RCPsych Philosophy SIG newsletter

I've just been sent the Royal College of Psychiatrists Philosophy Special Interest Group newsletter. It seems that beer is being offered for a review of my shilling shocker. I would have specified it was beer only for a favourable review!

Conference ennui

Although going to conferences in one’s own subject should be good for one’s morale, I seem too often to slip into a kind of ennui.

It is not as bad as experience of conferences in other areas although I suspect the worst case is an area only marginally distinct. I get bored in large straight psychiatry conferences which are mainly opportunities for quick overviews of the latest drug research and there’s no culture of questioning the speaker. But I was positively disturbed by a conference on reasons at St Andrews a few years ago.

Thinking that ‘reasons’ cropped up in familiar phrases such as ‘space of reasons’ and that I at least understood the outlines of debates about particularism concerning moral reasons, I assumed I’d understand the conference. Not at all. It turned out that there was a debate just to one side of the philosophy I know about which seemed to concern the correct representation of reasons, or the holding of reasons by an agent, and clearly involved some fine technical work and innovation. But I could not work out what problem such representations were supposed to ease. Even surrounding myself with PhD students working in the area and paying in beer for their post-session explanations I remained queasily at sea through out.

But even in areas where I do feel at least a little at home, initial enthusiasm tends to dissipate. I think the reason is predictable. There are always people who have read more, are more gifted, have thought longer about the issues, and some who are sufficiently motivated that they will talk of nothing else at all for the three or four days of the conference without let up. In the face of that, my own enthusiasms rarely seems enough.

But I think I’ve discovered the solution at the INPP conference. By equipping myself with a companion who was, by background discipline, a genuine outsider at the conference (although clearly interested in, and on top of, the issues discussed) the contrast helped slow down my own gradually growing sense of alienation. I must organise a more regular arrangement with academics in quite different areas, to attend respective conferences, akin to the pairings between politicians of opposing parties in the British parliament.

Anish Kapoor at the Royal Academy

I went to the Anish Kapoor exhibition at the Royal Academy in London on Saturday. At Tate Britain (for what turned out to be a disappointing Turner Prize exhibition), Halloween activities had been organised for children who were constructing bats (the flappy sort), masks, hats etc but there was no such obvious reason why the Royal Academy was so busy except for the fact Kapoor has become something of a pop star. Having bought tickets in advance I was spared the queue which was about 50 yards long.

Inside there was no escaping the masses. Oddly, for a couple of pieces, this seemed somehow right. Whilst photographs of Svayambh (“auto-generated”) installed in other, empty, exhibition halls suggest it might be a process calling for quiet contemplation, on a busy London Saturday, it became a piece of, albeit dramatically slow, theatre. One elderly gent, chivvying his companion to hurry (quite unnecessarily given that it must move only an inch a minute) to the next room, turned to me almost apologetically to explain that it was unexpectedly exciting.

In another room, a cannon fires a slug of paint through a doorway onto a (fake Royal Academy) wall every 20 minutes. For the whole of the waiting time, the room was packed, spilling out into the next gallery with the quiet middle class expectation of a Glastonbury crowd. I cannot really see the point of this piece without such a crowd. The pleasure is in that shared expectation.

But other exhibits could not cope with this sort of background. An enormous yellow indentation in a wall really needed solitary space, with other viewers merely a distraction.

On such occasions I see the attraction of our own tiny gallery in this northern fastness, far from the Big Smoke: the Abbot Hall. Last month I went from an almost empty gallery looking at the small but beautifully formed David Nash exhibition. The opposite of theatre.

Recovery, values and subjectivity

I’ve been invited by Joana Ferreira, a psychiatry resident in Coimbra, Portugal and lecturer in psychopathology to psychology students at at the Catholic University of Braga and who attended the INPP conference in Lisbon, to submit a paper based on my grouchy presentation on recovery to their college magazine on psychiatry, psychology, philosophy and religious themes.

So here is a very rough first rough stab (coming in at 3,500 words).

Recovery, values and subjectivity

Introduction
In the UK, the recovery model has been promoted to guide mental healthcare in reaction against what is perceived to be an overly narrow traditional bio-medical model. It has also begun to have an influence in thinking more broadly about mental health both for individuals and for communities and in the latter case has been linked to policies to promote social inclusion. In this widening application, however, there is a risk that the model (assuming that it is a model) becomes too broad and includes too many factors, severing its connection to health.

In this short paper, I attempt to sketch (although not rigorously defend) an argument for a recovery model that distinguishes it from a bio-medical model through the essential presence of a normative dimension in the values that characterise its goal. Nevertheless, I argue that, by distinguishing hedonic from eudaemonic values, it is still possible to maintain a degree of normative assessment in what should properly be called a matter for recovery.

Background
A recent policy paper published by the Sainsbury Centre for Mental Health called ‘Making recovery a reality’ begins by summarising some key points of emphasis which characterise the 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 & Slade 2008: 0]

As this list suggests, recovery is not so much an explicit theoretical model of the nature of health and illness as a practical orientation to the kind of care that should be involved and the roles of patients or service users and clinicians or carers. Nevertheless, the points listed do suggest an implicit theoretical model which I will attempt to draw out. A key clue to that is the idea that recovery is to be characterised through a positive goal of health and wellness rather than the avoidance of the negative aspects of pathology and illness. That positive goal is connected to the agency of the individual, to their own situation-specific self management of the process, and to their identity.

The list also connects recovery to social inclusion through the empirical claim that social inclusion promotes recovery. But given the links between policies promoting recovery at the individual level and policies promoting social inclusion at the level of communities this raises a further question that helps shed light on the connections between recovery and values: need recovery promote social inclusion? By stressing individual autonomy as the final arbiter of the values that form the goal of recovery, the model suggests a view of society as a group of individuals satisfying their private preferences. That seems to threaten, rather than support, the notion of social inclusion and the idea of collective values or goods.

But further, if the satisfaction of just any preference can be part of the conception of recovery then the model degenerates into subjective whimsy, unconnected to the notion of health, and the use of the label ‘recovery’ is misleading. It is not so much a corrective of the bio-medical model as a totally different venture.

I will attempt to sketch a justification for a conception of recovery which is distinct from a bio-medical approach but which is still sufficiently normatively charged that it can avoid both of these risks. I will not, however, attempt to defend it against rival approaches to recovery. My aim is to rationalise rather than justify a model of recovery.

The normativity of illness / disease / disorder
To begin, it will be helpful to look back to the recent history of discussion of mental health and illness. In his attack on the very idea of mental illness, Thomas Szasz stressed that the concept of illness, whether physical or mental, carries with it the connotation of deviation from a normative standard, a standard that carries a distinction between correctness and incorrectness. (In what follows ‘normative’ will be used to refer to any such standard; the key contrast is with the merely statistically normal.)

The concept of illness, whether bodily or mental, implies deviation from some clearly defined norm. In the case of physical illness, the norm is the structural and functional integrity of the human body. Thus, although the desirability of physical health, as such, is an ethical value, what health is can be stated in anatomical and physiological terms. What is the norm, deviation from which is regarded as mental illness? This question cannot be easily answered. But whatever this norm may be, we can be certain of only one thing: namely, that it must be stated in terms of psychological, ethical, and legal concepts… [Szasz 1971: 15]

Szasz used this point as the basis for an argument against mental illness. Nothing can both satisfy this condition and the condition of being medically treatable. Thus one possible route to defend that concept would be to disagree that illness need carry a normative connotation. (A distinct defence is to accept the condition but argue that it does not support the conclusions Szasz draws [Thornton 2007: 11-19].) Perhaps illness could be defined in merely statistical terms. But as even as biologically minded a psychiatrist as Robert Kendell realised, such an approach cannot work. Reviewing the history of the debate he commented:

By 1960 the ‘lesion’ concept of disease, and its associated assumptions of a single cause and a qualitative difference between sickness and health had been discredited beyond redemption, but nothing had yet been put in its place. It was clear, though, that its successor would have to be based on a statistical model. [Kendell 1975: 309]

But, as Kendell went on to say, whilst a statistical model may address some of the weaknesses of a single lesion model, statistical abnormality by itself cannot distinguish between ‘deviations from the norm which are harmful, like hypertension, those which are neutral, like great height, and those which are positively beneficial, like superior intelligence’ [ibid: 309]. Some further criterion is needed to address the fact that illness is a specific kind of deviation from the norm and Kendell followed the work of the British chest physician, JG Scadding in suggesting that biological advantage is the key idea.

More recently there has been an attempt to explain this normative dimension using the idea of biological or proper function of sub-personal traits (not just advantage or disadvantage to whole individuals). The hope is that whilst illness or disease may carry the irreducible notion of harm, a core notion of disorder can be fitted within a purely descriptive scientific account, drawing on evolutionary theory. The prima facie normative dimension of disorder can be explained through the apparently normative notion of biological function. But functions can be analysed through the plainly descriptive or factual notion of what best explains their continued presence within evolved organisms.

A natural function of a biological mechanism is an effect of the mechanism that explains the existence, maintenance or nature of the mechanism via the same essential process (whatever it is) by which prototypical nonaccidental beneficial effects... explain the mechanism which cause them... It turns out that the process that explains the prototypical non-accidental benefits is natural selection acting to increase inclusive fitness of the organism. [Wakefield 1999: 471-2]

The aim is thus to milk a normative function from a plain description of evolutionary history. There are, however, two challenges to this approach. First there is the longstanding objection raised elsewhere in philosophy that norms are smuggled back into the particular choice of evolutionary explanation [Godfrey-Smith 1989, Thornton 1998: chapter 2, Thornton 2000]. In other words, functional explanation is not plainly descriptive. More specifically for psychiatric disorder, it is unclear that the necessary distinction between natural and merely social functions can be maintained [Bolton 2008: 124-5].

In what follows, I will assume that there is no prospect of a plainly descriptive account of disorder and hence of illness or disease. If so then to identify some of the behaviour of either a whole person or a sub-personal biological system as expressive of illness is to conceptualise it in normative terms. To put this another way, different behavioural dispositions have to be filtered through some sort of normative sieve to yield a conception of illness or disease.

There have been attempts to analyse the nature of the normativity of illness or disease. KWM (Bill) Fulford, for example, has proposed and defended a model of illness as a ‘failure of ordinary doing’ [Fulford 1989]. Drawing on Austin’s characterisation of ordinary doing as the kind of action that one ‘gets on and does’ without explicit intentions or trying, Fulford argues that a failure to be able to do this kind of thing, in the absence of external constraint, captures the paradoxical character of experiences of illness [Austin 1957]. He suggests that it helps to explain its normativity or, more specifically, values-ladenness because the ineliminable concept of failure (of ordinary doing) itself suggests an ineliminable (negative) value judgement.

It is still a matter of debate whether Fulford’s account successfully accounts for illness. However, even if the norms that characterise illness cannot be reduced to some other normative notions in the way that Fulford, for one, proposes, the failure of a reduction to the plainly descriptive leaves the concept of illness as an essentially normative notion. That, however, may not imply that recovery is, as I will now discuss.

The normativity, or not, of recovery
Even if one assumes that the concept of illness is essentially normative (statistically unusual behaviour is not sufficient for illness, for example), recovery may not be so. On the picture sketched above, one identifies tracts of behaviour (of people, or of their biological systems) as expressive of illness by filtering all forms of behaviour through an appropriate normative sieve. The filter may use other normative terms such as Fulford’s failure of ordinary doing or be a primitive amd irreducible notion such as sufficiently resembling paradigmatic illnesses. Once it has been applied, what remain are normatively selected states or behaviours.

Recovery itself might plausibly be thought of as the return from such states to a state of health. Health itself, however, might be conceptualised in merely statistically normal (rather than normative) terms. If so, whilst the states that individuals have an interest in recovering from are those with particular normative properties (whatever precisely those are), recovery itself might be characterised in non-normative terms.

For physical health, this is at least a reasonable picture although some initial qualifications are necessary. Age, for example, makes a difference. What is a healthy physical state for an 80 year old will not be for an 18 year old. Further, it may even be statistically normal for most members of particular groups of people (small children, the elderly) to have some illness or other in some or other biological system. If so and if health were defined in normal terms, normality would have to be defined for each such sub-system rather than for the wholse person. But given suitable qualification, there is something plausible about such an approach. It avoids any idealisation of health. One can be healthy – that is: not ill – without being at the peak of physical condition. The fact that one would prefer to be fitter, stronger or more muscled does not imply that one is not healthy as one is.

An analysis of physical health in statistically normal (rather than normative) terms helps rationalise a bio-medical approach to recovery. Once the starting point has been identified, a state picked out as an illness, no further mention need be made of normative notions, for example values. Recovery, so construed, would be merely an engineering problem for the human body.

If a non-normative model of physical health helps to justify a bio-medical approach, can a contrasting recovery model be articulated? I suggest one can based on the following line of thought. Although it is plausible to define physical health in statistical terms, in the case of mental health, however, the end point might have to be essentially normatively, or more precisely, evaluatively characterised. According to this line of thought, mental health cannot be construed as a statistically average kind of life but rather, in line with the opening quotation, a particular kind of life autonomously chosen, valued and hoped for by the individual concerned, the kind of life connected to their identity.

If this were the case, there would be no hope of defining the endpoint of recovery for mental health in non-normative or non-evaluative terms. A specific endpoint would be correct for, or suited to, each individual. And thus recovery should be aimed at a specific and normatively characterised or valued endpoint.

Is this the only way of approaching matters? I do not think so. To defend, rather than merely rationalise, a recovery model for mental health so construed would require dismissing a variant of the statistically normal approach. Whilst characterising a statistically normal kind of life seems misguided, the capacities that enable one to live a life so chosen may be more appropriate for that treatment. So, in the service of an autonomously chosen and hoped for life, mental health might be defined in terms of statistically normal mental abilities. I will, however, ignore this possibility in what follows.

To summarise this section, contrasting approaches to physical and mental health help to justify two contrasting approaches to recovery:
Recovery1: a return to normality (albeit from a position picked out by a normative sieve).
Recovery2: a move (from a position picked out by a normative sieve) to a normatively characterised endpoint, for example, a conception of a valued form of life.

Recovery2 suggests that whether someone has recovered or not depends not on the plainly descriptive matter of whether they have returned to a statistically normal state but rather on reaching a normatively or evaluatively characterised state that constitutes wellbeing.

But if there are no constraints on how that endpoint is selected, if it is simply a matter of personal preference, of the expression of individual autonomy, then that suggests that recovery is a matter of subjective whimsy. The idea of recovery is severed from any notion of health. Further, it threatens the aim of social inclusion with which recovery has historically been associated.

The right values for recovery?
The key assumption in my rationalisation of a recovery model for mental health is that the endpoint of recovery has to be characterised in normative terms. There is something appropriate or correct rather than merely usual about the endpoint. But, perhaps because of the rise of autonomy as the key medical ethical value, there is a standing temptation to construe this normative dimension in a particular way. That is, in accord with the preferences of the individual concerned. And put like that, it is tempting to wonder whose preferences should be preferred. Nevertheless, if the norms are subjective preferences then the idea of recovery collapses into the idea of individual preference satisfaction and that also puts the idea of social inclusion at the level of communities under pressure.

But that is not the only way to think about the normativity implicit in the recovery model. Consider two contrasting views of wellbeing: hedonic and eudaemonic. On the hedonic view: wellbeing is a matter of satisfying one’s preferences. The normativity of recovery based on this approach is exhausted by the combination of the satisfaction of the preferences (only some ways the world comes to be satisfy an antecedent wish; the wish imposes a normative constraint on ways for the world to be) and by issues of rationing of scarce resources or balancing conflicting wishes.

On a eudaemonic view, wellbeing is ‘activity in accordance with virtue’. It thus builds in the idea that some values are more valuable than others and not merely more (that is, statistically) preferred. By keeping the key connection between eudaemonia and flourishing or wellbeing in focus, an approach to recovery based on it can restrict the kind of values that characterise its aim: values relevant to flourishing and not just subjective preferences.

Thus, in addition to the normative standards implicit in the hedonic view, a eudaemonic view introduces two further degrees for normative assessment. First, the values that characterise the endpoint of recovery are not just any preferences but values connected to human wellbeing. This helps maintain the pre-theoretic notion that recovery is connected to health and wellbeing. Second, values can be better or worse and can be subject to rational criticism and scrutiny. Thus, for example, if human flourishing really does depend on social inclusion then that fact places principled limits on the value of individual autonomy and thus principled limits on the nature of recovery. Not just any preferred endpoint constitutes the proper aim of recovery, so construed.

Having sketched the conceptual space for a normatively charged conception of recovery based on a eudaemonic view I will finish with three clarificatory comments.

First, Aristotle himself held substantial views about the nature of human flourishing. According to his doctrine of the mean, for example, flourishing requires achieving a middle ground across character traits where both deficiency and excess amount to vices. But a broadly eudaemonic view of recovery need not be tied to any particular view of flourishing, such as Aristotle’s. What flourishing is needs to be investigated and subject to ongoing critical scrutiny.

Second, especially in the light of the flight from medical paternalism to patient or service user autonomy, the idea that some values are more valuable than others may smack of authoritarianism. But it need not. Just as the empirical world serves a normative standard for what empirical beliefs we should hold without that implying that science has to be authoritarian, so a conception of real and objective values need not lead to authoritarianism either. Rather, it imposes a standing obligation for critical reflection on the values we hold.

Third, the eudaemonic view of recovery does not preclude a role for hedonic values in mental health care. Sincerely held, harmless hedonic values may indeed play a role in a broader values based practice. The subjective preferences of service users, who indirectly pay for the services, should indeed be taken into account. And thus models for managing competition for limited resources and other values-based conflicts will be needed. But it is surely a point in the favour of the a eudaemonic view that such values need have nothing to do with what we ordinarily understand by ‘recovery’ and its direct connection to health.

Conclusions
I have sketched an argument for (although not fully defended) a model for the goal of mental healthcare distinct from a bio-medical model in which recovery1 is a characterised in non-normative and value-free terms. On the alternative view sketched above, the goal of recovery2 has to be determined through the conception of a life autonomously chosen and valued by the subject concerned. Such a conception is normative or value-laden in so far as it fits, or is appropriate to or correct for, the individual’s self-identity. There is a danger, however, that such a view collapses into a subjective whimsy which severs the connection between recovery and health or wellbeing and may undermine the related goal of social inclusion. For those reasons I have argued for a eudaemonic rather than hedonic view of the values in play. On the eudaemonic view ‘recovery’ can retain a firm connection to health and healthcare, without collapsing back into a narrow bio-medical model.

Bibliography
Austin, J.L. (1957) ‘A plea for excuses’ Proceedings of the Aristotelian Society 57: 1-30
Bolton, D. (2008) What is mental disorder, Oxford: Oxford University Press
Fulford, K.W.M. (1989) Moral Theory and Medical Practice, Cambridge: Cambridge University Press
Godfrey-Smith, P. (1989) ‘Misinformation’ Canadian Journal of Philosophy 19.
Kendell, R.E. (1975) ‘The concept of disease and its implications for psychiatry’ British Journal of Psychiatry 127: 305-315
Shepherd, G., Boardman, J. & Slade, M. (2008) Making Recovery a Reality London: Sainsbury Centre for Mental Health
Thornton, T. (1998) Wittgenstein on Language and Thought, Edinburgh: Edinburgh University Press (translated into Portuguese as Wittgenstein - Sobre linguagem e pensamento, Brazil: Edições Loyola)
Thornton, T. (2000) ‘Mental Illness and Reductionism: Can Functions be Naturalized?’ Philosophy, Psychiatry and Psychology 7: 67-76
Thornton, T. (2007) Essential Philosophy of Psychiatry Oxford: Oxford University Press
Wakefield, J.C. (1999) Mental disorder as a black box essentialist concept. Journal of Abnormal Psychology 108: 465-472

The philosophy of the social aetiology of mental illness

I've been asked to contribute to an initiative to develop training in the area of the social aetiology of mental illness for a Canadian initiative called SAMI. I’ve knocked up an outline which I would develop if I ever get the time (although it wouldn’t be funded work so I am a bit unsure when I could, in good conscience).

The philosophy of the social aetiology of mental illness

A proper understanding of the social aetiology of mental illness requires an understanding of causation; its connection to laws of nature; the contrast between a causal explanation and an understanding based on reasons; and the issues raised by attempting to reconcile meaningful factors within causal models. Additionally, it prompts an assessment of the role of understanding individuals and how this relates to general law-like understanding.

1: Aetiology and problem of understanding individual causes

The practical problems of establishing the aetiology of illness and disease are compared to the principled problem identified by Hume of seeing causal connections in even the best possible circumstances. Hume’s general response is sketched. An initial link is forged to issues of validity in psychiatric taxonomy and the rise of EBM.

Main readings:
Rizzi, D.A. (1994) ‘Causal reasoning and the diagnostic process’ in Theoretical Medicine 15: 315-333
Hume, D. (1975) Enquiries Concerning Human Understanding, (Oxford: Oxford University Press sections II and III pp17-24.

2: The link between causation and laws of nature

Building on the first topic, the relation of causes and laws of nature is set out. This raises the question of distinguishing lawlike generalities from merely accidentally true generalisations. The role of laws in underpinning scientific explanations is also set out.

Main readings:
Mackie, J.L. (1993) ‘Causes and conditions’ in Sosa, E. and Tooley, M. (eds.) Causation, Oxford: Oxford University Press: 33-50
Papineau, D. (1987) ‘Laws and accidents’ in MacDonald, G. and Wright, C. (eds.) Fact Science and Morality, Oxford: Oxford University Press:189-218

Davidson, D. (1995) ‘Laws and cause’ in Dialectica 49: 263-279

3: Reasons vs causes

Whilst within natural science causes are best understood in the context of a system of natural laws which also connect to causal explanation, understanding using reasons fits into a different kind of conceptual structure. The distinction between the ‘space of reasons’ and ‘realm of law’ is explored via the notion of rule governed activity. This suggests that understanding is fundamentally distinct from causal explanation.

Main readings:
Winch, P. (1988) The Idea of a Social Science and its Relation to Philosophy, London: Routledge chapter 3 pp66-94
Bolton, D. and Hill, J. (1996; second edition 2003) Mind Meaning and Mental Disorder, Oxford: Oxford University Press

4: Meaning and social constructionism

The claim that mental illness has a social aetiology has both more and less radical forms. One route to a more radical account is via the claim that mental states and thus mental illnesses are socially constructed. Arguments for and against this claim are discussed. The less radical claim that mental illnesses are socially caused but not socially constituted is examined.

Main readings:
Sabat, S.R. and Harre, R. (1994) ‘The Alzheimer’s disease sufferer as a semiotic subject’ Philosophy Psychiatry and Psychology 1: 145-160
Thornton, T. (2005) ‘Discursive psychology, social constructionism and dementia’ in J. Hughes, S. Louw and S. Sabat (eds) Dementia: Mind, Meaning and the Person Oxford: Oxford University Press: 123-141

5: Fitting meanings into aetiological structures

The distinction between reasons and causes suggests that one can seek either to understand mental illness or to explain it causally via aetiology. But it is plausible to think that psychiatry can and should aim to do both: to fit meaningful factors into aetiological models. This session explores three general approaches to this: via the reduction of meanings to causes, via the idea of intentional causation and via a more subtle local accommodation as exemplified in Brown and Harris’ Camberwell study of the aetiology of depression.

Main readings:
Bolton, D. and Hill, J. (1996; second edition 2003) Mind Meaning and Mental Disorder, Oxford: Oxford University Press
Brown, G. W. and Harris, T. (1978) Social Origins of Depression, London: Tavistock
Thornton, T. (2009) ‘On the interface problem in philosophy and psychiatry’ in Bortolotti, L. and Broome, M. Psychiatry as Cognitive Neuroscience, Oxford: Oxford University Press: 121-136

6: Idiographic versus nomothetic understanding

In addition to the idea that mental illnesses can have social aetiology there is a further idea that person centred care requires a particular kind of understanding of the experiences and particular social context of individuals. The WPA, eg., calls for a psychiatry for the person to include idiographic understanding. But if so, what is idiographic understanding, does it threaten diagnostic validity and how does it relate to narrative understanding?

Main readings:
Windelband, W. (1980) ‘History and natural science’ History and Theory & Psychology 19: 169-85.
Phillips, J. (2005) ‘Idiographic Formulations, Symbols, Narratives, Context and Meaning’ Psychopathology 38: 180-184
Thornton, T. (2008) ‘Should comprehensive diagnosis include idiographic understanding?’ Medicine, Healthcare and Philosophy 11: 293-302

Key written resources

Fulford, K.W.M, Thornton, T. and Graham, G. (2006) The Oxford Textbook of Philosophy and Psychiatry Oxford: Oxford University Press chapters especially Part III
Fulford, K.W.M. (Bill) and Thornton, T. (forthcoming) ‘The role of meanings and values in the history and philosophy of the science of psychiatry’ in Basant Puri, B. and Treasaden, I. 9eds) Psychiatry: an evidence-based text for the MRCPsych, London: Hodder Arnold, Health Sciences
Thornton, T. (2005) ‘Discursive psychology, social constructionism and dementia’ in J. Hughes, S. Louw and S. Sabat (eds) Dementia: Mind, Meaning and the Person Oxford: Oxford University Press: 123-141
Thornton, T. (2007) Essential Philosophy of Psychiatry Oxford: Oxford University Press
Thornton, T. (2008) ‘Should comprehensive diagnosis include idiographic understanding?’ Medicine, Healthcare and Philosophy 11: 293-302
Thornton, T. (2009) ‘On the interface problem in philosophy and psychiatry’ in Bortolotti, L. and Broome, M. Psychiatry as Cognitive Neuroscience, Oxford: Oxford University Press: 121-136

From the 2009 INPP conference in Lisbon

I am at the INPP conference in Lisbon enjoying, if not the sun I had expected, at least a packed schedule of plenary and parallel sessions from 9am until 8pm each day. The conference is well attended. Martin Baum is selling books from the OUP IPPP book series as though they were hot cakes. This is, I guess, the conference of the book series and a number of OUP authors are speaking.

As sometimes happens, I’ve enjoyed the short (perhaps too short in some cases) presentations rather more than the formal plenaries. (They happen in a huge formal hall which doesn’t make for interaction.)

Three, randomly picked such sessions, have been:

Jeffrey Bedrick argued that it was a mistake to worry about the nature of the concept of disorder in mental disorder. Instead one such concentrate on the mental and let that take care of disorder. In a Kantian tradition he argued that the mental is the realm of freedom. He then suggested that mental disorders are thus disorders of freedom.

Now if the premises were true, this last step would be analytic. But he wanted a little more. The scale of full freedom to its lack not only maps the mental to its opposite but also health to its opposite. Now that seems an interesting idea but I wondered why he assumed that freedom would deal with both issues. On the face of it, only particular kinds of failure of freedom would correspond to illness.

Dominic Murphy argued against something Rachel Cooper says in her most recent book. She says, I understood, that, in psychiatry, causal explanation is complemented by two distinct other forms: natural history explanations (Miffy is afraid of dogs because she is a rabbit) and case histories. But in a brisk presentation, Dom suggested that both additional forms are, however, not really distinct from causal explanation. Natural historical explanation works because it gestures at where one should look for causal explanation (and serves as a standard for purported natural kinds).

But I couldn’t help noticing that his argument presupposed the virtues of causal explanation and then used it causally to underpin natural historical explanation. It didn’t, in other words, address an opposition to such an underlying assumption about the importance of causal explanation such as a teleological view of natural historical explanation. But the real question I went away with was whether he aimed to undermine the idea of a distinct logic of explanation or whether it was more modestly that a different logic was, as a matter of fact, underpinned by causal connections.

Neil Pickering (pictured) used his 15 minutes to criticise a view he ascribed to Richard Gipps that mental illnesses are illnesses merely in secondary sense. His argument certainly helped to make that idea seem a desperate move. I’ll have to remind myself of what the argument for it might be. But one comment he made seems interesting. With the background thought that secondary sense is distinct from metaphor or simile because there are no shared features that justify it, he commented that a secondary extension of the use of a word is under no rational obligation.

That seems right, in the context of the contrast with simile, but less so without a codification of rationality. Isn’t it rational for those with minds like most of us to rebel against the substitution of synonyms in poetry, to treasure the picture of one’s beloved and so forth? I’m not sure. (I’m also not sure because a firm criterion here - ruling those out as instances of rationality - might come back to bite in the context of what following a rule isn’t: ie being gripped by a self-interpreting interpretation of a general rule.)

More generally, a few years ago when the INPP conference was organised by Gerrit Glas in Leiden I noticed the rise of ‘three e’ approach to the philosophy of mind within analytic philosophy: embodied, embedded, enactive. This year there has been a similar emphasis from within the phenomenological tradition on the role of the person and claims about the both upwards and downwards causation and the role of intersubjectivity in characterising individuals.

Over a coffee, Dariusz Galasinski expressed the worry that this might simply be a kind of cloak. Although presenting a comparatively rich picture of the person, the fact that it is still biologically based might be enough to justify, eg, drug interventions although now described as intervening in an embodied person rather just a body.

I didn’t have that suspicious reaction. But I have felt the lack of a right to this sort of approach. There’s been no reductionist opposition, no scrapping a satisfactory result of which would have given the picture some justification.

I have left until last one solitary but important session: the first at an INPP conference (I am told) organised by a mental health service user group. Jan Verhaegh, Service User Activist and member of the European Network of (ex) Users and Survivors of Psychiatry (ENUSP), held a workshop to address a number of questions but mainly how mental health service users, clinicians and philosophers could be brought into useful dialogue. It was pointed out by one member of the group that this discussion was held in a tiny windowless room in the basement whilst all the more luxurious rooms were occupied by other, obviously non mental health service user led, discussions. So, at the very least, one might aim for a higher priority in the future.

I can say that this is one of the aims for the next INPP conference in Manchester next year, organised by UCLan in conjunction with ENUSP. At the same, I also worry a little that we had better make the dialogue positive for all concerned otherwise the clinicians we would most want to engage may simply not come out of a kind of professional anxiety.

My own presentations are here: on the uncanny; on recovery; and on diverse logics.

Research @ ISCRI

I’ve been trying write the organisational cv for part of my school at UCLan: ISCRI (the International School for Communities, Rights and Inclusion). The challenge is to try to put as succinctly as I can the two dimensions of overlap that characterises it.

At the level of research methods, ISCRI has three overlapping approaches:

1) a practically innovative but theoretically minimal (ie adopting no particular social science research method) approach to community engagement. The approach is ideological rather than theoretical: the communities researched are treated as partners in the research, subjects for rather than objects of, perhaps.
2) a psycho-social research method. Not only is the interaction of the psychological and social of interest but it is (often) approached according to models drawn from the psycho-therapeutic literature.
3) philosophical, phenomenological and conceptual research: the kinds of issues researched are philosophical as much as they are empirically complex and thus conceptual clarification is a necessary aspect of inquiry.

At the level of research subject, the broad concerns are with the nature and norms governing community interaction and cohesion. This might vary from a bespoke inquiry into the needs of a particular and perhaps excluded social community (an ethnic grouping in a particular northern town) to the fundamental norms that should guide our interaction with the natural environment as a whole. (My own research in philosophy of mental healthcare connects to this agenda through understanding the interactions between clinicians and service users. Of course, not everything I do, nor others within ISCRI, fits this. But it a shared central area of research.)

Discussing this yesterday with David Morris (pictured), of NSIP, he asked what role philosophy could have in his own work for social inclusion. I should add that, as an elder of the Institute for Philosophy, Diversity and Mental Health at UCLan, he asked this with a twinkle of the eye (the same ocular twinkle which, together with his silver locks, strongly suggests that he will be giving us his Father Christmas in many an ISCRI panto to come).

David’s work concerns not just issues of social inclusion but also ‘recovery’, construed along the lines of the recovery model in mental health. David expressed an interest in the question of whether intervention (via social policy) aimed at individual recovery was likely to increase inclusion at community level. (Not an a priori truth, it seems to me.) But this, immediately, prompts philosophical as much as empirical questions. What conceptions of inclusion and recovery are in play? And even if one is thought of as a matter for individual subjects and the other for communities, can social inclusion be thought of as individual community recovery?

But more interestingly, if the uber value at the heart of recovery/inclusion is autonomy, and if policy aimed at inclusion aims to track the particular values of individual subjects or communities, is this just a matter of preference satisfaction? And, if so, this prompts the question of the status of those particular values. Surely any decent model of inclusion should include a role for a normative investigation of the values espoused?

(An example: very few people from the Asian sub-continent visit the Lake District National Park despite significant populations within striking distance. Now, there may be active barriers preventing this. But it might also be the result of a lack of education as to just how beautiful and accessible the Park is. And if so, policies for inclusion should challenge those values that help block the thought that the Park is a natural place to go.)

Thus one ought to augment any evaluation of the success of policies of social inclusion with a critique both of individual values and of the models of inclusion and evaluation in play.

David expressed some worry that this might result in direct criticism of the policies. Whilst I am not sure why that would be a problem, if policy agencies are such delicate creatures, one might simply provide a kind of conceptual articulation of the explicit and implicit models being used, the assumptions and values on which they are based, and how other possible assumptions might lead to other possible models. Either way, I can’t see how one could attempt seriously to assess social inclusion without hiring a philosopher for, say, half a day a week at professorial rates.

PS: One result of this lunch time chat was this presentation at Lisbon, and thus this draft paper.