Wednesday, 26 October 2011

Notes after a SAMI discussion of an idiographic addition to diagnosis

There’s a widespread intuition expressed in frustration by a reviewer of one of my papers (because it was critical of idiographic understanding) that runs as follows:

[T]he real problem in diagnosis comes when the nomothetic is given too much emphasis. Time and time again what is required is something like the idiographic. Time and time again the categorical, pigeon-holing, approach to diagnosis has to be bent in order to accommodate the individual account. The question is merely how to characterise such an account.

The idea that the ‘question is merely how to characterise such an account’ shows that the intuition is more that there must be something distinct from a pigeon-holing approach to diagnosis even if one does not know quite what. The danger, however, is that the intuition may be mistaken and the hope misplaced. That is that ‘idiographic’ is a place holder but nothing can slot into its supposed place.

What would it be for something to meet the felt need? I think three conditions have to be met.
  1. It must be a form of understanding, or information, or sensitivity to facts which is distinct from criteriological approaches, understood broadly. ‘Broadly’ because merely adding a new diagnostic category to DSM / ICD would not address the underlying intuition. So it has to be distinct from any innovation within the criteriological approach.
  2. It must somehow capture the individuality of individuals.
  3. It must be a genuine form of understanding or judgement. That is, it must aim at truth or validity even if only as applied to an individual: the truth about him/her.
With these conditions in place we can look at the clues given in the IGDA document and Jim Phillips paper to see what this form of judgement is.

Class discussion suggested that responding to the uniqueness of each client/patient and their context (in family and society etc) might be a clue. But to understand the movement of an apple juice carton requires relating it to every other object with mass in the universe (ie its context) and that is likely to be a different set of vectors than any other object, as it is in a particular place (hence uniqueness). So the uniqueness and context-dependence of the subject matter does not distinguish idiographic psychiatry from physical science explanation which itself is a form of criteriological / lawlike explanation.

Nor is does the sense of idiographic understanding found in psychology meaning based on qualitative small scale research helpful because it is not distinct. Even criteriological diagnosis concerns individuals. The target is thus small scale. The question remains how is idiographic understanding distinct? How is a focus on individuals achieved?

Hence looking at Windelband. Now there are a number of interesting ideas in his paper, but at no point does he manage to substantiate what he means. There is a key emphasis on the idea that whereas nomothetic understanding concerns generality (eg understanding individuals as instances of generalities) idiographic understanding concerns individuality: individuals as individuals.

In their quest for knowledge of reality, the empirical sciences either seek the general in the form of the law of nature or the particular in the form of the historically defined structure. On the one hand, they are concerned with the form which invariably remains constant. On the other hand, they are concerned with the unique, immanently defined content of the real event… The former disciplines are nomological sciences. The latter disciplines are sciences of process or sciences of the event. The nomological sciences are concerned with what is invariably the case. The sciences of process are concerned with what was once the case. [Windelband 1980: 175-6]

[T]he more we strive for knowledge of the concept and the law, the more we are obliged to pass over, forget, and abandon the singular fact as such… In opposition to this standpoint, it is necessary to insist upon the following: every interest and judgment, every ascription of human value is based upon the singular and the unique... Our sense of values and all of our axiological sentiments are grounded in the uniqueness and incomparability of their object. [Windelband 1980: 181-2]

But this focus is not just on individuals (nomothetic understanding can be applied to just this very apple juice as an example of an object of its general physical properties) but somehow not related to other individuals, cases, the future etc. A completely one-off understanding. And the problem with this is that it is not clear it makes any sense to say that this is a judgement, aiming at truth and validity, at all.

Hence instead following the other clue. Perhaps we need narrative judgement. This looks more promising but still needs to meet the three conditions. Can it? Well we need to say what we mean by ‘narrative’. It can’t mean a particular narrative genre (because that would be unrealistic and restrictive). So I suggest we just mean the form of understanding that places things in a space of reasons, that shows how they make sense. If so on the conditions above:
  1. making sense is a normative notion (ie correctness involving) rather than typical / usual and so is distinct.
  2. whilst sense-making is a constraint (not everything could make sense even if anything could in the right context), it is a very flexible constraint suited to charting individuals mentality.
  3. such understanding does aim at the truth of a person’s reasons.
But is that good enough to meet the underlying intuition? And, more practically, if diagnosis involves both standard DSM criteria and a narrative, won’t the former be the aspect that does all the work?

IDGA Workgroup, WPA (2003) ‘IGDA 8: Idiographic (personalised) diagnostic formulation’ British Journal of Psychiatry, 18 (suppl 45): 55-7

Phillips, J. (2005) ‘Idiographic Formulations, Symbols, Narratives, Context and Meaning’ Psychopathology 38: 180-184

Windelband, W. (1980) ‘History and natural science’ History and Theory & Psychology 19: 169-85.