paper adopts Aristotle’s causality notion and teleology as a theoretical framework. The first section introduces these notions, while the second section explores contemporary conceptions of causality and teleology. The third section applies the former theories to the analysis of social sciences –specifically, economics—and looks at Carl Menger’s classification of economic disciplines.

There is real challenge in giving seminar presentations to interdisciplinary audiences. I think that Ricardo, a charming and amusing Argentinian philosopher of economics, was torn between a more concrete presentation on the philosophy of economics - crucially, how a normative notion of final cause changed the kind of accounts available - and a thorough account of the relation between his Aristotle-influenced account and modern philosophical discussion of normativity, teleology and functions. So, as sometimes happens, the talk fell a little between stools.

But I wondered how such a view might work. For simplicity, one might concentrate not on the four levels of the abstract but the contrast emphasised in discussion between efficient causes and final causes with the latter connected to talk of teleology and functions. Given that passing mention was made to philosophers who were reductionists or eliminativists about functions, reducing them to merely efficient causes, what might be claimed by stressing the importance of teleology and final causes in a discipline such as economics? 

My diagnostic thought ran something like this. Imagine that someone only ever offered accounts of phenomena in efficient causal terms, explanations, we might say. That might capture the full explanatory ambitions possible for worldly happenings. But still, there would be something missing from the account from the perspective of someone who also thought of the world in normative terms, of what the right or correct or ideal thing to happen was. Given that I am an IAS Emergence fellow, I could say that the normative emerged from the efficient causal history of happenings. To someone who also wanted such normative understanding, mere efficient causality is only part of the story. But I am not sure that that is news to anyone, that we need a philosophy presentation to say that. (I could be wrong about economic theory, of course, but I doubt it given the talk I have overheard in pubs of rational choices and rational choice theory.)

But post Darwin, there is a further possible disagreement. If one thinks that reductionists about – apparent, we should now say - teleology aim to show how the pattern of intelligibility of normative notions can be fully captured or explicated in causal efficient terms then the addition of normative notions to an efficient causal story is not an addition of kind after all. The addition is merely a neat shorthand for notions fully capturable in the former account. So in insisting on teleological notions one might be announcing a disagreement with the possibilities of such reductionism. One might be saying that any teleological addition is irreducible. (If so, though, I would expect the argument to focus on just this point. Why, eg., is Milikan wrong to claim that logic will become an empirical science?)

Note two ways of reading the reductionist ambition. It might aim merely to show how efficient causal processes can track normative one, independently understood. Or it might aim to explain the latter concepts. I take Milikan to be aiming at the latter, more ambitious project. She wants to show that the very teleological concepts are really disguised efficient causality concepts. A more modest reading would return us to the position outlined a little earlier: we can render unto Caesar teleological concepts whilst showing how they add nothing to the history of happenings in the efficient causal history-of-happenings' own terms.

But Ricardo's stress not on teleology and normativity in general but on final causes makes me suspect he has another thought in mind. I wrote, above, that accounts of phenomena in efficient causal terms might capture the full explanatory ambitions possible for worldly happenings. Now one might accept that but think that some further insight is offered through normative understanding. Jaspers seems to think this. Davidson too, though he struggles to hold onto the idea given his other commitments. But perhaps the stress on final causes suggests a picture in which the addition is not just another way of seeing patterns, the point, for example, of construing happenings as doings, but a distinct and competing way in which things come about at all. Such causes do not emerge from but perhaps compete with efficient causes. That seems a really interesting and premodern idea.

Tuesday, 14 October 2014

The Shock of the Real: which welfare interventions work for whom?

At the end of last week, I took part in a seminar organized in Durham by Jeremy Clarke and Nancy Cartwright concerning the connection between unemployment and mental illness and the contrast between two governmental approaches. The Department for Work and Pensions sees the cause as a moral problem of worklessness and approaches it punitively. The Department for Health sees the underlying cause as a form of illness and thus approaches it medically. This was set out less crudely in one of the briefing papers thus:

“In recent years the UK has embarked on two policies simultaneously: welfare reform and improving access to talking therapies for depression. It is widely understood that both policy problems are linked – if we are going to reduce welfare dependency we need to support claimants whose primary problem is depression; and – if we are going significantly to increase investment in therapies to treat depression we need to realize cost-savings that will also reduce the burden on welfare spending. What is not known is whether the approach favored by the Department for Work and Pensions – crudely, first get people back to work with benefit sanctions as a stick (Freud, 2007) – or the approach favored by the Department for Health – crudely, first offer them CBT with ‘happiness’ as a carrot (Layard & Clark, 2014) – is the best approach for reversing the trend: rising numbers of people with depression as the single biggest welfare claimant group who become and remain jobless (OECD, 2014).
Both policies are necessary but neither on its own will solve the problem. And if badly combined could exacerbate matters. The Treasury in any case may trump them in its determination to cut welfare spending by £30bn. Thus, the challenge for evidence-based policy making is urgent.”

A background assumption of the seminar was that it was highly likely that there were a number of causal factors interacting. The assumption – ascribed to Richard Layard – that there is a single main factor was unwarranted. Thus practical intervention would have to find some way to deal with this complexity. (Nancy Cartwright outlined some of the difficulties of justifying the application of even good RCT based evidence to particular populations in particular cases and the various ways in which complex causes interact negatively and positively.) An illustration of problems for a single, simple, medical-only approach was that typically there is a 50% fall off of those referred for IAPT services actually reaching them. Typically only 50% who went to the first session went further. And only 50% of people who complete a course of CBT are helped by it. Thus an IAPT / CBT only approach looks likely only to help 12.5%. Surely, therefore, some sort of multi-factorial approach is necessary.

Seminar participants were charged with thinking about an alternative approach which would deploy a range of ‘interventions’, starting with referral routes, the initial judgements or ‘diagnosis’ of key workers, choices for interventions and so on. Jeremy Clarke hoped it would be possible to articulate a kind of decision making model to deal with the causal complexity and thus underpin a rational process without over simplifying it. He gave an example of a model for decision making widely used by the police.

I was completely convinced by the background rationale for the seminar and of the likely complexity of the practical problem but rather less sure of the right response to it. First, as a fan of the situation specific, tacit dimension to good (clinical) judgement, I am not at all sure of the point of a decision making model. As Matthew Ratcliffe pointed out, there is a strong tradition in psychiatric diagnosis of thinking that the modern criteriological approach is only part of the story. I’m reminded of some of the things Mario Maj says about the DSM and schizophrenia (I think it carries over to depression and unemployment related misery).

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 favours the former hypothesis. 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 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.

So I worry about the development of a model of decision making in this case, too. The police model may work because it lacks substantive codification. ‘Measure three times and cut once’ is good advice - a good warning to be careful - but not a piece of wood/shelf specific substantial guidance of what measuring its length correctly involves.

My sub-group was charged with thinking about a way of dealing with a multi-factorial causes in a diagnosis of the problem for particular clients. But guided by the practical experience of service provision by one of us, it seemed to me that there was a principled way of avoiding the tricky problem of trying to codify a response to complex causes. Why not, instead, take a leaf from the recovery model and ask what would need to be done – what causal intervention - to promote the conception of flourishing of each client. That could start with something like Nussbaum’s Aristotle inspired list of the universal aspects of human flourishing even if each had to be realized in specific ways. The complexity of retrospective causal reasoning could be replaced by still complex but surely clearer prospective causal reasoning. 

JC asked whether we thought one could then go back to look for the historic causes of a client’s state. But although one might be able to, one virtue of a recovery orientated approach is that seems merely of academic interest.

Freud, D. (2007). Reducing dependency, increasing opportunity: options for the future of welfare to work: An independent report to the Department for Work and Pensions.
Layard, R. & Clark, D.M. (2014). Thrive: The Power of Evidence-Based Psychological Therapies London: Allen Lane.
Maj, M. (1998) ‘Critique of the DSM-IV operational diagnostic criteria for schizophrenia’ The British Journal of Psychiatry 172: 458-460
OECD: Singh, S. & Prinz, C. (2014). Mental Health and Work: United Kingdom. OECD Publishing.

Sunday, 5 October 2014

Two short thoughts after the death of my father

My brother called me an hour ago to tell me that my father, Grahame, had died quite suddenly, albeit in hospital, in front of him. He had complained of feeling ill and then suddenly stopped being alive. (I want to pause in this parenthesis to stress, and to wonder at, the inadequacy of saying, as we tend to, that he has shuffled off this mortal coil, that he is an angler on the lake of darkness. No, the not being rules out all this nonsense. And I recoil from the very thought so just expressed. I write it but cannot - dare to - think it.) Despite worrying fairly constantly about, and thus almost anticipating, his death for the last few months, especially since my mother died, the news came as a shock. Sitting here now I feel terribly... (everyone can fill in the obvious gaps which start ‘alone’ and move more self-pitying).

Having lost one parent recently (and to lose two really does seem a kind of carelessness as though it must have been something we did) I know a little of what is to come. First an interchange of numbness and pain (much unpredictable keening I'm afraid) then later an acceptance of the fact but a kind of illness or sickness and lack of vim and later still, surely, some sort of normality (I had not reached that stage yet after Mij). But the reason for writing two short thoughts down right now on something as public as a blog is the desire to throw a bottled message into the sea to say that knowing this is no help at all in the moment. Later, through a pattern of thought and slowly changing feeling, in which reasons (not, unnaturally, shorn of affect (both of those commas are necessary)) play a role, it will/must be possible to get better. But there seems to be no shortcut to that right now. There's nothing now to think (ie that it would be right or good to think). Reason seems to let me down. (And this is a pity since I need to decide, for example, how to pass this evening, what to do best to cope and then the next day.)

Second, I am appalled to find that my thoughts turn instinctively away from my father and back to me. I think about thinking about him. Talking to a colleague recently about how the death of my mother had caused me (as an unexpected brute symptom) to like myself rather less, he gently asked me whether it was right ever to aim at such self-liking. Surely better, he argued, for the self to be a transparent medium through which to engage with the world directly. That seems right but the fact that, in the immediate experience of grief and loss, I wonder about how I will feel is a poor indicator of my real grasp of that thought.

Thursday, 18 September 2014

Two draft abstracts for presentations in Durham

6th October:
On the role of the Constitutive Ideal of Rationality. Does inter-personal understanding emerge from shared rationality?

According to an influential, although contested, thought experiment in the philosophy of language, facts about linguistic meaning and belief contents derive from facts about interpersonal understanding which, in turn, presupposes comparison to an ideal of rationality. Thus, belief and meaning must be essentially rationally structured. This provides a rationale for holding that such understanding emerges from shared rationality. There are, however, two distinct ways of interpreting such a claim depending on whether or not it is possible to gain independent purchase on the notion of rationality in play. This seminar will explore both options and their consequences for thinking of the emergence involved as related to reduction or abstraction.

13th November:
On the therapeutic status of McDowell’s representationalism.

In Mind and World and other papers written around the same time, McDowell presents his representational account of experience as contributing to the dissolution of felt problems attaching to transcendental empiricism which he describes as, itself, innocent. With echoes of Sellars’ Myth of Jones, the content of experience is modelled on that of judgements and provides a philosophically minimal account of the rational friction of world on thought. But since ‘Avoiding the Myth of the Given’, the account has become a more complex theory of perceptual experience. Given McDowell’s meta-philosophical aims, the very substance of the recent stages of the evolution of the account suggests the need for a re-examination of the argument for representationalism in the first place.

One in Four Film Festival, Mental Health: It's everybody''s business

6TH -10TH OCTOBER 2014
The One in Four Film Festival 2014 is a week-long free event featuring films which explore the effects of mental ill health upon individuals, communities and families. The aim of the Festival is to raise awareness of and stamp out the stigma associated with mental ill health. The Festival is sponsored by the School of Health.
Every evening a film that explores mental health is shown at 7pm, the film is introduced by the person who has nominated the film for the festival and then a service user speaks about their own personal experience of living with a mental health diagnosis. By the use of film and the following debate we can explore and dispel some of the myths associated with mental ill health.
The One in Four Film Festival will be officially opened at 7pm by the Mayor of Preston and the Film Festival Committee 2014. Music will be provided by Mathew Clare from 6.15pm.
Mitchell & Kenyon Cinema, Foster Building, University of Central Lancashire, PR1 2HE
The One in Four Film Festival has as its highlight a day focused on entertainment and information. The event will be held on the 8th October 2014 from 10.30am to 3.00pm at 53 Degrees.
The day comprises of a number of artists playing music, performing poetry and dance. We also have a market stall space available for students to meet and find out more about local mental health statutory and voluntary services.

This year we will also have a number of UCLan academics hosting seminars focusing on the mental health research they have carried out. The research will provide valuable insight into mental health and will foster debate across a wide audience.

Friday, 5 September 2014

UCLan Philosophy HeRMI

What’s a HeRMI? 
The School of Health is setting up a number of ‘Health Research Methodology and Implementation Hubs’ in areas such as Qualitative Research, Health Informatics, Systematic Review, User Engagement. Their focus is thus on particular methods or approaches to research rather than on particular subject areas. Although the nature of the activity undertaken will vary as appropriate between the different hubs, their initial aims are:
• To build methodological capability
• To act as a link to external methodological resources and networks
• To support high quality bids and research activity by providing specialist methodological input
• To work towards a profile in methodological innovation for REF2020

HeRMI Philosophy Group 
Healthcare raises as many conceptual as empirical questions concerning the nature of health, illness and recovery, capacity and autonomy and normative questions concerning justice and fairness in research and treatment. Philosophical research aims to answer such questions through a priori argument and reasoning rather than by empirical methods although drawing on empirical results. The justification for different empirical approaches is also a matter for philosophy.
The purpose of this group is to highlight and develop innovative philosophical work on healthcare and to foster a greater critical and reflective understanding of key concepts and research methods in healthcare.