Wednesday, 27 April 2011

On reading Arthur Frank's Letting Stories Breathe: a socio-narratology

I have been looking today at Arthur Frank’s recent book Letting Stories Breathe: a socio-narratology in the hope that I could helpfully summarise it. Sadly, that does not seem to be possible for me for a reason which is familiar when looking outside philosophy into social science but frustrating nonetheless. It is a useful and very readable book which gives a sense both of the sort of inquiry of a narrative researcher who focuses on narrative to look more broadly at the social world and of some practical recommendations for what the researcher / reader should look for in stories. Nevertheless, it is hard to isolate particular theses advanced and so to summarise or assess an argument or a concrete view of the nature of narrative or stories, which is what I was looking to it for.

I have a hunch as to why that is. (Perhaps it is foolish to use the word ‘hunch’. Perhaps this is just the obvious intended approach. Still, for me, it remains mere hunch.)

One theme of the book is exemplified in the title: letting stories breathe. Frank does not seem to want to provide a theory of stories so much as let them be. So when, late in the book, he discusses the idea of a typology of narrative forms, he addresses a worry that this is a vulgar thing to do in these terms:

Typologies risk putting stories in boxes, thus allowing and even encouraging the monological stance that the boxes are more real than the stories. In a world where simplification is a pretext for knowing, and knowing is a pretext for controlling, typologies are risky...
Elaboration of types of narratives allows recognizing the uniqueness of each individual story, while at the same time understanding how individuals do not make up stories by themselves. Each story is singular; none is a mere instance. Yet, stories depend on other stories: on recognisable plots, character types, conventional tropes, genre-specific cues that build suspense, and all the other narrative resources that storytellers utilize. A typology of narratives recognizes that experience follows from the availability of narrative resources, and people’s immense creativity is in using these resources to fabricate their stories. The types in a typology are of narratives, not people. No individual storyteller is reduced to any narrative type. [Frank 2010: 118-9]

‘Monological speech’ closes itself off from a response by another and asserts rather than engages, we learn. It is likened to a judge sentencing. So if that is a risk from setting out a typology and if typology is surely a fairly preliminary aspect of theory construction, it is no wonder that Frank cannot easily give us a theory of narratives or narrative understanding. He has, instead, to attempt to engage with us without theory.

And at its best, that is what the book does. It starts with a series of stories that can then be used – a little clunkily, I thought, but that’s perhaps just a philosopher’s drier taste – to illustrate some key claims (risking the monological!) but later describes uses of narrative in accident investigation, civic action and dementia care. These piecemeal discussions offer a kind of half way house between literary criticism and sociology and I found them very helpful. Sadly, that is quite a small proportion of the book.

There is also a helpful first chapter on the capacities of stories, of what they can do, from which it is possible to draw some sort of answer to the question of what Frank’s subject matter is because he says ‘Stories, to be stories, must have a sufficient number of these capacities’ [ibid: 28]. But this claim is in tension with the comment elsewhere ‘I make no attempt to define stories. The emphasis is on watching them act, not seeking their essence’ [ibid: 21]. Of course, a kind of family resemblance or cluster analysis does not seek an essence, but it might still be thought to be a definition of sorts.

In fact Frank does offer another ‘understanding’ (not a definition, he says, although he doesn’t explain the difference he has in mind between understanding and definition) of narrative: ‘one thing happens in consequence of another’ [ibid: 25]. If so, however, any causal connection in physics, say, will be a narrative but they will generally fail of the capacities he also outlines. So: a tension between articulating a thesis and letting stuff just happen.

The capacities form an interesting list. They begin:
Stories have the capacity to deal with human troubles, but also the capacity to make TROUBLE for humans.... Stories have the capacity to display and test people’s character... Stories have the capacity to make one particular perspective not only plausible but compelling... Stories make life dramatic and remind people that endings are never assured... Stories have the capacity to narrate events in ways that leave open the interpretation of what exactly happened... Stories are like the magic spell that Mickey Mouse creates in the ‘Sorcerer’s Apprentice’... Stories inform people’s sense of what counts as good and bad... Stories echo each other... 
(There are four more listed.)

This suggests a question. If the subject matter of the book is picked out by what fits sufficient of these, do we have a sense of what that might mean? For one thing, the list starts with talk of ‘capacity’ (although, as above, that word then drops out). If a particular potential story does not display the capacity to make trouble, does it still have it? (Capacities need not be displayed all the time.) Again, it is not clear whether a claim is being advanced about the nature of stories or not. And so it is hard to know whether it is worth even seriously thinking whether what it says is true or not. That is, there is some doubt as to whether that is the game it is in.

Elsewhere substantive theoretical claims are advanced through the introduction of a terminology. For example ‘stories interpellate characters. In every story I can think of, at least one character is interpellated, or hailed, or cast, or called to a certain identity... Coyote is called on by the story to know himself as one who will inevitably do what he has done in the story. But while Coyote is hailed most directly, those who listen to the story are also being interpellated...’ [ibid: 50]. And a page later: ‘This casting is my socio-narratological version of the term SUBJECT POSITION: the character’s more or less reflective awareness of who the type of narrative requires him or her to be, of what being that character requires him or her to do. The subject, both in the story and hearing the story, feels a tension between hitching a ride on the immanent volition of the story and being carried where such a story usually goes’ [ibid: 51].

I must say that I found this kind of theory-introduction a little irritating. I want to hear some sort of justification – a justification I’m quite sure Frank could provide – or explanation for treating the subjects within stories and the hearers of the stories in the same way. That seems an interesting substantive claim. But because the theory is so insidiously injected, there’s no chance, as it were, to object.

A similar case is the claim that ‘narrative habitus’ – a kind of second nature – described as ‘the embedding of stories in bodies’ [52] (although I think the emphasis on body as opposed to person is not helpful) frames the way in which people react to and understand stories. It involves a repertoire, a competence, a taste and plot expectations. This is then compared to a psychoanalytic notion borrowed from Bayard of an inner library. But it is not clear how much Frank believes this idea (‘This whole line of argument is psychoanalytic in the best and worst senses’ [ibid: 58]) nor whether his own claim is meant to be analytic or empirical. Do we, of necessity, hear new stories only via the conceptual structuring of narrative second nature? It must, I guess, be empirical because we are then told that some ‘vital, breathing stories can break through the filters and grids’ [ibid: 59]. So it is not a necessary claim. Is it therefore a psychological truth? Again, it is hard to work out what kind of a framework this is supposed to be.

Some parts of the book seem starkly monolingual, however: ‘Interpretation begins with letting each point of view have its moment of being the perspective that directs the consciousness of storyteller and listener’ [106-7]. Does it? Persuade me! And even how we are supposed to ‘read’ this book: ‘These chapters are pervaded by a sense of the limitations of standardizing methods in social science’. A sense for whom? I am not sure they were for me. And thus given that the book sometimes risk direct assertion, I would have preferred a bolder but slower and more explicitly theoretical account in general of the nature of stories and our narrative understanding.

But perhaps I wouldn’t. There is, in fact, a body of bold claims about how stories are themselves actors who ‘conduct people, as a conductor conducts an orchestra’. They ‘make life social’. Stories and humans ‘work together’. They go even further (in a rare ugly sentence) in underpinning a form of idealism: ‘The story performs the truth of making a situation real because it is now narratable’ [ibid: 92] I am not sure what performing the truth is but this sentence seems to say that because reality is narratable, stories make situations real. This is all radical stuff and fine as a kind of metaphor. But it would be odd if on ‘–ology’ of stories, their logos or truth, were couched merely as metaphor. Frank can’t be serious about this, can he?

PS: Some time later I had the following thought. There is a suggestion in the book that narratives can accrue two kinds of truth. There is the familiar idea that stories can tell it as it is. They can be literally true. But there is another kind of truth: a truth in the story which inheres in it merely in virtue of the story being told. (That is not quite right but I hope Frank would forgive this crude summary.) Now if that is right (that is, if that is what the book says, whether the second claim is actually true in the first sense or not; by its own lights it might be true in the second sense merely by being said!) why assume that a lover of stories would aim, in his account of stories, at the first pedestrian sort of truth? Surely, the kind of truth proper to a story is the one unique to it: the truth in stories. And if that’s the case, then surely the point of the book is not an ‘-ology’ of stories as I suggested but a story about stories. And thus that is how one should judge the idea that stories sing reality into being. It is a much nicer idea.

Frank, A.W. (2010) Letting Stories Breathe: a socio-narratology, Chicago: University of Chicago Press

Tuesday, 26 April 2011

International PhD Scholarship

International PhD Scholarship

School of Health

Reference No INT-061Thornton

Applications are invited for a full-time scholarship available in the School of Health. The scholarship is tenable for up to 3 years for a PhD (via MPhil route) [subject to satisfactory progress] and is open to international applicants only. UK/EU applicants are not eligible to apply. The scholarship will provide £15,000 towards the cost of the International tuition fee over 3 years.

Project Title: Understanding delusion

Project Description:
This project aims to bring philosophical resources to bear on the problems of understanding delusion.

There has been much recent philosophical work developing models to explain and perhaps understand particular delusions (eg Capgras, Cotard, Fregoli). The aim of this PhD project, however, is not directly to contribute to that debate by building or refining such models. Instead it aims to examine what other philosophically grounded resources are available for understanding the subjects who have delusional experiences. It aims to explore the possibility of a middle ground between, on the one hand, the mainstream philosophical approach which tends to play down the bizarre and sometimes disturbing experiences of severe mental illness and, on the other, a pessimism inspired by Karl Jaspers about any possibility of empathy in such cases.

The project will draw on recent research in the philosophy of mental health carried out by philosophers, clinicians and service users, including published work by the main supervisor, to connect philosophical analysis of meaning and experience with models of understanding.

Applicants should have, or expect to receive a qualification equivalent to a high class UK honours degree.

Informal project related enquiries may be directed to Tim Thornton email Tel 01772 894646

Application Forms can be found at:

Completed application forms should be emailed to

The closing date for applications to the Graduate Research Office:
Friday 13 May 2011 5pm British Summer Time

Proposed Interview Date: 31 May 2011

Wednesday, 20 April 2011

The recovery model, values and narrative understanding

An edited version of this chapter is forthcoming in Rudnick, A. (ed) The Recovery of People with Mental Illness Oxford University Press. (See also this article on the recovery model and this poster.)

Whilst recovery has been promoted as the proper aim for mental healthcare, there has been little agreement about what it involves. It is, however, often proposed as a contrast to a bio-medical view of psychiatric care, referred to as a recovery model. In this paper I examine what this claim might amount to by exploring the logical geography of a recovery model.
To count as a model, I assume that it must involve a theoretical conception of what ill-health, or health, or something akin to health is. I set out an analogy with a different area of the philosophy of psychiatry. The bio-medical is sometimes claimed to neglect the social aetiology of mental illness and thus be replaced by a social model. But since one could hold that mental illness can have distant social causes whilst still assuming that this is mediated or constituted by local failures of biological function, a distinct social model of mental illness has to hold that it is constituted rather than merely caused by social factors. A recovery model must, similarly, contrast with a bio-medical on some understanding of both.
Using the distinction between a focus on health versus illness and between evaluative versus plainly factual accounts, I suggest that a recovery model can be thought of as an essentially evaluative conception of mental health, or something like health, broadly construed, and examine arguments that that is the most valid or truthful model.
Supporters of the recovery model do not, however, generally proceed this way. They do not argue for the truth of their model, via, for example, the incoherence of rival models, but rather for the value of the recovery model. I thus examine the ground rules for this style of argument and examine whether it undermines the initial analogy with a social model of mental illness.
Finally I consider the connection between recovery and narrative understanding hinted at in, for example, recovery stories. If recovery is aimed at a person-specific conception of a valued way of living, then narrative understanding is particularly apt for articulating the particular reasons for identifying and valuing an endpoint.
Although much recent thinking about the aims of mental healthcare stresses the role of recovery, there is little agreement about what, precisely, that means. Larry Davidson and David Roe, for example, summarise the situation thus: ‘There is an increasing global commitment to recovery as the expectation for people with mental illness. There remains, however, little consensus on what recovery means in relation to mental illness’ [Davidson and Roe 2007: 450]. Glenn Roberts and Paul Wolfson comment:
The term ‘recovery’ appears to have a simple and self-evident meaning, but within the recovery literature it has been variously used to mean an approach, a model, a philosophy, a paradigm, a movement, a vision and, sceptically, a myth. [Roberts and Wolfson 2004: 38]
In the UK, a 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, it is suggested, characterise any broadly recovery-based approach. These points include:
Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems.
Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness.
Hope is central to recovery and can be enhanced by each person seeing how they can have more active control over their lives (‘agency’) and by seeing how others have found a way forward.
Self-management is encouraged and facilitated. The processes of self-management are similar, but what works may be very different for each individual. No ‘one size fits all’.
The helping relationship between clinicians and patients moves away from being expert / patient to being ‘coaches’ or ‘partners’ on a journey of discovery. Clinicians are there to be “on tap, not on top”.
People do not recover in isolation. Recovery is closely associated with social inclusion and being able to take on meaningful and satisfying social roles within local communities, rather than in segregated services.
Recovery is about discovering – or re-discovering – a sense of personal identity, separate from illness or disability. [Shepherd Boardman and Slade 2008: 0]
The Scottish Recovery Network summarises its views of recovery in similar terms:
Recovery is about living a satisfying and fulfilling life.
Recovery is about more than the absence of the symptoms of illness. Some people describe themselves as being in recovery whilst still experiencing symptoms.
There can be lots of ups and downs during the recovery process – some people describe it as a journey.
For this reason people often talk about being in recovery rather than recovered.
Some people consider recovery as being ‘back to the way things were’ or back to ‘normal’ but for others recovery is more about discovering a new life or a new way of being. [Scottish Recovery Network 2007: 3]
As both these lists suggest, recovery is not so much a precisely articulated explicit theoretical account of the nature of health or illness as a practical orientation to the kind of care that should be provided and the roles of patients or service users and clinicians or carers.
Nevertheless, advocates of recovery in mental health often talk of a recovery model, with the implication that it stands in opposition to a bio-medical model of health or illness [Davidson and Strauss 1995]. In this chapter, I will attempt to sketch out the ‘logical geography’ of a recovery model, outline an argument for it but then consider whether it is even appropriate to argue for the correctness of the model. Finally I will outline how a recovery model connects to a narrative form of understanding.
Ground rules
To articulate a recovery model, in contrast, for example, to a bio-medical model, is not simply to say that recovery (construed in some broad way) is a desirable aim of mental health care. That amounts to a recovery approach by contrast with holding a recovery model. One might share the broader aims of mental healthcare as characterised by a recovery approach whilst still holding a narrower bio-medical model of what illness and health is. That would not be a recovery model and would not stand opposed to a bio-medical model. To count as a model, it must offer more than just a broad aim but rather a theoretical conception of what illness, or health, or something like health is. (The need for the qualification ‘something like health’ will become clearer shortly.)
There has also been a recent change in attitude to the possibility of recovery from mental illness amongst mental health professions. This is, in part, the result of changes of empirical beliefs about the prognosis for various illnesses and the development of new therapeutic interventions. But at least some such changes might be accommodated within a bio-medical model in the way that improvements in cancer care have improved prospects for recovery and remission, even construed in specific bio-medical terms. At least part of the change in attitude to the possibility of recovery from mental illness is not due to such changes in empirical beliefs, however, but a change in the way that illness, health and recovery are thought about. Articulating a coherent account of that is articulating a recovery model.
An analogy may help clarify the task. The bio-medical model is sometimes criticised for failing to take account of social factors in the aetiology of mental illness. It is thus contrasted with social approaches to mental illness. But, if such approaches merely stress the fact that mental illness can have social causes in addition, for example, to genetic predisposition, that need not stand in conflict to a bio-medical model which takes mental illness to be caused by, or supervene on, brain biology. Such a bio-medical model would need to insist that the eventual mental effects of social causes were mediated by changes of biology – that is the point of the model – but it need not deny that such changes can have distant social causes as well as local or endogenous causes.
To get a genuinely distinct social model of mental illness (by contrast with what might be termed a social approach: any approach which stresses the importance of social factors), one would need to claim not merely that mental illness were caused by social factors but rather that it were constituted by social factors or relations. It would be like the status of being married which is not a matter of internal physiology but rather a social and legal status (whether or not the status may have subsequent local physiological effects in the health of married men, for example). A model in which social factors constitute illness contradicts a model in which they are constituted by individual biology. If such a social model correctly described the nature of mental illness then a bio-medical model would be guilty of the same sort of error as a martian anthropologist who sought to understand the nature of marriage – of what it is to be legally married – by carrying out physiological examination. That would be simply looking in the wrong place.
Examples of constitutive views of mental illness include those based on Foucault’s work, Bateson’s model of schizophrenia (according to which individuals do not suffer schizophrenia but rather families) and, to an extent, Szasz’ view. Szasz’ account is complicated by the fact that he argues that the combination of a socially constitutive view of the identification of supposed mental illness – in terms of psycho-social, ethical and legal norms – with a bio-medical view of their treatment is logically incoherent and thus results in mere myth. So it is not that he believes that there are mental illnesses but which are socially constituted. Still, the underlying problems of living, which are not mythical but which are, according to him, confused with mental illnesses, are socially constituted.
The analogy with a social model of mental illness, based on a constitutive claim, not only helps clarify the requirement that alternatives models of illness and health must be genuinely distinct from, by conflicting with, one another. It also suggests a way in which the opposition can help clarify what the bio-medical model, as well as its alternatives, might be. That is important because, just as it is far from clear what is meant by ‘recovery’ (or a social model of mental illness) so it is not entirely clear by what is meant by a ‘bio-medical model’ to which it stands opposed.
In fact, later, I will argue that there is an important potential disanalogy between a recovery model and a social model. It is not clear that the former is put forward as a true account of the nature of recovery, whereas I take it that it that a social model is at least proposed as a true account of mental illness, whether or not it actually is. But for the moment, the analogy helps clarify conditions on a genuine model.
(One question on which I will not speculate here is what the relation, if any, might be between a recovery model and a social model. The purpose of the analogy is not to suggest a close relation via a joint opposition to some version or other of a bio-medical model.)
My first aim in this chapter is to set out what a recovery model might be. One condition on that endeavour is thus that it must be a genuine contrast with a plausible construal of a bio-medical model. It does this by having a different theoretical account of what illness, health or something akin to health is. But a second condition is that it must capture enough of what those who support recovery approaches to mental healthcare say to characterise their views. A proposal for a recovery model must respect what is already published in support of a recovery approach.
Two distinctions
How can a recovery model be articulated, distinct from other models in mental healthcare? I suggest that two distinctions help frame a ‘logical geography’ in which to locate it. First, a distinction of focus between pathology and whatever is its relevant contrast, perhaps health. Second, a distinction between what is evaluative or normative and what is merely plainly factual.
The philosophy of psychiatry, and more generally the philosophy of medicine, has tended to focus on the illness end of a spectrum between health and illness. The key concern has been with the notion of illness (or disease or disorder) rather than with health. One reason for that has been the origin of the debate at least within the philosophy of psychiatry in the response to Thomas Szasz’ argument that mental illness is a myth [Szasz 1972]. Szasz’ claim that mental illness was an oxymoron prompted responses by biologically minded psychiatrists who attempted to devise models of illness (or disease or disorder) which accommodated not only physical but also mental illness [Kendell 1975, Boorse 1975]. That in turn has led to an ongoing debate focusing squarely on ill health [Fulford 1989, Pickering 2006, Wakefield 1999]. There was no equivalent Szaszian argument for the mythic status of mental health and hence no incentive for a philosophical defence of that notion.
Against a background focus on the nature of illness, recovery can seem to be simply a return from, or a removal of, that status. Whatever illness or disease is, recovery is its negation. By contrast, concentration first on the health end of the spectrum is at the heart of the recovery approach (thus according with the claim from ‘Making recovery a reality’ that ‘Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness’) and thus is a prerequisite of a substantive recovery model. A recovery model will thus need to do more than just take the aim of healthcare to be the removal of illness.
The second distinction is between views of mental illness in particular, or illness more generally, as essentially evaluative. Does the analysis of mental illness contain reference to values or not? Some philosophers and psychiatrists argue that at the heart of the idea of illness is something that is either bad or wrong for a sufferer or is a deviation from a social or moral norm. Both of these are evaluative or normative notions and hence both are ‘values in’ views.
Others argue that it is, what I will call, a plainly factual matter. Typically, they argue that illness involves a failure of a biological function and function – and hence deviation from, or failure of, function – is a plainly factual, biological term couched in evolutionary theory.
Having sketched the two distinctions, I suggest that a clue to articulating a recovery model which genuinely contrasts with a medical model is to locate it on the health-focused rather than pathology-focused side of the first distinction and on the values-in or normative side of the second. That remains just a clue: more work has to be done. But it might be objected that the first of these two distinctions is unnecessary: we can articulate a genuine contrast to a bio-medical model simply by using the second distinction.
The idea is that a bio-medical model construes mental illness as value-free, as, for example, reducible to plain facts about biological function. Adopting the opposite view – that illness is an essentially evaluative notion – stands in genuine contrast. And a conception of recovery from illness, so construed, might be enough to count as a recovery model because of that genuine, substantive contrast.
Whilst such a position is a genuine contrast to a plausible candidate for a bio-medical model of illness, it does not seem to capture an important element of the recovery approach: a particular goal or aim of therapy which is not defined merely as the absence of illness. It is instead captured in specific terms such as a hope, autonomy and social inclusion.
One specific problem is that even if one thinks of illness as an essentially evaluative notion, that is not a sufficient reason to think that health is. It might be the mere absence of an evaluatively identified illness state. Health might be conceptualised in merely statistically normal (rather than normative or evaluative) terms as perhaps the state of most people, or, alternatively, the state one was previously in. If so, whilst the states that individuals have an interest in recovering from are those with particular normative or evaluative properties (whatever precisely those are), recovery itself might be characterised in non-normative non-evaluative terms. And that does seem to fit the way the recovery approach is characterised by its supporters.
What of the other distinction? Could a recovery model be defined simply as one which focuses on a positive conception of health, or something like it, rather than merely the absence of pathology, however construed? Again, no. As the authors of ‘Making recovery a reality’ make plain, they have a very particular conception of the aim of recovery tied to a conception of hoped for and autonomous life connected to social inclusion. That specific content is not captured merely by a focus on health which, as I have just argued, might be thought of in bland statistically normal terms.
To capture what is characteristic of a recovery approach in order to frame a recovery model, it seems that both aspects are needed: a focus on a conception of health, or something like it, and in normative or evaluative terms. A recovery model is thus one which construes the positive aim of mental healthcare to be a state essentially characterised in normative or evaluative terms.
Arguing for the correctness of a recovery model
It is one thing to locate a recovery model in a logical geography that distinguishes it from a bio-medical model (and at the same time partly characterises a bio-medical model). It is another to argue for it. I will now try to sketch the beginnings of an argument for a recovery model for mental health, construed on these lines. To do this, I will employ a contrast with physical health. The argument will take the form of suggesting that, whilst a non-normative or non-evaluative approach to physical health is at least plausible, it is not plausible for mental health. (In the end, I am not confident that such an argument can quickly be successful.)
A non-evaluative approach is at least a possible picture of physical health and hence for recovery from physical illness. On this view, the aim of physical healthcare is a return from a state of illness – whether evaluatively or non-evaluatively understood – to a state identified in non-evaluative or plainly factual terms. One version of this approach would be to define the state in statistically normal terms. A statistical model of health has an obvious advantage over a statistical model of ill-health based on the idea that illness is a statistically unusual state. The latter model has the problem that for some features of human nature, deviation from the norm in one direction may not be, in itself, unhealthy at all. Having a very high IQ or being able to run very quickly is not equivalent to having a very low IQ or low mobility. Since a statistical model of health – by contrast with its lack – can be based on what is normal rather than abnormal, there is no analogous problem.
Nevertheless, to have initial plausibility, some qualifications would have to be built in. Thus, for example, what is normal for a 20 year old may not be normal for an 80 year old. The same state of health may be healthy for the latter but an illness for the former. 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 to be defined in normal terms, normality would have to be defined for each such sub-system rather than for the whole person. But given suitable qualification, there is one plausible feature of 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 what seems plausible to call a bio-medical approach to recovery. Even if illness were construed as an evaluative notion, the aim of recovery could be described in value free terms to return human functioning to a normal state. (That it is an aim, is of course, an expression of it being valued. But picking out what the valued state is need not involve normative or evaluative notions.)
Whilst, however, a non-normative statistically normal model of physical health seems at least to be plausible, it seems less plausible for mental health. Mental health cannot realistically be construed as a statistically average kind of life but rather, in line with the quotation from ‘Making recovery a reality’, a particular kind of life valued and hoped for by the individual concerned, the kind of life connected to their identity. If this is the case, it threatens the idea 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 would properly be aimed at a specific and normatively characterised or valued endpoint.
In setting out a condition on a recovery model, I have suggested that it needs to offer a substantive conception of health, or something like it, so as to count as a model rather than merely an approach. The need for the qualification - ‘or something like it’ – should now be apparent. The recovery approach – on which I am basing an articulation of a model – takes the aim of mental healthcare to be more than a narrow construal of health but a significantly richer mode of being. Not just a state or capacity but something like an ongoing set of choices and practices. Whether this is a broad conception of health or a conception of something broader than health such as wellbeing I will leave aside.
Whilst a recovery model seems more plausible than a crude statistically normal model of mental health, that is not the only available alternative that would have to be rejected to defend a recovery model as the only viable valid one. Here are two more. First, one could define mental health not, absurdly, as the living of a statistically normal life, but as the possession of statistically normal mental capacities: capacities, for example, to make autonomous life choices. Or, second, one could define mental health as involving one’s mental traits functioning in accord with their evolved biological functions.
I will not attempt an argument against these alternatives but will suggest some lines of thought that could be adopted against them and thus in favour of a recovery model. The key line of objection to the second approach is to question whether the articulation of the biological functions of mental traits can really be viewed as independent of, rather than presupposing, a conception of human flourishing. The challenge for a plainly factual account is that only some of the actual evolutionary history of happenings accord with the normative account of what a trait is selected for. So by what principle of choice are some picked out to exemplify the trait’s purpose? The obvious answer is not available: via an understanding of what contributes to a value-laden conception of human flourishing.
It is harder to pinpoint an obvious line of weakness in the other plainly factual account of mental health (possession of normal mental capacities). But one subtle worry runs as follows. Key capacities for mental health, as exemplified in the recovery approach, surely include the capacities for autonomous choice. But the identification of such capacities – before the issue of considering what is statistically normal – cannot itself be a plainly factual matter. Such capacities are governed by what Donald Davidson calls the Constitutive Principle of Rationality [Banner 2010, Davidson 1980]. But rationality is not merely a statistical normal pattern of reasoning [McDowell 1985]. It involves, essentially, a notion of what one ought to think in the face of such and such reasons, evidence and values. And there is thus no hope of identifying the capacity for choice in neutral terms.
Is that the right kind of argument for a recovery model?
Although I have sketched the shape of a possible debate over the correctness of a recovery model, supporters of the recovery approach have not in general proceeded in this way. They have not offered arguments for the correctness of a recovery model as the only appropriate or valid conception of mental health or aim of mental healthcare. Rather, they have put it forward as a desirable approach to mental healthcare. How should that be understood and does it undermine the idea of a recovery model?
The argument sketched above turns on the role of values in an articulation of the content of the aim of mental healthcare. (To repeat, all can agree that the fact that it is an aim means that it is valued. But there can be disagreement on whether the identification of the state to be aimed at itself presupposes any evaluative or normative language.) Thereafter, however, the argument turns on whether the recovery model is more descriptively accurate than a rival non-evaluative or plainly factual model. The best argument for a recovery model is that the alternatives cannot plausibly describe the aims of mental healthcare because, it seems, those aims turn on a conception of a life worth living which will be individually tailored.
Such a view accepts a particular construal of the debate: models are to be assessed as to whether they are valid – in the sense of getting something right – or true. Given an antecedent set of views of health and illness and the proper aims of healthcare, some models capture those views more accurately. But that is not the only way of thinking about the debate.
To explain this, it is helpful to contrast the debate about recovery with philosophical debate about moral values and judgements. In that debate, although there is disagreement about particular ethical judgements in difficult cases, there is sufficient agreement about the broad outline of the practices of making moral judgements to make descriptive accuracy a rational aim of meta-ethical or moral philosophical debate. Although the adoption of a philosophical theory of moral judgements might force the revision of some judgements, the practices serve as a standard for testing the philosophical theories. It is thus a rational claim by rival supporters of Kantian deontology, utilitarianism or neo-Aristotelian moral particularism to say that their particular account, by contrast with the others, is the correct description of our moral practices and, unless we are widely in error in those moral practices, of the moral realm itself. Thus, although the debate concerns the nature of moral values, an approach may rationally aspire to being factually or descriptively correct or truthful account of them.
It may be, however, that there is a key disanalogy between debate about moral judgement and debate about the proper aims of mental healthcare. I have characterised the latter as concerning health (or something like it). But it does not seem that the recovery model simply aims at health. It aims, rather, at a richer conception of flourishing: the living of an autonomously chosen life. That, in turn, suggests that it may not be put forward so much as the most descriptively or factually accurate conception of the (possibly evaluative) aims of mental healthcare as itself the most desirable. If so, it is doubly evaluative. Not only does it claim that the aims of mental healthcare are not simply factual but rather evaluative or normative (right for the particular individual) but it also presupposes that the debate about the nature of those aims is itself a matter of values not just of facts. The recovery model is not so much supposed to be true as desirable. That it should be adopted is a ‘should’ of value rather than of truth or fact.
If so that marks a disanalogy also with the example of the social constitution of mental illness raised at the start. In that debate, the claim that mental illness is a matter not of individual bio-medical facts but rather societal relations is not put forward as a value in itself. The arguments for a socially constitutive view aim to capture or describe the real nature of mental illness (or what is mistakenly confused with mental illness in Szasz’ case) rather than as a desirable way to think about things. When supporters say that mental illness should be understood as constituted by social relations the ‘should’ is the ‘should’ of truth not desirability.
But given that I presented that case as an example of a healthcare model, does the disanalogy threaten the idea that a recovery model could be proposed in this way – as desirable rather than true – but still count as a model?
I do not think so. Even when proposed in that way, it is a theoretically articulated conception of the business of healthcare. It stands to past healthcare practices as idealised political structures (such as a socialist utopias or a fully deregulated market economies, depending on one’s politics) stand to present social and political actualities. Whilst an idealised political model is not simply a description of any present society, it is a complex of fact and value which includes claims about how societies could function and what would be the consequences of that.
Arguments for political utopias have to make the case that we should adopt such systems because they are valuable. Socialism is not true, but desirable, according to its supporters. But arguments for its desirability will involve some claims which purport to truth. One might argue, for example, that socialism promotes equality and that more equal societies tend to be happier societies. If happier societies are to be valued, then that might form the basis for adopting a socialist structuring of society. Opponents might argue that socialist societies tend to generate less wealth including for those at the bottom end of the income level. Given that wealth is to be valued, then that that might form the basis of an argument against that social structure. Both arguments mix facts and values.
Equally, if the recovery model is proposed with the ‘should’ of desirability, arguments for it will mix facts and values. They might concern facts about symptoms, suffering and stigma. But at the same time they appeal to a ranking of one over another which is a matter of value not fact. There is thus no conflict between articulating a recovery model, by contrast with a mere approach, and putting it forward not because it is a true account of the aims of healthcare as they presently stand but rather as an account of desirable possible or potential aims, albeit ones which are recognisable as relevant to current practices. They still concern healthcare broadly construed, for example.
Having now sketched the broad outline of a possible recovery model and distinguished two kinds of argument for it (based either on its descriptive truth or its value) I will now turn to a distinct question. Would such a model require, or at least motivate, the adoption of a different approach to understanding? Would it rationalise the adoption of a narrative approach to understanding, by contrast with the criteriological diagnosis more familiar within a broadly bio-medical model?
The link to narrative
There have been a number of claims that there is a close direct connection between narrative understanding and recovery. One indication of this is the proliferation of ‘recovery stories’ as part of the promotion of the recovery approach. These explore:
the personal and existential dimensions of recovery, taking the form of subjective and self-evaluated accounts of how an individual has learned to accommodate to an illness. These accounts have become the founding stories of the recovery movement [e.g. Chamberlin, 1978; Lovejoy, 1984; Deegan, 1988, 1996; Leete, 1989; Unzicker, 1989; Clay, 1994; Coleman, 1999; Ridgeway, 2000], and anthologies of these personal stories have been used by governments and professions as a means of combating stigma and reasserting a focus on personal perspectives [Leibrich, 1999; Lapsley et al, 2002; Ramsay et al, 2002]. [Roberts and Wolfson 2004: 38-9]
More generally it is claimed that people who have suffered mental illness can be helped towards recovery through a narrative based theory. Pat Bracken and Phil Thomas, for example, cite both Larry Davidson and Glen Roberts.
In their work on recovery, both Davidson and Roberts choose not to use an approach grounded in traditional descriptive psychopathology, but turn instead to narrative theory and methods, seeing this as providing a rigorous empirical and clinical methodology in helping people suffering from chronic psychosis to move to recovery. [Bracken and Thomas 2009: 245]
On this view, narrative theory informs clinical work which is distinct from traditional Jasperian descriptive psychopathology and which, they suggest, is both intellectually rigorous and therapeutic.
Roberts himself makes the connection between recovery and narrative even closer (or at least even more explicit). By contrast with Bracken and Thomas, he sees a narrative view as consistent with Jaspers’ view of understanding (by contrast with explanation).
A narrative view values content, and in seeking to understand delusions and hallucinations, as opposed to explaining them [Jaspers 1974], one is engaged in re-contextualising the illness in the life experience of the individual. This in turn may inform the rehabilitation process and give insight into the complexities of recovery, which for some will include the loss of the compensations of delusional beliefs and re-engagement with the implications of having a severe mental illness and what preceded it [Roberts 1999]. [Roberts 2000: 436]
But he goes on to suggest (or at least, to repeat, to make explicit the idea) that subjects or patients themselves possess a narrative understanding (rather than just clinicians) and it is this which can help or hinder them in recovery.
Patients with self-sufficient, unelaborated, dismissive narratives need to be encouraged to break open their defensive stories and consider other possibilities. Conversely, those who seem unable to find a narrative thread and to be drowning in the chaos of their experience need help to find a shape and pattern that enables them to fit things into place [Holmes, 1999]. In therapy, patients learn to build up their storytelling capacity, their “autobiographical competence” [Holmes, 1993]. [Roberts 2000: 436]
Across the literature there is evidence of an idea that narratives structure subjects’ lives in such a way that partially determines what seems possible to them. Therapists can propose new life ‘plots’ and help map out new possibilities in the face of mental illness and hence new possibilities for recovery. To take a non-mental health example, therapists can propose new plotlines to spinal cord injured patients for whom there is, sadly, no going back to their past able-bodied plots. They have suffered a kind of ‘narrative wreckage’ from which they need rescuing in a dialogue with therapists.
Whilst that direct connection between narrative understanding and recovery is potentially an important clinical one, it is not a necessary connection. Exploring the options for a flourishing life through the idea of stories may in itself be directly therapeutic for many people, but it is possible that such an approach might fail because, for example, it tended to remind people of what they could not do. Since my aim is merely to explore the logical geography for a recovery model, I will sketch a more modest alternative connection between recovery and narrative understanding which is not hostage to empirical fortune. (Sad to say, this makes the connection rather less interesting.)
What is the conceptual or logical connection between a recovery model and narrative understanding? On the proposal I have sketched, a recovery model is health- or wellbeing-orientated rather than illness-orientated and it is evaluative (that is it involves values as well as facts) rather than plainly factual. In sum, it is an evaluatively-rich, person-specific conception of the aims of mental healthcare.
Narrative theorists typically articulate components or aspects of narratives in different, rival ways, albeit with some significant overlap. For example they may divide narratives into: abstract, orientation, complicating action, evaluation, resolution and coda. Or, alternatively: temporality, people, action, certainty (or not) and context. By decomposing a whole story into such elements narrative theorists can arrive at a generalisable sub-structure which still stop, they hope, short of a positivist or reductionist analysis.
On the face of it, there is no obvious necessary connection between these two things. But that, I think, is because this is an overly restrictive conception of narrative understanding. Whilst narratives may often have the elements narrative theorists favour, and whilst this may contingently be true of the kind of ‘recovery stories’ often published in support of the recovery approach, there is no need to link the whole of narrative understanding to any particular theory of the component parts of narratives. But if not that, what does characterise narrative understanding?
I propose a modest account. It is the kind of understanding that connects together beliefs, desires, intentions and so forth in rational patterns. It deploys a framework of propositional attitudes whether this is thought of as codified in an implicit ‘theory of mind’ or more directly applied in response to behavioural expressions or through empathy. It is thus broader and narrower than a particular literary style: narrower, in that it is restricted to the understanding of rational agents rather than any sequences of worldly events. Not all stories are stories of human agency. But it is also broader, in that it is presupposed by any particular story of rational agents.
Indeed, Wilfrid Sellars argues that it runs deeper than that. The central role of this approach to understanding other people stems from the fact that that it employs the very same form of reasoning necessary for being a rational agent oneself.
The ‘manifest’ image of man-in-the-world …is… the framework in terms of which man came to be aware of himself as man-in-the-world… [A]nything which can properly be called conceptual thinking can occur only within a framework of conceptual thinking in terms of which it can be criticized, supported, refuted, in short, evaluated. To be able to think is to be able to measure one’s thoughts by standards of correctness, of relevance, of evidence. [Sellars 1963: 6]
Sellars’ idea seems to be this. Just as to be capable of thought – of rational or conceptual thought – requires an ability to assess one’s reasons for belief and action, so that same ability is what forms the basis of ascription of mental states to others. This is not the same as saying that selves are constituted by narratives. It is a weaker claim that rational agents, who may or may not be the same as selves, are describable by narratives in the sense described here. This is enough, however, to mark an important distinction from the criteriological or nomological explanation that characterises diagnosis of mental illness and thus suggest a distinct role for understanding in underpinning a recovery model.
Narrative judgement contrasts with nomological or lawlike understanding or explanation because it is normative. Narrative judgements thus answer to a different kind of internal logic to non-normative nomological accounts. In the vocabulary John McDowell has developed from Sellars, they belong to the ‘space of reasons’ rather than the ‘realm of law’ [McDowell 1994].
That makes it particularly appropriate for the recovery model, as I have outlined it. If the proper aim of mental healthcare is an endpoint selected as what is hoped for valued by a subject as right for him and her as a mode of being then it is an endpoint that has to be weighed and evaluated for reasons. The characterisation of the endpoint is not independent of why it is wished for. And thus it is tied to a subject’s reasons, explored through narrative understanding.
I have attempted to address the question of what sort of model a recovery model would be. In doing that, I have assumed that to count as a model it must not merely aim at recovery, since any model might do that, but it must involve a conception of what health or a related but broader notion is. Using a pair of distinctions - between health and illness and between an evaluative and plainly factual account – I suggested that the recovery model is an evaluative conception of the mental health, broadly construed, of a subject, a state right for him or her and supported by reasons.
Having sketched the logical space for a recovery model, I considered whether it could be justified. One approach would be to show that no alternatives are coherent accounts of the nature of mental health. But, although, there are promising lines of argument towards that conclusion it is not a simple matter. Furthermore, that is not the way the recovery model is usually supported. Like a political ideal, it is usually proposed not so much as a true account but a desirable one. But that need not undermine its status as a model.
Finally, the outline of a recovery model set out is consistent with the often made connection to a narrative approach. On the reasonable assumption that what marks out a narrative approach – by contrast, for example, with criteriological explanation in psychiatry – is that it is normative, that fits the idea that the aims of healthcare are selected for reasons.
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Tuesday, 19 April 2011

Revamped expertise website at Cardiff

Dear all,

We have very much revamped our expertise website

It should now be much easier to navigate and find stuff.


Professor Harry Collins

Wednesday, 13 April 2011

Mad Activism and Academia

I went to a workshop at UCLan organised by Mick Mckeown and Helen Spandler, yesterday, called Unsettling Relations: Mad Activism and Academia. It was organised in part because of a visit by David Reville and Kathryn Church (pictured) from the School of Disability Studies, Ryerson University, Canada with whom UCLan has a relationship.

The explicit theme for the day was how mental health service user experience could be brought into academic life. The implicit tension was how this could happen in a way which didn’t distort, abuse or ‘colonise’ service users.

One of the commentators suggested that a key aim often missed was to value the lived experience of service users. Another said that academic researchers should not merely benefit from the experiences of service users: they should also give something back. A third (a service user researcher) expressed concerns about the idea of undergoing a PhD viva examination in order to validate her experiences. They needed no such validation, she argued, because they were valid in themselves in virtue of her having had them.

These concerns seem to me to be substantial and understandably motivated. But I wonder whether part of the problem is something that runs deep and confuses the issues. One of the central aims of academia is understanding and analysing the world, including the world of human subjectivity. Thus there is a difference between the having of experiences and finding a way to understand them. A key approach to such understanding is to draw out what is general in particular cases, for example by subsuming instances under general concepts. That is one very important way in which individual experiences might be valued in academic life: they exemplify a pattern and thus serve as a basis for prediction or explanation. So there is more to understanding than a mere re-presentation of an experience. Thus it is a kind of category error to think that experiences might – or might not – be validated in a viva: it is the analysis of the experiences that might be not the experiences themselves.

If so, I wonder whether issues become confused when what is to be valued, and how, becomes confused. One can indeed value and respect someone’s experiences. Suffering, to take one example, seems to demand a kind of respect as well as sympathy in its own right. But I don’t see that as primarily an academic matter but rather a more general inter-personal obligation. By contrast, the kind of valuing that belongs particularly to academia is the value of understanding, in this case, experience.

The potential for a confusion between experience and an understanding of experience seemed to me increased by the main mode of presentation at the workshop. Most of the ten presentations took the form of first person narratives. Now a narrative is not simply a brute presentation of experience. Kathryn Church, for one, made explicit reference to how much and how often she had worked on parts of her own self-account. (Her book, by the way, carries the subtitle: Critical Autobiography as Social Science.) There’s an implicit analysis in the selection of what is presented and what not. But none of these stories attempted to advance an argument or make a general claim. By the end, I wondered whether the sequence of particular cases was part of the problem. With merely an aggregation of individual cases and an eschewing of an argument to a general claim, it was hard to frame a good reason to change one’s mind on anything. What follows from any, possibly unrepresentative, particular case?

PS: For a related point which grew from this workshop see this later entry.

Thursday, 7 April 2011

Draft commentary on Pies, Thommi and Ghaemi

Ronald Pies, Sairah Thommi and Nassir Ghaemi,
(Professor of Psychiatry and Lecturer on Bioethics & Humanities, SUNY Upstate Medical University; and Clinical Professor of Psychiatry, Tufts University School of Medicine; Research Assistant, Mood Disorders Program, Tufts Medical Center; and Professor of Psychiatry, Tufts University School of Medicine; Director of the Mood Disorders Program, Tufts Medical Center)
have written a paper called ‘Getting It from Both Sides: Foundational and Anti-Foundational Critiques of Psychiatry’ for the AAPP Bulletin commentary process.

Their papers begins:
“Modern-day psychiatry has been the target of numerous social, philosophical and scientific critiques over the past century, sometimes lumped together as manifestations of “anti-psychiatry.”  The aim of the present paper is to place the critics of psychiatric theory and practice in the broader framework of two philosophical traditions: logical positivism and post-modernism. Even more broadly, we want to distinguish two “meta-categories” of philosophical discourse, which we call “Foundational” and “Anti-Foundational.”  To oversimplify greatly, logical positivism may be considered a subset of foundational philosophies; and post-modernism, a subset of anti-foundational philosophies.  We make the latter claim, fully aware that the term “post-modernism” is subject to many interpretations; is sometimes considered vague to the point of meaninglessness; and is, in some ways, more a literary and cultural attitude than a well-articulated philosophical position.  Nevertheless, as a particular subtype of anti-foundational philosophy, post-modernism remains a useful heuristic term in understanding various critiques of psychiatry.
The burden of this paper will be to outline the historical roots of foundational and anti-foundational philosophies; describe how these philosophies have provided the basis for a “double-barreled” assault on modern-day psychiatry; and finally, to adumbrate very briefly why both kinds of attacks on psychiatry are generally unfounded.  First, however, we need to provide at least a notional idea of what the term “antipsychiatry” encompasses.”

My very rough draft commentary runs – today, at least – as follows:

Why taxonomise anti-psychiatry?
Of all disciplines, psychiatry is particularly keenly aware of the importance of a good taxonomy. Whilst in some scientific disciplines the explicit focus is on explanatory theories and there is only implicit attention to the taxonomies they presuppose, in psychiatry, getting the taxonomy right is one of the key foci of intellectual endeavour. This attention has helped reveal different virtues of taxonomies. Thus until recently, the key virtue aimed at for the DSM taxonomy has been reliability: roughly, the non-collusive agreement in applications of the taxonomy in classificatory judgements.
For DSM V, the key aim is, we are told, validity. But even validity can be subdivided. It might mean, for example, any of these or others:
·         Face validity: the extent to which a classification appears to be of relevant features (which has consequences for the acceptability of tests to test users ad subjects [Rust and Golombok 1989: 78]).
·         Construct validity: roughly, the extent to which it relates to underlying theory. Kendell articulates this thus: ‘the demonstration that aspects of psychopathology which can be measured objectively… do in fact occur in the presence of diagnoses which assume their presence and not in the presence of those which assume their absence’ [Kendell 1975: 40]. Anastasi says it is ‘the extent to which the test may be said to measure a theoretical construct or trait’ [Anastasi 1968: 114].
·         Predictive validity: the extent to which the classification allows us to predict future properties.
·         Content validity: ‘the demonstration that the defining characteristics of a given disorder are indeed enquired into and elicited before that diagnosis is made’ [Kendell 1975: 40].
So it is appropriate in thinking about a proposed taxonomy of forms of criticism of psychiatry – forms of anti-psychiatry – to examine the intellectual virtue of the proposal in something of the same spirit as critical reflection of psychiatric taxonomy itself. In this case, my concern is not so much whether anti-psychiatry can be divided into forms which are foundational and forms which are anti-foundational (although I do have worries about quite how this is proposed). It is rather whether we learn anything from doing that. I am not sure that we do.
An initial requirement for the taxonomy
I can illustrate one challenge to a taxonomy of this sort by looking at the business the paper sets itself. Called ‘Getting it from both sides’ it says:
The burden of this paper will be to outline the historical roots of foundational and anti-foundational philosophies; describe how these philosophies have provided the basis for a “double-barreled” assault on modern-day psychiatry…
A key theme is that psychiatry is criticised from both sides of a distinction. This sets up a particular kind of expectation about the significance of the duality that forms the taxonomy which I will illustrate indirectly.
One way to fail to meet the expectation would be to propose a taxonomy of forms of anti-psychiatry based on the position in the alphabet of the first letter of the first author of the attack. If this were a simple duality – of first half versus second half – then (given the names ‘Foucault’ and ‘Szasz’, eg.), psychiatry would come under fire from both sides, a ‘double-barreled’ assault on modern-day psychiatry if you like. In that hypothetical case, there would, however, be no significance (such as, perhaps, a bitter irony) that psychiatry were attacked from both sides. Although the distinction is in one sense perfectly valid, and cuts anti-psychiatry at the joints of author nomenclature, it fails something like construct validity. It fits no deeper theory of anti-psychiatry.
So one test of the proposed taxonomy is that it does have significance. The ideas of foundationalism and anti-foundationalism should shed light on the nature of the anti-psychiatry in a way that mere surnames do not (because of the ‘arbitrariness of the signifier’ as Postmodernism, in particular, has taught us to say).
But there is a worry from a potential response to this. Suppose that from anti-foundationalist premises, a form of anti-psychiatrist were justified, it followed logically. And from foundationalist premises, another form of anti-psychiatrist were similarly justified. Then on the assumption that either foundationalism or anti-foundationalism is true, some form of anti-psychiatry would be justified come what may. So, as far as a defence of psychiatry goes, we had better hope that the relation of significance (between the category and anti-psychiatry) is not implication.
Whatever the kind of significance turns out to be, at the very least, some kind of light should be shed on anti-psychiatry by seeing it in the context of the taxonomy.
What is foundationalism?
The paper suggests that foundationalism has two key aspects. One is a traditional epistemological notion. Knowledge is based on a foundation (of experience, or belief) which is not itself (inferentially) dependent on anything else.
Logical positivism in its various forms is a modern-day expression of the foundational world-view...  [It] essentially held that all knowledge is based on logical inference grounded in observable fact...
Foundationalism, in this traditional epistemological sense, is usually held to contrast with forms of holism which deny that any of our beliefs, such as perceptual beliefs, are privileged and instead each is potentially subject to revision. A belief in the theory dependence of observation is one reason to support holism in the philosophy of science.
The other aspect is expressed in this way:
In simplest terms, foundational philosophies and philosophers hold that we can reliably describe a coherent, objectively-measurable “reality” or “truth,” whether one considers the world as a whole, or specific aspects of it, such as the classification of disease.  Anti-foundational philosophies and philosophers deny this claim, asserting that there are no objectively demonstrable “truths”—only various “perspectives” or “narratives” that cannot be privileged as uniquely or objectively “true.” 
Whilst this does contain an epistemological element in the claim that our descriptions can be reliable, the main thrust is ontological. It is the idea that foundationalists hold that there is an independent world to serve as a standard for truth. Elsewhere they describe this as ‘a confidence — some might say, a faith — that the world and its constituents actually exist’. This aspect would often be described as a form of (ontological) realism which contrasts with the anti-foundationalists’ claim that there are no objectively demonstrable truths.
(It may not be quite realism in a standard form, however, since the most obvious opposition to ontological realism is idealism, whilst the authors take Berkeley to be a foundationalist: ‘Berkeley effectively dispensed with the concept of material substance, but most certainly was a foundational philosopher: he merely argued that the “foundation” of reality consisted of ideas in the mind of God!’ But even in this case, the idea may be that whatever the substrate of the world, it is independent of claims made about it. That serves as a test of truth and thus stands in contrast with the anti-foundationalists’ mere interplay of narrative.)
There is some danger in combining both these aspects – epistemological and ontological – under a single term which can be illustrated by a philosopher mentioned in the paper: Quine. In his famous paper ‘Two dogmas of empiricism’ Quine explicilty rejects the idea of foundations when he rejects the’ dogma of reductionism’ which is the ‘supposition that each statement, taken in isolation from its fellows, can admit of confirmation or infirmation at all’. [Quine 1953: 41] But he continues ‘My counter suggestion… is that our statements about the external world face the tribunal of sense experience not individually but only as a corporate body.’ So whilst he rejects privileged epistemological foundations he does not reject the idea that our beliefs answer to something independent of us.
This is significant because that combination of ideas is the dominant view held by philosophers and self-conscious scientists alike. Epistemological foundationalism is dead. No observation is thought to be free of its theoretical context and thus, like any scientific statement, is fallible. But rejecting that view does not commit one to a denial that our beliefs answer to a world largely independent of us, nor to the embrace of mere shifting narratives.
Given that the taxonomy is offered, not for philosophy as a whole, but rather for anti-psychiatry, it might be that no anti-psychiatrist fails to combine the appropriate epistemological and ontological views. But if the taxonomy is to shed light on anti-psychiatry, such correlations should be explicit and subject to explanation rather than hidden in the taxonomy.
The application of the taxonomy
Having set up the taxonomy, the authors apply it to particular critics of psychiatry. I will discuss just the first: Szasz. Responding to a recent summary by Szasz of his original argument they say:
A full-blown critique of this argument is beyond the scope of this paper.  However, it is instructive to note some of the key “properties” of Szasz’s claim: (1) It is based on an implicit assertion that “analytic truths” are not empirically falsifiable—a claim that Quine is at pains to challenge; (2) It appears to remove from the realm of scientific investigation the question of whether schizophrenia or bipolar disorder, for example, are diseases or illnesses; (3) It conflates the terms “disease”,“illness”, and “disorder” without any attempt to discern conceptual or clinical distinctions among them; and (4) It implies that there is a single, univocal “materialist-scientific definition of illness” to which one can appeal, and which then can be used unambiguously to compose an “analytic truth.”  Also note that the hyphenated term “materialist-scientific” implicitly suggests that science and “materialism”—roughly, the view that the only thing that exists is “matter”—are linked in some essential way.
In the context of a paper suggesting a categorisation of anti-psychiatry, I would expect that this list would demonstrate how Szasz fits his assigned place: foundationalism. And indeed, pace my worries about Quine, the first point does. Szasz is within a tradition of philosophy which accepts analytic truths and Quine, at least, has argued that this is an important part of foundationlism. Point 2 does not obviously exemplify the category but, perhaps, neither does it contradict it. Point 3 seems to lie simply outside the terms of the taxonomy. One might be guilty of this which ever side one belonged to. Likewise, point 4 does not seem to be an effect of or have anything to do with foundationlism.
That is a bit odd. Only the first point helps locate Szasz on the foundationalist side of the taxonomy.
There is then an argument against Szasz. In a paper outlining a taxonomy, such an argument is not the main business. But it may illustrate what we learn from applying the taxonomy and thus why the taxonomy is helpful. The central argument runs:
Szasz’s argument purports to rest upon an analytic statement—similar in kind to “All bachelors are unmarried males”—while implicitly drawing upon the historical and empirical claims of “materialist” science. Yet any putative “materialist-scientific definition of illness”—to the extent we can even specify one—did not arise ex nihilo or out of some syllogism; but rather, from specific empirical observations of cells, tissues and organs, by pathologists like Virchow and von Rokitansky.  Thus, Szasz’s argument that “mental illness is a metaphor” seems to us far from a straightforward “analytic” claim; rather, it appears to be a pseudo-analytic claim that depends critically on a huge body of historical, synthetic and empirical claims.
One way of approaching this argument is to think that it helps demonstrate the value of the taxonomy. If Szasz is a typical foundationalist and if typical foundationalists presuppose the analytic-synthetic distinction, but if that is an invalid distinction (as Quine has argued), then Szasz’ argument will fail and it will fail because he is a foundationalist. That would be a partial vindication for the taxonomy. Putting him into that camp helps shed light on why he is wrong.
But it is not clear that that is what the authors intend here. The comment that Szasz’ claim is ‘far from a straightforward “analytic” claim; rather, it appears to be a pseudo-analytic’ suggests that an analytic claim might be in perfectly good order. The problem is not so much that Szasz is appealing to the notion an analytic truth, rather, he is doing that badly. If so, the problem with Szasz’ anti-psychiatry is not that it is foundationalist but that it is bad foundationalism. But if that is the case, the taxonomy of anti-psychiatry into foundationalism and anti-foundationism does not seem to be carving the nature of anti-psychiatry at the right – significant, informative – joint.
It is also worth noting that if that is not the meaning of that phrase and that any appeal to analyticity is misguided (thus preserving the point of the taxonomy for the foundationalist side), the key architect of the downfall of analyticity is Quine whom the authors call an anti-foundationlist. So why would not the failure of foundationalist anti-psychiatry be a partial argument, at least, for the success of an anti-foundationalist variant? In fact in the later parts of the paper, anti-foundationalist anti-psychiatry is criticised on grounds which do not even mention analyticity. Thus no light is shed on criticisms of anti-foundationalists in virtue of their analyticity-eschewing position in the taxonomy. In either case, at least one side of the taxonomy will not be informative.
A different taxonomy?
I think that it is a mistake to hope that a binary opposition which locate forms of anti-psychiatry on both sides will, in itself, be very helpful. How could it? If a binary distinction exhausts logical possibilities – if everything is either in the one or the other category – then all the positions we can take will be in one or the other. All forms of philosophical view which support modern psychiatry will be located rubbing up against the views which oppose them. The taxonomy will not ehd light on the difference between the pro- and anti- view.
I think that a more fruitful approach is a taxonomy of approaches to the nature of mental illness itself. Here are two, related distinctions.
One key disagreement is whether mental illness in particular, or illness more generally, is essentially evaluative. Does the analysis of mental illness contain reference to values or not? Some philosophers and psychiatrists argue that at the heart of the idea of illness is something that is either bad for a sufferer or is a deviation from a social or moral norm. Both of these are evaluative notions and hence both are ‘values in’ views.
Others argue that it is, what I will call, a plainly factual matter. Typically, they argue that illness involves a failure of a biological function and function – and hence deviation from, or failure of, function – is a plainly factual, biological term couched in evolutionary theory. Of course, disagreement about the presence or absence of values in the analysis is just one aspect of the debate. It is a further question, for example, what follows from this for the objectivity of mental illness and the status of psychiatry as a science. For Szasz this is the basis of an argument against psychiatry. For Bill Fulford (and the authors of the paper), for example, it is not.
A second useful characterisation links the debate about mental illness to other debates in philosophy about the place in nature of problematic concepts. On this second construal, the question is whether mental illness can be naturalised. That is, can mental illness be accommodated within a satisfactory conception of the natural realm?
The most common form of philosophical naturalism is reductionism which attempts to show the place in our conception of nature of puzzling concepts by explaining them in terms of, and so reducing them to, basic concepts that are unproblematically natural. So on this second characterisation of the debate, a pressing question is whether, or to what extent, the concept of mental illness can be reduced to plainly factual concepts. If it cannot be naturalised, to what extent is it consistent with a scientific account of the world.?
What makes reductionism difficult is that different concepts can seem to behave quite differently from one another. Take, for example, a distinction drawn from the work of the philosopher Wilfrid Sellars, and repopularised by John McDowell [McDowell 1994] between the ‘realm of law’ and the ‘space of reasons’. Whilst the space of reasons concerns meaning-laden and normative phenomena that we take for granted in understanding minds, the realm of law concerns events that can be explained by subsuming them under natural scientific laws. In the philosophy of mind, reductionists attempt to show how the space of reasons can be completely explained using the resources of the realm of law. Anti-reductionists argue that the normativity of mental states and meanings – the fact that beliefs can rationalise and support one another, can be right or wrong – cannot be captured in terms, for example, of statistical laws of association.
In fact, value theorists in the debate about mental illness are making a similar point to anti-reductionists in the philosophy of mind. They argue that the very idea of mental illness is a normative notion – since values are normative and have a good versus bad dimension – and for that reason cannot be reduced to plainly factual or realm of law terms.
Using distinctions such as these provides tools for the diagnosis of assumptions made both by those who oppose and those who support modern psychiatry. In the paper, the authors criticise one ‘foundationalist’ anti-psychiatrist in this way:
Stevens’ foundational critique is built upon a scaffolding of selective quotes from a large cadre of mental health professionals... all in the service of showing that we cannot identify any biological abnormalities in any of the major psychiatric disorders; and that, absent such physical “causes,” these conditions cannot be considered bona fide diseases.
Whilst I agree with the criticism they go on to make, I do not think that it helps to characterise Stevens as a foundationalist. The quotation does not imply anything about his epistemological views nor would ontological realism about an objective world help shed light on his particular brand of anti-psychiatry.
What is picked out in the quotation is an assumption that he has made about what counts as real: biological abnormalities. And thus he counts as both ‘values out’ and reductionist in the two distinctions above. This is not yet to provide an argument against his position. But it does help outline the commitments he needs to maintain. He owes an account of why biological abnormalities are all that can count as real in this context. A biologically minded reductionist supporter of modern psychiatry will agree with Stevens on that metaphysical claim and will have to look elsewhere to disagree. But an anti-reductionist supporter of psychiatry can target that assumption. The assumption – and hence his reductionism – sheds light on his position.
In sum, I think it a mistake to aim a taxonomy at anti-psychiatry rather than at views of mental health and illness (or disease or disorder) in general. It will probably, at least, not be particularly helpful. If the aim is, additionally, to attempt to undermine anti-psychiatry, then it seems doubly mistaken because it cannot work. If – and this is a key assumption – we were to assume, from the perspective of a defender of contemporary psychiatry, that anti-psychiatry were simply misguided then a helpful analogy might be with Tolstoy’s views of unhappy families in Anna Karenina. There is little point in aiming to taxonomise arguments against psychiatry because whilst valid views in support of psychiatry are all alike; every unhappy anti-psychiatric argument is unhappy in its own way. But to evaluate that key antecedent assumption, we will need valid general taxonomies of views of health and illness and nature in general.
Anastasi, A. (1968) Psychological testing, New York: Macmillan
Kendell, R.E. (1975) The Role of Diagnosis in Psychiatry, Oxford: Blackwell
McDowell, J. (1994) Mind and World, Cambridge, Mass.: Harvard University Press
Quine, W.V.O. (1953) ‘Two Dogmas of Empiricism’ in From a Logical Point of View, Cambridge, Mass.: Harvard University Press
Rust, J. and Golombok, S. (1989) Modern Psychometrics, London: Routledge