A wake-up call for British psychiatry?

There has been a bit of interest in my Institute in a recent short article by a group of UK psychiatrists in the BJPsych (Craddock, N. et al (2008) ‘Wake-up call for British psychiatry’ British Journal of Psychiatry, 193: 6-9) and responses to it. In the article, the authors argue in defence of a medical model for psychiatry in contrast to what they call 'non-specific psychosocial support'. (By the way, anyone arriving at this page via a search engine might wish to browse within this blog for further discussion of the philosophy of psychiatry and mental healthcare.) They begin:

British psychiatry faces an identity crisis. A major contributory factor has been the recent trend to downgrade the importance of the core aspects of medical care. In many instances, this has resulted in services that are better suited to delivering nonspecific, psychosocial support rather than a process of thorough, broad-based diagnostic assessment with formulation of aetiology, diagnosis and prognosis followed by specific treatments aimed at recovery with maintenance of functioning. These changes have been driven in part by government, but there has been both active collusion and passive acquiescence by psychiatrists themselves. Our contention is that this creeping devaluation of medicine is damaging our ability to deliver excellent psychiatric care. It is imperative that we specify clearly the key role of psychiatrists in the management of people with mental illnesses. [ibid: 6]

The authors argue, among other things, for preserving a focus on mental illness not health, on a role for psychiatry experts rather than multi-disciplinary teams with distributed responsibility, and on a medical approach to severe psychiatric disorders, at least.

Many recent NHS changes, including, for example, those outlined within the National Service Framework for Mental Health, have provided an extensive discussion of important generic issues, including social inclusiveness, stigma and access. What they have not done, however, is to place sufficient weight on medical fundamentals such as the need to distinguish the major forms of mental disorder, the implementation of appropriate evidence-based treatments, the subsequent monitoring of mental state for optimal outcome and the importance of addressing the physical morbidity and mortality associated with almost all types of psychiatric illness. [ibid: 7]

Taken in isolation, these seem reasonable points. It would be surprising if psychiatrists writing in the BJPsych were, in general, pessimistic about the prospects for their discipline, especially in what it takes to be its core areas. (That I think explains the hostility of psychiatrists to fellow psychiatrist Jo Moncrief last month.) And it seems reasonable for there to be disagreement within a profession about how best to organise its services, especially if proposals seem to weaken the profession’s authority.

But what seems very surprising to me is that the article makes no attempt to engage with its opponents’ motivations, not least the reaction against paternalistic approaches to mental illness and questions about who should count a condition as pathological, what role for mental health service users? Without saying something about why the alternatives to a medical model have come to be explored and the rise of the service user movement as a constituency in thinking about mental healthcare, this seems simply to reinforce the worry that psychiatry in general tends not even to begin to listen to the people it aims to help.

(See also this.)

Calibration

I took a few days holiday last week and went for some solitary walks and cycle rides in the country. Used to walking with other people, I found, perhaps predictably, it difficult to find a suitable pace: instead either walking as fast as I could or, realising this, dawdling to an extent that put a post-walk pint at risk.

More interestingly, however, a lack of social calibration also has an effect on my emotional state. The isolated splendour of the eastern flanks (pictured) of Yoke and Ill Bell, overlooking the Kentmere Reservoir, produced alternating happiness and melancholy which would normally be smoothed out by conversational banter.

This reminded me of an experience I once had which gives me some sort of insight into Maher’s account of delusion. The idea is that in everyday life we can have what Maher calls ‘primary feelings of significance’. Based on Jaspers’ distinction between primary and secondary delusions, Maher calls these primary because they are directly experiential. Maher suggests that we normally refer to these by a variety of phrases such as ‘feeling of awareness’ ‘mood’, ‘atmosphere’, ‘feeling of significance’ and ‘feeling of conviction’. But the particular quality he is targeting is of an experience that something significant or important has occurred, whatever it is. Because such feelings are primary, their very existence is a basic datum for further cognitive processing, further inferences to be drawn.

This forms the basis for a theory of delusions. Having a feeling of significance in a case that does not merit it, the subject then hypothesises some underlying change – the content of the delusion – to explain the feeling.

He gives an example from Kurt Schneider (1887-1967), a German psychiatrist who investigated schizophrenia, of a patient who reported that:

A dog lay in wait for me as he sat on the steps of a Catholic convent. He got up on his hind legs and looked at me seriously. He saluted with his front paw as I approached him. Another man was a little way in front of me. I caught up to him hurriedly, and asked if the dog had saluted him too. An astonished ‘No’ told me that I had to deal with a revelation addressed to me. [Schneider 1959: 105]

Some years ago, I was driving from Leamington to Cambridge to teach a course on Wittgenstein. I was suffering from a kind of writer’s block at the time and was probably under some stress. I suddenly ‘realised’ that something was wrong with the car and pulled over. But when I stopped there was nothing apparently amiss: neither on the dials nor by a look at the engine (I went through the motions of opening the bonnet  hood but quite what I would have done I am not sure). Only then did I realise that what had actually happened was that I’d suffered a wave of anxiety and simply assumed that the reason for this was a perception of something wrong with the car.

Of course, social calibration makes this sort of error much less likely. People who manage to spend large periods alone – like Jack Kerouac’s jobs as a US forestry fire warden – without suffering from the effects of no social calibration are very impressive.

Recovery and wellbeing: The future of mental health assessment and diagnosis

A week after the end of my Institute’s annual colloquium (on the future of psychiatric assessment and diagnosis), I have just about recovered from it and the run of giving papers at five conferences in five weeks. A bit like organising a party, my involvement in the (shared) organisation of the colloquium ruled out both my being able straight-forwardly to enjoy it and also to have a clear view of how it went. (I'm told it went well.)

Like last year, we were able to invite members of ENUSP (the European Network of (ex-) Users and Survivors of Psychiatry) to join us. But we also had members of the WPA led by its current president, Prof Juan Mezzich. Coupled with the presence of philosophers, sociologists, psychologists, other local academics and members of national service user networks and our International Fellows (including John Sadler and Carl Bell), this made for a genuinely novel mix.

But it also raised the following challenge. Whilst a purely academic annual conference might comfortably return to the same discussion year after year, this group really wants to change mental health care. (The WPA were present to develop and promote their Institutional Program on Philosophy for the Person; they were, eg., challenged to put on record that psychiatric diagnosis is essentially different from diagnosis of physical illness and Prof John Cox, Secretary General of the WPA - and delightful house guest - said he would provide leadership on exactly this point.) This means that, if next time we meet, we discuss the same state of play, that will be evidence of our collective failure.

That said, next year I plan to hold a colloquium more squarely focussed on the philosophy of psychiatry. If so, we have two years to change the world!

Draft review of Lindgaard, J (ed) (2008) John McDowell: experience, norm and nature

This is a collection of papers based on two conferences in 2005. All but two the papers have already been published in the European Journal of Philosophy except for a useful introduction by the editor (and conference organiser) Jakob Lindgaard and, what is almost certainly the main reason to buy the book, a new paper by John McDowell. The book ends with new responses written by McDowell.

There is a danger with collections based on conferences that there will be a lack of thematic unity. But this is not true of this collection which concentrates on the connection of reason and nature in McDowell’s philosophy and especially the influences of Kant, Hegel and Sellars.

Both Willem de Vries and Michael Williams defend Wilfrid Sellars from McDowell’s partial assimilation and criticism. Both argue that, in different ways, McDowell has not properly understood Sellars’ philosophy although, as his replies make clear, the most dramatic difference between McDowell and Sellars is the former’s rejection of the latter’s scientism.

The moral philosopher Hans Fink articulates a general anti-reductionist account of nature and invites McDowell to explain more fully the supposed distinction of first and second nature. The Hegel scholar Christoph Halbig also takes issue with the distinction between first and second nature and suggests that a proper understanding of the purpose of Hegel’s discussion of nature, though not his theoretical constructions, helps ease residual tensions in McDowell’s philosophy. Fellow Hegelian Stephen Houlgate argues that there are greater differences than McDowell supposes between Mind and World and Hegel. In particular, he argues that according to Hegel, we can never directly experience or take in facts.

Sabina Lovibond draws on Alasdair MacIntyre’s discussion of animals to suggest that McDowell’s distinction between humans and animals – with only the former able to enjoy a free and distanced orientation to a world – is too sharp for his own purposes of showing that humans are not super-natural.

The paper by Kenneth Westphal criticising McDowell’s account of the relation of Kant and Hegel shows a difficulty in assessing therapeutic philosophy from outside. Westphal has no sympathy for McDowell’s diagnostic and therapeutic philosophy and little can be learnt from their rather bad tempered exchange.

I will spend a little more time on the papers by Bill Brewer, Charles Travis and John McDowell himself because these seem, to me at least, most to further our understanding of recent developments in McDowell’s philosophical account of experience of nature.

Bill Brewer’s paper ‘Perception and content’ attempts to highlight difficulties with any view of experience which grants it representational content. Content can be true or false and thus according to a ‘content view’, genuine perception is a success, where the contents are true, and cases of illusion have false content. Brewer suggests, however, that there is a tension between the possibility of falsity and the idea that perception can present us directly with the objects in the world around us. Thus, he argues, a content view has to minimise the possibility of falsity (which is why Brewer’s own previous content view made both subject and predicate object-dependent).

Brewer argues, however, using the example of the Muller-Lyer lines that the content view is not successful in accounting for falsity because it is not possible to say what the content of the illusory experience is:

Is the line with inward hashes represented as shorter than it actually is; or is the line with outward hashes represented as longer than it actually is; or both; and by how much in each case? [ibid: 19]

McDowell’s response compares the content of the experience with a propositionally structured judgement.

Suppose I say, of two lines that are in fact the same length, that one, say A, is longer than the other, say B. It does not follow that I am saying that A is longer than it is, or saying that B is shorter than it is, or saying that both of those things are the case. One of those things would have to be so if what I say were true, but I am not saying of any one of them that it is so. [ibid: 201]

So, equally, McDowell argues, the experience need not be any more determinate than the linguistic judgement.

Brewer’s second objection is that the generality of the content view precludes direct access to worldly features.

[P]erception… does not consist in the simple presentation to a subject of various constituents of the physical world themselves. Instead, it offers a determinate specification of the general ways such constituents are represented as being in experience: ways which other such constituents, qualitatively distinct from those actually perceived by any arbitrary extent within the given specified ranges, might equally correctly – that is, truly – be represented as being. [ibid: 24]

Thus, Brewer argues, limits on perceptual acuity introduce a range of cases into the specification of content available.

Again, McDowell rejects this, claiming that the element of abstraction in Brewer is a mistake. Whilst the colour an object visibly has cannot have a determinacy that outruns a subject’s visual acuity, it is still that colour that directly determines the truth condition for experientially based perceptual judgements.

But McDowell’s fundamental argument is to stress a disjunctivist account of experience. On the good disjunct, error is not merely reduced (in accord with Brewer’s earlier account) but eliminated altogether.

In ‘Reason’s reach’ Charles Travis argues that McDowell subscribes to a condition for experience to be able to exert a rational constraint on thought: ‘something non-conceptual… could not impinge rationally on what one is to think.’ [ibid: 180] Travis argues, however, that whilst McDowell attempts to accommodate the condition, it should be rejected.

Frege distinguishes between extra conceptual items and conceptual items. The former can be perceived but not the latter. Perceivable items can represent only under an interpretation but that something is taken to represent is not itself perceivable. Conceptual items also possess a kind of generality. Even a concept of being Frege could be instantiated in a number of ways even if only by Frege.

According to Travis, McDowell’s attempt to meet the condition means that he can trade only in items belonging within the conceptual but if so not to what is directly perceivable. By contrast, Travis urges that perception can be of extra-conceptual items, items that instantiate conceptual generalities. Whilst it requires expertise to recognise that something does fit the general normative requirement of the conceptual, that is not outside the reach of reason. Thus Travis argues that reason can reach beyond the conceptual to the extra-conceptual items that instantiate concepts.

McDowell’s response is to argue that his picture of the conceptual as having no outer boundary was meant to undermine any worry that reason is shut off from embracing objects lying outside it. He accepts a condition: ‘reason’s reach extends no further than conceptual capacities can take it’ [ibid: 259] This places no objects outside it but does express a limit: nothing can impinge on a subject’s rationality except through their conceptual abilities. It is this which underpins McDowell’s rejection of the myth of the given.

In his own paper ‘Avoiding the Myth of the Given’ McDowell makes two changes to the account of experience defended in Mind and World as a method of avoiding the Myth of the Given.

I used to assume that to conceive experiences as actualisations of conceptual capacities, we would need to credit experiences with propositional content, the sort of content judgements have. And I used to assume that the content of an experience would need to include everything the experiences enables its subject to know noninferentially. But both these assumptions now strike me as wrong. [ibid: 3]

As to the first, he still holds that experience is conceptually structured but it need not include all the claims that one might noninferentially make because of it.

Suppose I have a bird in plane view, and that puts me in a position to know noninferentially that what I see is a cardinal. It is not that I infer that what I see is a cardinal from the way it looks, as when I identify a bird’s species by comparing what I see with a photograph in a field guide. I can immediately recognise cardinals if the viewing conditions are good enough…On my old assumption, since my experience puts me in a position to know noninferentially that what I see is a cardinal, its content would have to include a proposition in which the concept of a cardinal figures… But what seems right is this: my experience makes the bird visually present to me, and my recognitional capacity enables me to know noninferentially that what I see is a cardinal. Even if we go on assuming my experience has content, there is no need to suppose that the concept under which my recognitional capacity enables me to bring what I see figures in that content. [ibid: 3]

If experience does not include all the conceptual contents I might judge, what subset does it include?

A natural stopping point, for visual experiences, would be proper sensibles of sight and common sensibles accessible to sight. We should conceive experience as drawing on conceptual capacities associated with concepts of proper and common sensibles. So should we suppose my experience when I see a cardinal has propositional content involving proper and common sensibles? That would preserve the other of those two assumptions I used to make. But I think this assumption is wrong too. What we need is an idea of content that is not propositional but intuitional…[ibid: 4]

So this connects to the second change. Experience is conceptually structured but not propositionally structured. It is intuitionally conceptually structured.

Propositional unity comes in various forms. Kant takes a classification of forms of judgement, and thus forms of propositional unity, from the logic of his day, and works to describe a corresponding form of intuitional unity for each... [But] [i]t is not obvious why Kant thinks the idea requires that to every form of propositional unity there must correspond a form of intuitional unity. And anyway we need not follow Kant in his inventory of forms of propositional unity. [ibid: 4-5]

The concept of a bird, like the concept of a cardinal, need not be part of the content of the experience; the same considerations would apply. But perhaps we can say it is given to me in such an experience, not something I know by bringing a conceptual capacity to bear on what I anyway see, that what I see is an animal… because ‘animal’ captures the intuition’s categorical form, the distinctive kind of unity it has…In an intuition unified by a form capturable by ‘animal’, we might recognise content, under the head of modes of space occupancy, that could not figure in intuitions of inanimate objects. We might think of common sensibles accessible to sight as including, for instance, postures such as perching and modes of locomotion such as hopping or flying. [ibid: 5]

Both the changes in the view of experience have a rationale. It seems plausible that the structure or articulation of experience is distinct from explicit propositional judgement. And it seems plausible that not all the concepts that one might deploy non-inferentially are actually present in an experience. But taken together they undermine the tidy picture of how a conceptualised picture of experience makes the rational constraint of thought by the world unproblematic. What is the nature of the connection between intuitional experience and propositional judgement? Secondly, how can the question of what concepts (animals and perching but not birds, eg) structure intuitional content be answered? The fact that that question arises suggests that the new picture of experience has left the comparative innocence of merely therapeutic philosophy.

Diagnosis in psychiatry

Last week I parachuted into a single session of the Royal College of Psychiatry annual meeting to take part in a debate on diagnosis. I was slightly worried that a philosophically based session would not fill enough of the main lecture hall in which we’d been scheduled but I was wrong. That said, whilst Phil Thomas’ talk on moral aspects of diagnosis and mine on the relation of idiographic and narrative approaches generated enough questions to fill the time it was Jo Moncrief’s talk that generated all the heat.

Jo is a member of the critical psychiatry movement and the main aim of her argument was to criticise the application of the idea of diagnosis to mental health care. One of her many points was to stress the social or historical interdependence of the availability of kinds of psychotropic drugs and the ‘availability’ of a corresponding diagnosis. Thus one reaction by members of the audience was to stress that such diagnostic categories had really existed prior to the marketing of treatments.

I was struck by the parallel with forms of sociological analysis of scientific knowledge in general. It is easy to see a contrast between a simple-minded realism in which scientists can simply ‘mainline’ on the facts and a contrasting view in which social factors, rather than natural scientific facts, play an explanatory role. On the simple minded contrast, the presence of social factors can only play a debunking role. But there is a range of other views which recognise that scientific projects are social projects and require great social and managerial skills but nevertheless think that these factors are deployed in order to persuade nature to reveal itself.

What was not clear to me at the Royal College meeting was that Jo’s argument had actually established a debunking reading of the role of social factors in the history of psychiatric diagnosis rather than simply pointing out the complex background of any recent (correct or incorrect) scientific claims. It was clearly her intent but I had the feeling that the audience reaction was premature.

For more on the idea of debunking versus realist use of sociology see this.