Tuesday, 19 April 2016

Lancaster workshop on impact

Very embarrassingly, I’ve been asked to contribute to a workshop on impact at Lancaster University. Embarrassing, since I have no impact case study and have never achieved impact as understood by the Act. But I believe that I am to talk at the start of the day, perhaps presenting a problem to be solved by those with brighter ideas as the day goes by. At the very least, I’ll learn something in return for my uneasy self-consciousness.

The difficulty of Wittgensteinian philosophy

The goal or target of achieving impact is more difficult for some subjects than it is for others. In general, the humanities do not have a technology. Equally, there isn’t an industrial setting for researchers in the humanities who do not wish to be based in higher education. Philosophy inherits these difficulties. Why?

I think that there are two characteristic claims made by philosophy.
  • This is how things are because this is how they must be. (The modal status goes some way to explain the lack of need for empirical justification.)
  • This is how things ought to be.
The latter seems the more likely source of impact - a normative claim aims to change the world - but is sadly unavailable to the philosophy of thought and language / metaphysics / epistemology etc. all of which are restricted to the former. Further, it is worse in some sub-disciplines of philosophical method, such as mine.

Wittgenstein argued that there were no such things as substantive philosophical problems calling for substantive explanation or theorising. Rather, apparent problems should be dissolved. By contrast with Marx’ claim that ‘The philosophers have only interpreted the world, in various ways; the point is to change it’ Wittgenstein says: ‘Philosophy must not interfere in any way… It leaves everything as it is.’ [Wittgenstein 1953 §124]. How then is impact so much as possible?

An autobiographical note

Having written my first book on Wittgenstein and a second on the Wittgensteinian philosopher John McDowell, I was approached in 1994, at Warwick University, by Bill Fulford to teach on his new Philosophy and Ethics of Mental Health masters programme. I knew nothing about the philosophy of psychiatry but Bill optimistically suggested that there would be connections between what I did know about and conceptual issues lying behind mental healthcare and these would come to light in conversation with clinicians. That much was right.

The promise for impact of the new philosophy of / and psychiatry

Although a Wittgensteinian approach to the nature of philosophy raises challenges for achieving impact, the sub-disciplinary subject area of philosophy of psychiatry pulls the other way.

Whilst, in mainland Europe, philosophy carried out in the phenomenological tradition retained a close connection to psychiatry throughout the 20th century, Anglo-American or broadly analytic philosophy largely lost touch. Analytic philosophy of psychiatry has been reborn in large part as a response to the rise of the anti-psychiatry movement in the 1960’s. This was because, whatever its broader political underpinnings, the disagreement between anti-psychiatry and biologically-minded defences of psychiatry was a philosophical rather, than an empirical, disagreement. It thus prompted a fresh philosophical examination of the nature and conceptual underpinnings of psychiatry.

This new ‘philosophy and psychiatry’ (where ‘and’ means both ‘and’ and ‘of’) is a joint enterprise of philosophers and psychiatrists with co-editorships of key books and journals. The international network (the International Network of Philosophy and Psychiatry) holds conferences attended by both academics and practitioners. The issues and problems that interest clinicians reflect conceptual as much as empirical issues:
  • the nature of illness or disease and of recovery;
  • the objectivity of psychiatric taxonomy;
  • issues about the mind-brain relation;
  • capacity;
  • the justification for coercion.
These all look philosophical (and I’ve published on all of them). So surely philosophical analysis of these issues provide a route to impact?

Further, there are examples of impact (though whether or not strictly REF-able impact, I’m less sure, because I am not sure how the explicit paper trail works). For example, Fulford’s analysis of the concept of mental illness draws not on Wittgensteinian philosophy but on a related equally descriptive movement: Oxford ordinary language philosophy. He argues on the basis of analysis that the concepts of mental illness and physical illness are both value laden (and hence both sides in the major 1970s debates are wrong) but that only mental illness looks value-laden because there is widespread disagreement about the relevant values by contrast with agreement on the values pertaining to physical health and illness. If so, however, then the influential stress on evidence based medicine is incomplete without a worked out form of values based practice which Fulford then articulated (though contentiously cashed out in merely subjective terms). Since then he has been assiduous in promoting this in clinical training with some successes. He has now set up Collaborating Centre for Values Based Practice at St Catz, Oxford to act as a focus for interested clinicians and academics.

That looks like a flow of ideas from the analysis of concepts to some practical consequences for how mental healthcare should be carried out, though the grounds for impact depend on moving from the first to the second key philosophical claim (from how they are to how they should be).

But despite that rationale, it has proved surprisingly difficult for me.

Here are two possible leads but so far unfulfilled. The first seems a kind near miss; the second needs thought as to practical application.

Idiographic understanding

Attending a World Psychiatric Association conference, at Bill Fulford’s suggestion I attended a session organised by its president Juan Mezzich on person centred medicine and heard presentations on the role of a more comprehensive approach to psychiatric diagnosis called an idiographic formulation. It seemed to me that there was some confusion in what they – clinicians – meant by ‘idiographic’ and its connection to narrative.

Charged by my university to invite Mezzich and some of his colleagues to a workshop with a European service user movement at UCLan, I presented a critique of ‘idiographic’ understanding there and later at a workshop in London funded by the Department of Health. I wrote four overlapping papers, one for a humanities journal and two for psychiatry journals and one for a general medical journal. I was invited to present this at the main German annual psychiatry conference and more recently as the first non-Italian plenary speaker at the Italian national clinical psychology conference from which two further publications will emerge.

But, whilst the papers have a thesis, the general issue of how to devise a broader diagnosis was of interest to the WPA and remains part of the Person Centred Medicine movement and is also of concern to mental health service users, pushing a model of what is involved hasn’t connected to non-academic impact.

Tacit knowledge and clinical judgement

The academic itch draws on the problem of understanding individuals: the intuition that clinical skill involves something other than codified knowledge. Further, a role for clinical expertise in addition to research evidence was set out in one of the founding books on evidence based medicine. One possibility is that this extra element is tacit knowledge. I have written four papers, two chapters and a book on this issue, one of which is my most cited paper and has been cited across a range of disciplines and linked to a number of different areas.

At conferences, the idea of there being a distinct and intellectually respectable form of knowledge which, nevertheless resists codification, finds favour with clinicians for whom it seems to have ‘face validity’. But how to connect gentle interest to impact?

(My first thought: a network on the epistemology of values based practice on a version which is not cashed out in subjective terms and to connect to the Collaborating Centre for Values Based Practice.)

A few tentative conclusions

Impact is harder to achieve if one’s discipline is constitutionally averse to changing anything!

In philosophy, normative claims – about how things should be – look easier ways to draw out practical import than descriptive claims about how they are.

But given a partner discipline with its own practical problems, even philosophically therapeutic work could, at one remove, have practical consequences.

That, however, doesn’t make the connection easier and, in my own case, I suspect that a psychological resistance probably plays a role in defaulting to relatively pure philosophy instead. I can always return to writing a paper / chapter with relatively certain chance of publication.


Some years ago I worked as an administrator at the LSE within the space planning and facilities management division. It was the time of the LSE’s attempt to buy County Hall for a peppercorn as a way once and for it to solve its space shortage. In the meantime, it needed a large auditorium and considered buying a neighbouring theatre. Sadly for the LSE, the theatre was governed by planning laws which did not allow it to be ‘dark’ for more than a certain fraction of the year. Thus if the LSE bought it, this could not stop it continuing to be run as a theatre. I arrived at work one morning to discover my then boss pouring over self-help books describing the role of the theatre impresario. Although by training and career he was a university administrator, if solving the space problem that was his responsibility required that he learn how to commission plays and assemble a company of actors, that consequence would not stop him. That attitude, I suspect, is needed to milk impact out of a descriptive humanity.