Thursday, 12 March 2015

‘The co-production of what?’ Notes for a workshop at Keble College, Oxford

I am giving a talk at a workshop in Oxford next week called Therapeutic Conflicts: Co-Producing Meaning in Mental Health. I suspect it’s a closed mulling-things-over event as I’ve not noticed any publicity for it. The background is:

‘Therapeutic Conflicts: Co-Producing Meaning in Mental Health’ is a year-long project involving Edward Harcourt (Principal Investigator), Anita Avramides, Bill Fulford, Matthew Broome (Co-Investigators), Toby Williamson, David CrepazKeay (Partners, Mental Health Foundation) and Elianna Fetterolf (Post-Doctoral Research Fellow). The project grows out of three interdisciplinary half-day workshops in 2012-13 organized jointly by the Oxford Faculty of Philosophy and the Mental Health Foundation, and starts with a problem in the delivery of mental health services - roughly put, the problem of ‘shared words, unshared understandings’ - which (we think) is why some recent mental health initiatives have achieved less than intended. We then bring to bear some philosophical tools – for example from the philosophy of language and from epistemology – to theorize this problem and to propose ways in which it might be addressed.’

My own thoughts are, sadly too obviously, very preliminary and rough.

The co-production of what?

Ground rules: ‘Co-production’ implies something more than joint discovery. Joint constitution, perhaps. If so, it carries conceptual costs. Philosophy as accountancy (rather than determining what one should think on an issue, it counts the philosophical costs in terms of necessary other supporting commitments of the various options). But even joint discovery deserves investigation if it is not merely an accidental matter.

I will sketch four possible options although there is no reason to think them exhaustive. Co-production might apply to any of the following (in the reverse order of the clinical process)
  • Recovery
  • Idiographic formulation
  • Criteriological diagnosis
  • Diagnostic categories / taxonomy
1: The co-production of recovery

More precisely, the co-production of an individually tailored conception of recovery. However ‘recovery’ is a contested notion lacking agreed meaning. See for example:

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]

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]

It seems to me that there are two broad senses of recovery. The first reflects a conventional view of getting better. The second is the modification applied within mental healthcare in the last 20 years or so.

Recovery1: a return to statistical normality (from a position which may, or may not, be evaluatively characterised, depending on the account of illness).
Recovery2: a move (from a position which may, or may not, be evaluatively characterised, depending on the account of illness) to an evaluatively characterised endpoint, eg.: a conception of a valued form of life.

The latter fits some views of recovery in mental healthcare.

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. [Shepherd, Boardman & Slade 2008]

Does this latter notion of recovery fit co-production, is it apt for it? One, after all,  might think that recovery should be, solely, patient-or subject-produced rather than co-produced. But it depends on which of two conflicting views one takes. Contrast this views:

There can be no recovery without self-determination… Mental illness may pose an obstacle to the person’s achievement of the kind of life he or she wishes to have, may make it more difficult to live that life, and, at its most extreme, may even deprive the person of life altogether. In none of these cases, though, does mental illness fundamentally alter the basic nature of human beings, which is that of being self-determined agents, free to choose and pursue the kind of life they as individuals value. Mental illness does not rob people of their agency, nor does it deprive them of their fundamental civil rights. [Davidson 2009: 4-1]


Deprivation and disgrace can so corrode one’s self worth that aspiration can be distorted, initiative undercut and preferences deformed. Sensitive work will be needed to recover that suppressed sense of injustice and reclaim lost possibility. [Hopper 2007: 877]

The latter view sustains co-production because the subject may need a second view of what is available by way of a flourishing life. Contra Davidson, mental illness may rob people of their agency (though not their civil rights). It may, however, look a matter of mere co-discovery. But the point of recovery is to adopt a view of a way of living, to determine it to be one’s conception of flourishing.

2: Co-production of idiographic formulation

The WPA initiative Psychiatry for the Person calls psychiatric diagnosis or, more broadly, psychiatric formulation to include an idiographic element. A comprehensive model or concept of diagnosis to include as Idiographic (Personalised) Diagnostic Formulation.

This comprehensive concept of diagnosis is implemented through the articulation of two diagnostic levels. The first is a standardised multi-axial diagnostic formulation, which describes the patient’s illness and clinical condition through standardised typologies and scales... The second is an idiographic diagnostic formulation, which complements the standardised formulation with a personalised and flexible statement. [IDGA Workgroup, WPA 2003: 55]

Could idiographic formulation require co-production? Three possibilities strike me.

i: The co-production of the meaning of the account. Cf the social constructionist view of meaning of discursive psychology.

In keeping with the discursive approach to psychology, this study is based on the principle that meanings are jointly constituted by participants in a conversation.
From the discursive point of view, psychological phenomena are not inner or hidden properties or processes of mind which discourse merely expresses. The discursive expression is… the psychological phenomenon itself…
Personhood can be an interpersonal discursive construction, a property of conversations...
‘The mind’ is no more than, but no less than, a privatised part of the ‘general conversation’. Meanings are jointly constructed by competent actors in the course of projects that are realised within systems of public norms’
[Sabat and Harre 1994: 144-146]

But constructionism about meaning comes at a high philosophical price. (For the literature, see discussions of Wittgenstein on rules and especially responses to Kripke’s interpretation of Wittgenstein.)

ii: The requirement for the re-shaping of the subject’s narrative of a formulation by a clinician.

Giving voice to the WPA approach to an idiographic formulation, the psychiatrist Jim Phillips wrote this:

In the most simple terms, a narrative or idiographic formulation is an individual account with first-person and third-person aspects. That is, the patient tells her/his story, with its admixture of personal memories, events, and symptoms, and the story is retold by the clinician. The latter’s account may contain formal diagnostic, ICD- 10/DSM-IV aspects, as well as psychodynamic and cultural dimensions not found in the manuals. The clinician’s account may restructure the patient’s presentation, emphasizing what the patient didn’t emphasize and deemphasizing what the patient felt to be important. It will almost certainly contextualize the presenting symptoms into the patient’s narrative, a task which the patient may not have initiated on her own. Finally, the clinician will make a judgment (or be unable to make such a judgment) regarding the priority of the biological or the psychological in this particular presentation, and will structure the formulation accordingly. [Phillips: 2005: 182]

But this seems to subsume formulation under criteriological diagnosis. That is, it is refashioned not as a thing in itself but in the terms of a conventional diagnosis. Further, the priorrty of the clinicians editorial role looks paternalistic.

iii: The need to augment self-knowledge with external therapeutic insight

Cf psychotherapeutic approaches.
Cf Hopper’s view of recovery.
One may not be the best interpreter of one’s own life. A self-narrative may benefit from an interaction with a therapist. If so, however, this interpretation of co-production looks merely epistemic. The co-production of the narrative, of the selectional decisions, perhaps, but not what is narrated.

3 Co-production of criteriological diagnosis

The co-production of diagnosis assuming fixed diagnostic categories. However, holding constant that diagnostic category, there does not seem to be much space for the co-production of say a cancer diagnosis except in the sense of epistemic achievement. Diagnosis is fixed by the biomedical facts.

But some, at least, putative mental illnesses seem to permit variation depending on the distress of, or harm to, or social dysfunction of the subject. (NB this sense of dysfunction is not meant to be Wakefield’s biological dysfunction which is meant to be purely factual.) Not a decision of the subject, perhaps, but their being ill turns on their reaction to the phenomena. The co-production is of the joint interaction of the phenomenological facts and the subject's reaction to them.

4: Co-production diagnostic categories

This turns on the broader question of the difference between difference and pathology exemplified in the debate about the status of deafness as either a disability or as an identity. The same is disputed with respect to voice hearing, for example.

I think that Zachar and Kendler’s distinction between objectivism and evaluativism helps:

Is deciding whether or not something is a psychiatric disorder a simple factual matter (“something is broken and needs to be fixed”) (objectivism), or does it inevitably involve a value-laden judgement (evaluativism)? [Zachar & Kendler 2007: 558]

Objectivism suggests no space for co-production as the facts, alone, fix the illness status. So co-production presupposes evaluativism: Whether something is a pathology, rather than a mere difference, is a value-judgement.

But how do values affect co-production? Again, a clue from Zachar and Kendler:

How do we respond to historical claims that slaves who had a compulsion to run away [drapetomania] and advocates for change in the former Soviet Union were mentally ill? An objectivist would claim that those classifications contained bad values and progress was made when those values were eliminated. Their opponents would claim that the elimination of bad values is not the same as becoming value-free, and progress has been made by adopting better values. [ibid: 558 underl;ine added]

Evaluative progress implies value judgement is disciplined. Contrast undisciplined subjective preferences. So co-production either as an unconstrained exercise of preference.
Or: a merited response to external moral particulars.

Well sadly I don’t really have any. Each of these options comes at a philosophical cost of squaring one’s other conceptual commitments.

Davidson, L., Ridgway, P., Wieland, M., & O'Connell, M. (2009). A capabilities approach to mental health transformation: a conceptual framework for the recovery era. Canadian Journal of Community Mental Health (Revue canadienne de santé mentale communautaire), 28(2), 35-46

Hopper, K. (2007) ‘Rethinking social recovery in schizophrenia: What a capabilities approach might offer’ Social Science & Medicine 65: 868–879

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

Sabat, S.R. and Harre, R. (1994) ‘The Alzheimer’s disease sufferer as a semiotic subject’ Philosophy Psychiatry and Psychology 1

Zachar, P. and Kendler, K. (2007) ‘Psychiatric Disorders: A Conceptual Taxonomy’ American Journal of Psychiatry