Thursday, 18 September 2008

800 words on Thomas Szasz

Brendan Kelly is putting together a short composite article on Thomas Szasz from 5 or so short separate pieces. I know that I ought to be able to say something about someone so important to the philosophy of psychiatry at whatever length is required but this seems to me to be tricky. 800 words is almost enough to say something but I fear it would take more skill than I have to say something interesting in that limited space. Given that I think of myself primarily as a kind of philosophical journalist, this does seem disappointing.

Here is my first stab, though likely to change.

The Myth of Mental Illness fifty years after publication: What does it mean today?

In the Myth of Mental Illness, Thomas Szasz offered, or at least appeared to offer, a number of arguments against the reality of mental illness. The most important is expressed in this passage:
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… [W]hen one speaks of mental illness, the norm from which deviation is measured is a psychosocial and ethical standard. Yet the remedy is sought in terms of medical measures that – it is hoped and assumed – are free from wide differences of ethical value. The definition of the disorder and the terms in which its remedy are sought are therefore at serious odds with one another.[Szasz 1972: 15]

The argument here starts from the assumption that mental illness and physical illness involve deviation from different norms. Medical intervention, however, is capable of addressing only one sort of deviation – that of physical illness – and thus it cannot address the kind of deviation from a norm implicit in mental illness. Since the conception of mental illness involves the idea that it can be so treated, there is something incoherent about the very idea.

Since medical interventions are designed to remedy only medical problems, it is logically absurd to expect that they will help solve problems whose very existence have been defined and established on non-medical grounds. [ibid: 17]

Szasz also develops a shorter version of this argument. If mental illness is a deviation from a psychosocial norm then this leads by itself to an objection from circularity:

Clearly, this is faulty reasoning, for it makes the abstraction ‘mental illness’ into a cause of, even though this abstraction was originally created to serve only as a shorthand expression for, certain types of human behaviour. [ibid: 15]

Whilst neither of these arguments is compelling, they do suggest an important result that has shaped the philosophy of psychiatry since. They are not compelling because, even if mental illness is defined by, or identified through, psycho-social norms, this need not imply that it is identical to or constituted by such deviation. It may be that the illness is the cause of the deviation such that, even though it is picked out by its characteristic effects, it is not identical to them. (Firing the gun may be picked out as the cause of the death of the president; but it is not identical to the death: it slightly predates it.) If so, Szasz’ argument fails. To establish his conclusion he would need to establish the truth of a kind of mental illness behaviourism which goes beyond highlighting the role of societal norms in picking out illness.

Although the argument for the stronger conclusion fails, it is enough to block a common assumption that shapes biologically minded psychiatry. The assumption is that a successful biological account of a psychiatric syndrome places the condition on the same footing as a physical illness or disease. It would remove it from the debates around anti-psychiatry about deviation from societal norms. But that does not follow. If Szasz is right that conditions are only picked out as illnesses through deviations from societal norms, an aetiological account of the causes of such deviations does not remove the conceptual connection between mental illness and societal norms.

Thus what seems most important to the debate within philosophy of psychiatry about the nature of mental illness is Szasz’ premiss: that mental illness is picked out or identified in psychological, ethical, or legal terms. (In fact, Szasz himself recently suggested that the proposition that mental illness is a myth was not the conclusion of an argument he offered but something he accepted as a premise [Szasz 2004: 321]. This perhaps suggests that he did not aim to move much beyond the claim that mental illness is an essentially evaluative notion. That is why I said he may merely have appeared to offer an argument for the myth of mental illness.)

Szasz’ premiss also highlights a genuine complexity at the heart of current debate about psychiatric taxonomy. Assuming that deviation from a societal norm plays a key role in picking out mental illness, how is it to be specified? It might be specified either in terms which presuppose the concept of illness – hence a pathological deviation from a societal norm – or they might be specified in some other illness-independent terms. One, albeit implausible, example of the latter would be simply to say that any deviation from the – still to be defined – central norms is indicative of illness. Less implausibly, one might suggest mental illness is identified via specific politically defined deviations. This would be a Foucaultian reading of a broadly Szaszian approach to mental illness. It would also be a form of reductionism. The concept of illness would be reduced to other independent concepts. The alternative, by contrast, has to take illness or pathology to be a primitive, that is irreducible, term.

Take the case of those people who claim that the inner voices that they hear are indicative not of a pathology but of their membership of a different community. Their experiences are a deviation from a societal norm but does the deviation also amount to a pathology? The underlying problem now takes the form of a dilemma. If one can specify in illness-independent terms the kind of deviation that amounts to a pathology, then one has a neutral ground to assess the status of hearing voices. But, given the general failure of reductionist programmes within philosophy, that seems a difficult task. On the other hand, if the deviation in question has always to be understood in illness-involving terms, that will provide no help where the pathological status of an experience is precisely what is in question.
(PS: An update and Szasz’ reply is here.)

Szasz, T. (1972) The Myth of Mental Illness, London: Paladin
Szasz, T. (2004) ‘Reply to Bentall’ in Schaler, J.A. (ed) Szasz Under Fire, Chicago: Open Court: 321-6

Wednesday, 17 September 2008

Projectivism and causation

In trying to fill out the apparently Wittgensteinian idea that the conceptual order depends on some underlying contingencies – the ‘whirl of organism’ in Stanley Cavell’s phrase – and the contrast between such a thought and the idea of absolute representations, Gloria and I have been looking at Helen Beebee’s paper on a projectivist account of causation [Beebee, H. (2007) ‘Hume on Causation: A Projectivist Interpretation’, in R. Corry and H. Price, (eds.) Causation, Physics and the Constitution of Reality: Russell’s Republic Revisited Oxford: Oxford University Press: 224-49]. I must say, I’m quite confused at the moment both by the paper and by what I can recall of projectivism in Blackburn’s quasi-realism. I need to do some urgent revision.

The part of Beebee’s paper that is darkest to me is her response to an objection to Hume from Stroud. (The following section of the paper, by contrast, is striking.) Beebee summarises Stroud’s objection thus:

Stroud wants to think of Hume as ‘holding that we do really think of objects as causally or necessarily connected…’. In other words, he wants to think of Hume as holding that we are capable of believing – and hence of thinking – that c caused e… But to be capable of having such thoughts, Stroud thinks, the relevant idea – of necessary connection… – must be capable of representing the world as being a certain way: the idea of necessary connection must be capable of representing c and e as bearing that relation to each other… But, given that the content of those ideas is given by something internal – an impression of reflection or a sentiment – it seems that they cannot be capable of representing the world as being a certain way at all. [226]

Thus Stroud objects that Hume lacks the resources to explain how we can have even the idea of objective or worldly causal connections when their source is merely our own tendency to infer e from c. Beebee’s solution seems to be to accept the negative aspect of Stroud (and Hume) but to suggest that there is a positive account that Stroud has not spotted.

What is it to ‘speak and think as though’ causation were a mind-independent relation? It is important to realise that, on a projectivist view, this does not involve our mistakenly assuming that there are mind-independent causal relations. The non-descriptive semantics of our causal talk would rule out the possibility of our even being capable of making this assumption: to think that there are mind-independent causal relations. in the representational sense, requires that the meaning of ‘causal relations’ is descriptive, which of course is what is being denied. [228]

So whatever phenomena projectivism aims to save, they do not include our thinking that causation is a mind-independent relation. We cannot think that. (This contrasts with the idea that we do think that, though falsely. But also, since – I assume - projectivism is supposed to contrast with an error theory, it suggests some potential tension with a pre-philosophical description of what we do think. Projectivism will have to sell us a suitable account of that.)

What of the positive account? Beebee suggests that projectivism can give an account of how, despite their basis in our (non-descriptive) attitudes, our sayings can take on ‘propositional behaviour’. This brings ‘the resources for thinking of those habits as susceptible to critical scrutiny’ [229]. I’ll return to this a little later. Still sticking with the mainly negative aspect, Beebee continues:

Care is needed here, for it might seem as though to say that we cannot so much as think that there are mind-independent causal relations, as I did above, is tantamount to giving up on the thesis that we ‘do really think of objects as causally or necessarily connected’ , when part of the point of a projectivist interpretation of Hume is precisely that it allows him to uphold that thesis. The two claims are not really incompatible, however. To say that we cannot so much as think that there are mind-independent causal relations means, in this context, to say that we cannot genuinely think of or say two events that they stand in a mind-independent relation of causation to one another. [230]

Given what we have had already read, I take it that ‘genuine’ does not here mean correctly or truthfully thinking about mind-independent causal relations. It means it is genuinely the case that one is thinking the thought, true or false. She continues:

As Hume says, we are ‘led astray… when we transfer the determination of the thought to external objects, and suppose any real intelligible connexion betwixt them; that being a quality, which can only belong to the mind that considers them’. By contrast, to say that we do really think of objects as causally or necessarily connected is to say that we are not led astray – we are not making any kind of mistake – when we ‘speak and think as though’ causation were a mind-independent relation, in the sense just described. [230]

Whilst the phrase ‘think that there are mind-independent causal relations’ is simply to be rejected as a philosopher’s error, the contrasting phrase ‘think of objects as causally or necessarily connected’ is what is to be saved via a projectivist account. (There is something a bit odd about the fact that Beebee quotes Hume saying that we are ever led astray. According to her account, we are not led astray in our everyday causal talk because that cannot be about mind independent causal features. So she must have to think of the ‘we’ as we-philosophers reflecting on everyday linguistic practice, not we-ordinary people engaged in it.)

For to speak and think so [ie ‘of objects as causally or necessarily connected’] is merely for the expressed commitment to take on ‘propositional behaviour’. On the projectivist view, the propositional behaviour of our causal talk and thought does not amount to our genuinely representing the world as being a world of mind-independent causal relations, but it does amount to our really thinking of events as causally related. [230]

So as long we are happy that this phrase is all that does need saving and as long as the saving account is plausible, this seems to provide a way to sidestep Stroud’s worry.

Stroud presupposes that our ‘thinking of objects as causally or necessarily connected’ is a matter of our representing the world as being a certain way; and the problem is that of saying how it is possible for an idea whose origin lies in an impression of reflection to represent the world in any way at all. The projectivist interpretation resolves the problem by denying that Hume takes our thinking of objects as causally or necessarily connected to be a matter of representation in the first place. [230]

So if representing were the only form of words in play, Stroud would be right. Short of there actually existing causally necessitating features of the world to which we could stand in some sort of cognitive relation, there would be no way of even thinking about such features. Thus false thought about such connections would be impossible; falsity would rule such thought out completely. But there is another way of construing such talk (which might look to be as of such features) and that is all we ever took ourselves to be saying. Thus there is no ground level error.

My qualm is this. Because Beebee draws a sharp distinction between what is to be saved and thinking ‘that there are mind-independent causal relations’, the former cannot be interpreted as saying the latter. Given that, then it is not clear on the surface what it does mean. Outside this paper it would be reasonable simply to equate: thinking ‘of objects as causally or necessarily connected’ and ‘that there are mind-independent causal relations’. But the only other way of filling out what it does mean is via the projectivist account. That is, however, very sketchy. We are told what the purpose of such talk is - that by adopting a quasi fact stating form, our attitudes can be indirectly discussed and assessed [229] – but not what we are saying in it.

The move is further likened to teaching a novice speaker to adopt such quasi-realist utterances when expressing their colour experiences. The obvious interpretation of the colour case, however, is that the discipline a speaker learns to impose on his or her utterances is the discipline of aiming at descriptive truth about worldly colours. That may be false if an error theory of secondary qualities is correct but the case does not seem to help with the middle ground (between vindicating realism and an error theory of everyday talk) Beebee wants.

In fact, Beebee seems to say something more obviously implausible, at least in one sentence. By rejecting a representational interpretation of quasi-realist judgements of causation she says she is also rejecting an ‘intentional’ reading, in Stroud’s sense, of it. But Stroud seems merely to mean as if world involving. And rejecting that seems far too radical. Crucially, if the meaning of the utterance is not intentional in that sense, she has not so much sidestepped Stroud’s objection as conceded it whilst offering a kind of Kripkensteinian replacement (itself, of course, based on Hume). But a non-intentional meaning is surely not what we normally think we are saying in our causal talk. And thus we must be being led astray in the mismatch between what we think we are saying and what we are actually saying if quasi-realism is in fact correct.

Anyway, that is how it strikes me on an initial reading.

PS: a day later.

I’m not sure, today, about my summary. The passage that causes me most doubt, now, that I am at all following her line of thought is:

As Hume says, we are ‘led astray… when we transfer the determination of the thought to external objects, and suppose any real intelligible connexion betwixt them; that being a quality, which can only belong to the mind that considers them’. By contrast, to say that we do really think of objects as causally or necessarily connected is to say that we are not led astray – we are not making any kind of mistake – when we ‘speak and think as though’ causation were a mind-independent relation, in the sense just described. [230]

It’s the final words which seem to unpack the projectivism:

“when we ‘speak and think as though’ causation were a mind-independent relation, in the sense just described”

What I don’t get is how and whether we do speak as though causation were mind-independent. So is it that, although the semantics of our thoughts could never be of a mind-independent relation, slightly different words with totally different meanings (explained non-intentionally via their propositional behaviour) are still as though speaking of mind-independence? If so what gives them this appearance? Crucially, how can we say what the appearance is an appearance of, given our semantic predicament?

Sunday, 7 September 2008

Clinical judgement and individual cases

Advances in Psychiatric Treatment sent me a manuscript by Robin Downie (pictured) and Jane Macnaughton to review a few weeks ago. Although very much in agreement with the overall aim of the paper, I didn’t really get on with the way it worked. I suspect that, precisely because I agreed with its conclusions, I wished that it had set about arguing for them in a slightly different way.

Perhaps in response to my slight qualms, the editor who had accepted the paper asked me, this week, to write a commentary on it. Thus I’m presented with the problem of critically engaging with the paper whilst still making it plain that I think that its authors are very much on the side of the angels. I'm not sure, therefore, that this draft (knocked up as the rain rained down yesterday) has the right tone, yet. (PS: a year later the commentary came out thus.)

Clinical judgement and individual cases

Like Robin Downie and Jane Macnaughton, I think that judgement lies at the heart of good clinical practice in psychiatry [Downie and Macnaughton 2009]. I fully agree with the central thrust of their paper. But in this commentary, I wish to sound a note of caution about their likely success in defending judgement against those who criticise or neglect it without some further augmentation of their strategy. My assumption is that their paper is intended to be programmatic. Thus I do not wish to criticise it as incomplete (they have written much more elsewhere, eg.). Rather, my concern is that the route to a defence of judgement that it suggests is not the best route. Of course, my own brisk criticism and positive outline is even more programmatic.

In their paper, Downie and Macnaughton suggest that two factors disguise the central role of judgement in good clinical practice. One is the misapplication of numerical codification to judgement based on qualitative research (‘qualitative judgement’ in what follows) and the other is the rise of a consumer model of healthcare. In this short note, I can consider only the former.

Downie and Macnaughton on qualitative judgement

Downie and Macnaughton argue that the important connection between numerically codified analysis, generalisation and objectivity in quantitative research is mistakenly carried over into the domain of qualitative research and hence into qualitative judgement. They blame reductionism: ‘the process of seeing human beings and their interactions in terms of a number of discrete features’. And they object:

But to try to understand patients in this way, in terms of a finite number of discrete features, is to abstract from the complexity and totality of a human interaction. Blood pressure can helpfully be abstracted in this way and measured, but not a human response in its complex totality. There is something not only patronising but clinically misleading in the suggestion that the complexity of human relationships can be reduced to a few factors and ‘measured’ with an ‘assessment tool’. [Downie and Macnaughton 2009: **]

The problem with this as a defence of the role of clinical judgement, however, is that without some argument as to why reductionism is false, it remains merely a dismissal of the reductionist dismissal of judgement. Furthermore, whilst, like Downie and Macnaughton, I believe reductionism is false, those who oppose clinical judgement are likely to be those who believe it to be true – who believe that there is no limit to the application of the method of breaking down complex interrelations into discrete features - and thus simply asserting its falsity is unlikely to achieve the end of defending judgement against such critics.

In their corresponding positive characterisation of qualitative judgement, Downie and Macnaughton make a number of claims about it. They say that:

[It] is more akin to the understanding gained from literature and art than that gained from a numerical science…
It requires the active participation of the reader to identify with the situation and relate the findings to his/her own situation…
The route to understanding is through our identification with the situation. Through that identification we reach general features of human emotions…
Through identification with the particular situation the researcher or clinician can recognise the general elements in human emotion...
[E]ven if there is no universality in human emotions and reactions there is a broad similarity, and that may be all that is needed as a basis for individualised judgement.
[Downie and Macnaughton 2009: **]

These comments suggest that the sort of judgement Downie and Macnaughton have in mind is akin to narrative understanding (this is, however, merely my gloss on their phrase ‘literature and art’; I will return to it at the end); that it turns on general features of human emotion; that it requires that the clinician achieves understanding by identification with a subject; and that it is a particular kind of individualised judgement.

Especially within mental health care, narrative understanding looks to be a genuinely useful addition to criteriological understanding and I agree with the broad thrust of this account [IDGA Workgroup 2003; Phillips 2005; Thornton 2008, forthcoming b]. But I have some specific qualms about the proposed defence of clinical judgement generally based upon it.

Firstly, it would be a mistake to base a defence of the general role of clinical judgement on the need to understand individuals’ mental states in the same meaning-laden terms as are found in literary or narrative forms. Secondly and relatedly, a restriction of judgement to an understanding of human emotion (however relevant generalities are to be construed) seems misplaced. Both of these leave open the response by a reductionist critic that judgement may have a role in the broader surroundings or context of clinical care – in mere bedside manner, perhaps - but not in the core application of medical science itself. In other words, Downie and Macnaughton do not go far enough in their defence.

Thirdly, the claim that even within the context of a narratively structured understanding of another subject’s emotional states, judgement depends on an identification by a clinician with a subject is contentious. Of course, Jaspers held that such identification was a central aspect of empathy which was itself at the heart of psychiatric understanding [Jaspers [1913] 1974]. But, again, as a defence of clinical judgement against a reductionist critic, it ignores the widely influential approach to interpersonal understanding that claims that it is mediated by implicit knowledge of a ‘theory of mind’: the ‘theory theory’ approach. This approach likens an understanding of another person’s mental states to inference to the best explanation and thus, if it were true, would undermine the contrast Downie and Macnaughton rely on to distinguish qualitative clinical judgement from scientific research.

Perhaps the most telling argument against theory theory turns on the normativity of mental content and the impossibility, in general, of codifying those norms. Refuting theory theory in such a way would not, however, justify Downie and Macnaughton’s position without some further argument as to why direct awareness of another’s mental state was also rejected in favour of the indirect route they outline via identification. (Why would one need to identify with how things are for another person to understand how they are for them? Why would one need to imagine, for example, being in pain oneself to grasp that another is in pain? Might one not simply see in what they say and do, in what they express, that they are in pain) Thus characterising qualitative judgement in these terms seems needlessly contentious as a defence of clinical judgement in general.

Fourthly, as I have argued elsewhere, it is a grave mistake to think that judgement of individual cases requires a form of ‘individualised judgement’ [Thornton 2008; Thornton forthcoming a]. Such judgement, at best, falls prey to Sellars’ criticism of the Myth of the Given [Sellars 1997]. Downie and Macnaughton may merely mean a potentially general judgement about a particular situation but, as a defence of clinical judgement, the phrase is best avoided.

Thus whilst I agree with Downie and Macnaughton’s aims, I suspect a successful defence of judgement in clinical practice needs to be both broader and deeper than the approach outlined in this paper.

Towards a defence of clinical judgement

Clinical judgement lies at the heart of good clinical practice: in the core application of medical science as well as in the broader context of understanding service users and patients. That, at least, is the claim that needs defence. Here is one way to start to defend it.

Consider the way criteriological diagnosis is codified in DSM and ICD manuals. Syndromes are described and characterised in terms of disjunctions and conjunctions of symptoms. The symptoms, in recent years, have tended to be 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 offered by saying that a subject is suffering from a specific syndrome. Thus, presented with an individual, the diagnosis of a specific syndrome is justified because he or she has enough of the relevant symptoms.

The following further thought is tempting. Whilst the overall syndrome is quite general and is characterised in a way that abstracts it away from individuals, the specification of why it applies to someone is more specific in two respects. Firstly, because of the way both ICD and DSM base syndromes on a combination of conjunction and disjunction of symptoms, it is possible that a syndrome so defined may apply to two individuals with little, or even no, overlap of symptoms. The specification of symptoms is thus more tailored to individuals than the overall syndrome. Secondly, and independently of that, the heritage of operationalism suggests that individual symptoms are more closely tied, than syndromes, through a kind of measuring operation to individuals. Symptoms seem to tie more abstract syndromes to particular individuals.

There remains, however, a gap between the description or articulation of a symptom and an individual. The concepts of specific symptoms are, despite their specificity, general concepts that can be instantiated in an unlimited number of actual or potential cases. So how can one judge that a general concept applies to a specific individual case or individual person? One can attempt to bridge this gap. Textbooks of psychiatry can describe, rather than merely list, symptoms. But whatever descriptive account they give of symptoms, there will always be a gap between their general descriptions and concepts (which potentially apply to any number of individuals) and any particular individual. Bridging this gap calls for expertise. It calls for a skilled recognitional clinical judgement. In a nutshell, clinical judgement involves skilled coping with individual cases, both people and their situations, and this requires a kind of non-deductive expertise.

Immanuel Kant was aware of this gap. In his third major work, the Critique of Judgement, he draws an important distinction between what he calls ‘determinate’ and ‘reflective’ judgement. He describes these in this way:

If the universal (the rule, principle, law) is given, then judgment, which subsumes the particular under it, is determinate... But if only the particular is given and judgment has to find the universal for it, then this power is merely reflective. [Kant 1987: 18]

The model at work here is of judgement as having two elements: a general concept and a particular subject. Judgement subsumes a particular under a general concept. The contrast between determinate and reflective judgement is then between an essentially general judgement, when the concept is already given, and a particular or singular judgement, which starts only with a particular. The former, determinate judgement, appears to be relatively mechanical and thus unproblematic. The idea that if a general principle is already given then judgements which deploy it are relatively unproblematic can be illustrated through the related case of logical deduction where a general principle is already given. If, for example, one believes that
1: All men are mortal; and
2: Socrates is a man.
Then it is rational to infer that:
3: Socrates is mortal.

One reason this can seem unproblematic is the following thought. If one has accepted premises 1 and 2 then one has, ipso facto, already accepted premiss 3. To accept that all men are mortal is to accept that Tom, Dick, Harry and Socrates are mortal. So given 1 and 2, then 3 is no step at all [though see Carroll 1895 and Fulford, Thornton and Graham 2006: 98-105]. Furthermore, some central forms of deductive judgement, at least, can be codified using Frege’s logical notation. Given the codification, one can inspect the form of a deductive inference to determine whether true premises could ever lead to a false conclusion. (In fact, neither of these reasons for taking deduction, and thus determinate judgement, is quite so straight forward. Here, however, the perceived relative straight forward nature of determinate judgement is what matters.)

By contrast, for reflective judgement, there is a principled problem in how to get from the level of individuals to the level of generalities, or how to get from people and things to the general concepts that apply to them. That is not a matter of deduction because the choice of a general concept is precisely what is in question. To move from the particular to the general that applies to it is somehow to gain information not to deploy it. Reflective judgement thus cannot be a matter of mechanical derivation. Kant himself suggests that there is a connection between reflective judgement and aesthetic understanding. It may be this connection to which Downie and Macnaughton are referring when they talk of qualitative judgement as being connected to judgements of literature and art (to which I promised to return) However, there is reason to think that art cannot provide a substantial clue to further unpack the nature of the expertise involved in judgement [Thornton 2007].

But what is important about Kant’s account and the illustration of it in the case of psychiatric syndromes and symptoms is that it demonstrates how such judgement is always involved in the application of general knowledge to individuals. Whatever general claims can be gained from quantitative research – which lies at the heart of Evidence Based Medicine – their application to individuals necessarily depends on a kind of skilled expertise in judgement. This does not merely apply to understanding the psychological aspects of service users or patients (hugely important though that is). Even in judgements that are seen as paradigmatically empirical and scientific, skilled and uncodified expertise, or clinical judgement, lies at the heart of seeing that a general concept applies in an individual case or to an individual person.


Carroll, L. (1895) ‘What The Tortoise Said To Achilles’ Mind 4: 278-280
Downie, R. and Macnaughton, J (2009) **
Fulford, K.W.M, Thornton, T and Graham, G. (2006) The Oxford Textbook of Philosophy and Psychiatry Oxford: Oxford University Press
IDGA Workgroup, WPA (2003) ‘IGDA 8: Idiographic (personalised) diagnostic formulation’ British Journal of Psychiatry, 18 (suppl 45): 55-7
Jaspers, K. ([1913] 1974) ‘Causal and “Meaningful” Connections between Life History and Psychosis’, (trans. J.Hoenig) in Hirsch, S.R., and Shepherd, M. (eds.) Themes and Variations in European Psychiatry, Bristol: Wright: 80-93
Kant, I. (1987) Critique of judgment Indianapolis: Hackett
Phillips, J. (2005)
‘Idiographic Formulations, Symbols, Narratives, Context and Meaning’ Psychopathology 38: 180-184
Sellars, W. (1997) Empiricism and the Philosophy of Mind, Cambridge, Mass.: Harvard University Press
Thornton, T. (2007) ‘An aesthetic grounding for the role of concepts in experience in Kant, Wittgenstein and McDowell?’ Forum Philosophicum 12: 227-45
Thornton, T. (2008) ‘Should comprehensive diagnosis include idiographic understanding?’ ’ Medicine, Healthcare and Philosophy 11: 293-302
Thornton, T. (forthcoming a) ‘Does understanding individuals require idiographic judgement?’ European Archives of Psychiatry and Clinical Neuroscience
Thornton, T. (forthcoming b) ‘Idiographic versus narrative approaches to assessment’ Psychopathology

Wednesday, 3 September 2008


Further to my last round up, (and previous ones, here, here and here), a week after Psychopathology asked, a second journal asked to publish the paper I gave at the German Psychiatric Association (Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde), ie. a third paper on that same subject area. It seemed plausible, this time, to step back and consider from first principles how one might think that a special kind of ‘individualised’ judgement might be needed for understanding individuals. This is now in production with European Archives of Psychiatry and Clinical Neuroscience. I can't help feeling that it will sit uneasily in what is obviously a very medical journal but am impressed by their speed and efficiency. The Psychopathology paper (focusing more on the narrative alternative to idiographic judgement) seems, by contrast, to be languishing in a preproduction limbo.

The issue on Values Based Practice that I have been trying to edit for over a year for Philosophy, Psychiatry and Psychology is moving towards production, paired with some papers on EBM (for which Gloria Ayob and I wrote a couple of commentaries).

I’ve written a chapter with input from Bill Fulford for a WPA edited book on psychiatric diagnosis (Salloum, I.M and Mezzich, J.E. (eds) (forthcoming) Psychiatric Diagnosis: Patterns and Prospects, Hoboken: Wiley).

My chapter, ‘On the interface problem in philosophy and psychiatry’, is still forthcoming in Lisa Bortolotti and Matthew Broome’s OUP book Psychiatry as Cognitive Neuroscience, some time in 2009, I understand. An eccentric commentary - ‘Constitutive evaluativist externalism (Commentary on Zachar, P. and Kendler, K. (2007) ‘Psychiatric Disorders: A Conceptual Taxonomy’’ - I wrote some time ago for the AAPP is still in limbo. The paper ‘Should comprehensive diagnosis include idiographic understanding?’ is now out with the September issue of Medicine, Healthcare and Philosophy 11: 293-302. A joint paper on ‘Understanding, testimony and interpretation in psychiatric diagnosis’ is still in their e-published format.

A very unflattering and I thought rather misleading review of my EPP was published by Christian Perring on his site and, once my annoyance had subsided, I wrote a reply. Strange how depressing such reviews are (and I can't help feeling that the reviewer’s excuse for the caricatures he drew is pretty poor: ie. it’s only a review so it doesn’t have to be accurate).

A couple of other people’s research network bids in which I have an interest have been successful. Matthew Ratcliffe (pictured looking much madder than he really does!) and Tony Atkinson’s AHRC project ‘Emotions and Feelings in Psychiatric Illness’ will organise a workshop-conference series with which I hope to be involved. And there’s a French project organised by Pierre-Henri Castel which will run for a few years and involve a workshop at Uclan.

Finally, I have (with some reluctance because of the loss of freedom for research) just become the head of a reformed philosophy section in a reformed school within Uclan (ISCRI: the International School for Communities, Rights, and Inclusion). Given that the school is the size (only) of a large science department, I aim to remain an academic director of the subject area (hence, eg, Director of Philosophy) rather than the head of an insular mini-department, but will no doubt discover how possible this is.

After the flurry of applied and medically based stuff, I must now return to writing some pure philosophy.