Arguing for the correctness of a recovery model

I have been working on the middle section of my draft chapter for the OUP collection on recovery (Rudnick, A. (ed) The Recovery of People with Mental Illness Oxford University Press) plonked previously on this blog. Originally - as is obvious in the Thornton & Lucas JME paper - I was far from convinced that an argument for the model articulated worked. (That I was not was a bit of a surprise. Whilst I do not go around advancing theories of things, I have always taken illness to be normative at all levels.) I think I am now more convinced and I think this passage now makes that a bit clearer. Comments to my email would be very welcome.

Arguing for the correctness of a recovery model

It is one thing to articulate a possible recovery model distinct from a bio-medical model (and simultaneously partly to characterise the 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 is as follows. A non-normative or non-evaluative approach seems initially at least to be a promising approach to physical health and the aims of physical healthcare. That however can safely be conceded providing that there are reasons to distinguish between mental and physical health. Since there such reasons, these can be used to argue for a contrasting recovery model for mental health.

Note two preliminary points about the strategy. First, there are plausible objections to a non-normative conception even of physical health. But does not undermine the argument for a recovery model for mental health. If anything, it strengthens it. Second, however, the overall argument is open to counter-attack. I will sketch some lines of defence of the recovery model against this but concede, in the end, that it is an ongoing debate.

A non-evaluative approach seems to be a possible picture of physical health and hence for recovery from physical illness which does not amount to a recovery model. It could instead be thought of as a bio-medical approach to physical health. 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 (I will return to a second version, shortly).

Whether or not it is successful in the end, a statistical model of health has at least an obvious advantage over a statistical model of ill-health (based on the idea that illness is a statistically unusual state). Such a model of ill-health 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, it does not face an analogous problem. Furthermore, it avoids a implausible 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.

Nevertheless, to escape some obvious problems for it, some qualifications to a statistical approach 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 expected for the latter but an illness for the former. So health would have to be what is normal relative to an age. 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 (and/or perhaps psychological) system. If so, health would have to be defined as what is normal for each such sub-system rather than for the whole person at any one time.

Whether this strategy of careful selection of an appropriate reference group can work across the board is, however, open to question. Take the cases of obesity across whole affluent communities or dental cavities across whole populations. These are cases where what is statistically normal for the group in question does not seem to fit pre-philosophical intuitions about health. It is hard to see how a particular sub-group or other reference population could be selected to set the standard for physical health without begging the question: without, that is, the group being selected for being healthy.

For present purposes, I can, however, park that question since, on one assumption about the nature of mental health, then whether or not a statistical model of physical health can be defended against the objection just raised, it seems much less plausible for mental health. If, in line with the quotation from ‘Making recovery a reality’ at the start, mental health has something to do with living a particular kind of life, then it cannot – absurdly – be construed as a statistically average kind of life. It has instead to be thought of as a particular kind of life, valued and hoped for by the individual concerned, the kind of life connected to their identity. If the starting assumption is granted (that mental health has something to do with living a particular kind of life), it threatens the idea of defining the endpoint of recovery for mental health in statistical and hence 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. This serves as a partial argument for a recovery model.

(In setting out a condition on a recovery model, I have suggested that it has 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.)

This line of argument for a recovery model is not decisive because a crude model of a statistically normal kind of life is not the only potential alternative that would have to be ruled out. I will briefly outline 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. This approach might face the same kind of objection to the statistical approach to physical health I left parked a little earlier. Anxiety, for example, may well undermine the capacity to make rational choices but if it is normal in industrial countries it will count as a healthy state. But there is a more fundamental problem. How can mental capacities be so much as identified without presupposing a notion of human flourishing that they support. What, in other words, are the capacities for?

This general objection is connected to a specific issue raised elsewhere in philosophy. 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]. 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.

A second rival to the recovery model for mental health can be articulated by returning to another issue left hanging a little earlier. The statistical model is merely one form that a non-normative, non-evaluative approach might take for physical health. A more promising approach would be one based on biological function. Familiar in the case of illness or disease through the idea of failure of function, accord with function could serve as the correlative definition of health. On this approach, one’s physiological systems are healthy insofar as they are behaving in accord with their biological functions. And the same approach might be applied in the case of mental faculties.

The key line of objection this approach is to question whether the articulation of the biological functions of mental traits can 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 to a non-normative account: via an understanding of what contributes to a value-laden conception of human flourishing. This remains a matter of lively debate. On it turns the issue of whether an account of health based on accord with biological function is an alternative to the recovery model I have articulated or merely a disguised form of it.

Postscript on Arthur Frank’s Letting Stories Breathe

After writing an earlier entry on Arthur Frank’s Letting Stories Breathe, I have now 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, or whatever. It is a much nicer idea.

Sass and the need for an anti-resolute reading of the later Wittgenstein

I have realised that, having been marking essays for the last few days, I have only a couple of days to rewrite a paper for Emotion Review which includes a criticism of Louis Sass and a draft of which was here. One reviewer said it should be published as it stood but the other, Sass himself it turned out, understandably didn’t like the criticism of Sass in it. Responding to all his objections would require commenting in detail on about 20 pages of Wittgenstein so, in a 4,000 word paper whose original main theme was not actually Sass, that is not practical. (The paper now has three worked examples and a general claim about how to interpret the others. It will be up to readers to work out what they think.) But Sass’ first criticism is interesting and worth commenting on. He says of my paper that:

It is basically in the vein of those “new Wittgensteinians” who have a rigorous and rather exclusionary notion of what Wittgenstein would countenance as possible forms of meaningful discourse or understanding. Others in this tradition are James Conant, Cora Diamond, and Rupert Read. The position is best known for its re-interpretation of Wittg’s early book, the Tractatus Logico-Philosophicus, in which that book is seen as an essentially meaningless quasi-joke whereby Wittgenstein gives his readers the impression he is saying something, but then pulls the rug from under the feet of his readers; and in which the famous final line, “Whereof one cannot speak, thereof one must remain silent,” is viewed as itself a completely meaningless pseudo-statement. (The “new Wittgenstein” approach is not a unitary position, by the way, but a set of sometimes only loosely associated interpretative claims; some elements of the new Wittg are less relevant here, such as the idea that the early and later Wittgensteins should be seen as more congruent than previously assumed.)
I think that in this paper, there should be some acknowledgment of the above-mentioned ongoing debate re Wittg interpretation (referred to above as the debate re the “new Wittg”), both for the sake of clarifying just what sort of argument is being offered here, and also because that would avoid (what might be interpreted as) a dismissive tone—as if it were a simple matter of revealing the “correct” interpretation of Wittg, which would clearly show that Sass is simply in the wrong. Well, as this very well-informed author knows, there are many people who disagree with the version of the new Wittg mentioned above, including Hacker (see final chapter in the book The New Wittgenstein); and this is an ongoing and complex debate, perhaps ultimately an undecidable one. The new Wittg’ian position I mention above has been presented in a fascinating, often brilliant manner, and has reinvigorated various aspects of Wittgenstein studies; but there are also a great many problems with sustaining this new Wittg.ian position, some of which are outlined in the Hacker chapter just referred to, and some of which Sass alludes to in an earlier response to Rupert Read in the journal Philosophy Psychiatry Psychology or PPP.

The objection is that, like Rupert Read’s criticism of the use of Wittgenstein’s description of solipsism to shed light on other aspects of schizophrenia, it presupposes a recent and contested approach to Wittgenstein sometimes called the ‘New Wittgenstein’ [Read 2001, Crary and Read 2000].Since this approach to Wittgenstein is controversial (it is contested by such authorities as Peter Hacker, for example), it cannot simply be taken for granted as countering Sass’ own work.

This is a fair point and suggests that there cannot be a simple refutation of Sass’ hermeneutic project. But it is worth outlining something of the nature of the New Wittgensteinian approach. In The New Wittgenstein, Crary and Read suggest that this label gathers together approaches to the early and later Wittgenstein. In the former case, the ‘new’ approach is more familiarly known by its supporters as the ‘resolute’ approach. It is the approach which ‘resolutely’ accepts the nonsensical status of almost the whole of the Tractatus Logico Philosophicus and takes nonsense to be just that. What cannot be said, cannot be said and – in Frank Ramsey’s phrase – cannot be whistled either. Hacker’s critique of this approach (in his ‘Was he trying to whistle it?’ [Hacker 2000]) concerns the early Wittgenstein.

It is rather less clear what the ‘New Wittgenstein’ picks out when applied to texts after the Tractatus (such as the Brown Book). But Crary and Read suggest that it refers to a) therapeutic interpretations which b) take the rejection of external or platonic standards for judging language to be incoherent rather than merely false and thus c) do not see Wittgenstein’s critique as undermining pre-philosophical conceptions of objectivity [Crary and Read 2000: 3-4]. It excludes, in other words, both Kripke’s sceptical reading of Wittgenstein and Crispin Wright’s philosophical theory building. It is far from clear that Hacker, for example, who explicitly criticises sceptical readings of Wittgenstein, opposes a ‘New Wittgenstein’ approach to the middle and later period Wittgenstein including the §500 explicit view of nonsense (see below). So if Sass is to defend his account of the Brown Book as one which opposes a ‘New Wittgensteinian’ conception of philosophy as therapy, he will need to substantiate how he differs from this now more standard reading of the later Wittgenstein. (Simply opposing a ‘resolute’ reading of the early Wittgenstein is not enough.)

A different way to make this point is this. Sass can object to Read’s criticism of Sass as follows. Whilst Read, as a resolute reader, says that the passages of the early Wittgenstein that Sass invokes are strictly meaningless, there is a reputable anti-resolute view that says both that Wittgenstein intended them to be a special kind of nonsense which could still communicate an insight and that that is a reasonable intention. So Sass can use that special kind of nonsense to shed light on schizophrenia. But, by contrast, it is not clear that there can be an anti-resolute reading of the later Wittgenstein because the resolute reading of the early Wittgenstein reads into that early work what he says explicitly in his later work. He discusses the example of the orders ‘Bring me sugar’ and ‘Bring me milk’, which make sense, but not the combination ‘Milk me sugar’. He goes on to say, ‘When a sentence is called senseless, it is not as it were its sense that is senseless. But a combination of words is being excluded from the language, withdrawn from circulation.’ [Wittgenstein 1953 §500]. So on this later view, nonsense is simply a lack of sense. (That is the view behind the Brown Book.) A resolute reading of the later Wittgenstein is standard rather than unusual. But Sass needs an anti-resolute reading if his response to Read will also work here.

The only candidate I can think of as such an anti-resolute reader is Jonathan Lear who does think that Wittgenstein has to do philosophy by gesture, pointing beyond the limits of sense. If this is Sass’ view, he will need to do rather better than Lear in filling out the nature of this transcendental insight and then link it back into these Brown Book passages.

Crary, A. and Read, R.(eds) (2000) The New Wittgenstein, London: Routledge

Hacker, P.M.S. (2000) ‘Was he trying to whistle it?’ in Crary, A. and Read, R.(eds) The New Wittgenstein, London: Routledge
Read, R. (2001) ‘On approaching schizophrenia through Wittgenstein’ Philosophical Psychology 14: 449-475
Sass, L.A. (1994) The Paradoxes of Delusion, New York: Cornell

Wittgenstein, L. (1953) Philosophical Investigations, Oxford: Blackwell

Wittgenstein, L. (1958) The Blue and Brown books, Oxford: Blackwell

Outline for a potential short course on the philosophy of psychiatry

Charlotte Blease is teaching a five week x two hour course on What is psychiatry? over at Queens University Belfast. That prompts me to ask what I would teach, preferably - in my daydreams - in a room at the Castle Green Hotel in Kendal with access to Alexander’s Bar afterwards.

To be taught over five weeks of 90 minute sessions with meditative musing, over a pint, afterwards.

1) What’s special about psychiatry?
Psychiatry bridges some key divides. It crosses between mind and brain, understanding and explanation, individuals and their particular experiences and patterns in populations, bio-medical facts and values.
Modern psychiatry – arguably! – began with Karl Jaspers’ work a century ago and so this session examines his attempt to balance the ‘brain mythologies’ of his time with understanding. This leads on to both a model of phenomenology, to explore the ‘what it is likeness’ of experiences, and empathy: our shared access to how one experience leads to another. But is understanding really distinct from explanation? And do we need empathy to understand one another?

Reading: extract from Jaspers.

2) Szasz, anti-psychiatry and the reality or otherwise of mental illness
Whilst Jaspers combined philosophical and psychiatric interests, the recent focus (in the anglo-american world) on the philosophy of psychiatry has been in response to arguments against psychiatry from anti-psychiatrists. Thomas Szasz seems to advance two sorts of argument for the merely mythic status of mental illness. Are they persuasive? What else might they highlight about the nature of mental illness?

Reading: extract from Szasz and Kendell

3) Is mental illness value laden and does it matter if it is?
The debate about the reality of mental illness seems to turn on differences of opinion about the presence of values in psychiatric diagnosis. But, according to Bill Fulford’s analysis, the real issue is the status of physical illness. If illness, whether mental or physical, is essentially evaluative, why is there so much more debate about mental illness? And is Fulford right that there cannot be a value-free account of dysfunction based on whizzy evolutionary theory?

Reading: extract from Fulford

4) The DSM, reliability and validity and the loss of sadness
A key element of psychiatry is diagnosis of mental illness based on a classification or taxonomy. Since the WW2, the main aim of this has been ‘reliability’ which is a measure of how much clinicians agree in making the same diagnosis of the same condition. But recently, the concern has shifted to validity. Does psychiatric classification gets things right, does it cut nature at the joints? How could we begin to answer that question? One particular issue of recent debate is the boundary between sadness and depression. Is there a danger of pathologising what is an everyday, if regrettable, condition?

Reading: extract from Horwitz and Wakefield

5) Psychiatry and the relation of mind and brain
Since Jaspers’ day, our knowledge of the relation of mind and brain or mind and underlying biology has increased dramatically. But how much does this help with deciding what is and is not mental illness?

Reading: extract from Fulford et al.

Seeshop 5 programme

I do not know whether it would still be possible for anyone to attend this, but here is the programme for Seeshop 5 in Cardiff in June.

Dan Hutto's professorial lecture...

... is here.

Obligations to oneself?

I have failed, today, to go and run the Hawkshead 15km trail race. On waking, oddly exhausted, this morning, neither Lois nor I felt at all in the mood. Lois offered the following argument:

The fee for race entry (paid months ago) is ‘sunk capital’ and should no longer affect a calculation of what to do on the day. If, on the day, various factors counted against doing it, then we should not. And there were factors: not feeling physically great; heavy rain forecast; my having run the course last week and found it rather unpleasant; some ongoing muscular twinges; the fact that the alternative would involve a fine and leisurely breakfast with the Saturday Guardian etc. Whilst none of the reasons individually would have been sufficient to stop us running under other circumstances, collectively they tipped the balance of a utilitarian calculus.
Further, were one not to accept the ‘sunk capital’ view of the lost fee, it had had a worthwhile effect – worth the fee – of making us run often and pleasantly over the last month.

Three things struck me about reasoning whether to go or not.

1) The very possibility of not doing the run once mentioned seemed to exert a kind of platonic force. I have a similar issue with mid-week pizza. I enjoy cooking, properly, most evenings, enjoying the custom or habit of cooking for an hour from 7pm, listening to an arts review programme on the radio. But if that custom is partially disrupted, for example, by my getting home late, and I deliberate about whether to cook, then if the possibility of eating a frozen pizza is so much as mentioned (by Lois) that is enough to bring it about. I suspect that if we could train the cats to squeak ‘Pizza!’ in Cat or whatever it would still be. Hearing mention of the mere possibility of eating pizza, its presence as an unbidden thought, seems to mandate pizza, independent of any attempt by me to ‘author’ the thought through deliberation.

2) As is the case with excuses for social invitations, the number of reasons seemed to count against them. One single reason, forcefully stated, would have seemed more persuasive than a number. But in other cases (eg. choosing which holiday destination or bicycle to buy) assembling individually insufficient reasons and weighing them up is exactly the right thing to do.

3) Despite the obvious plausibility of the rational utilitarian calculus, I struggled to accept it. The fact that I had undertaken to run the race seemed to establish an obligation which was still in force even if not dominant, in the end, all things considered. Its continuing force was reflected in my regret. But that seems quite odd. Unlike a social gathering, the organisers would not feel let down by an absence. So the parties of the agreement establishing the obligation seem to be my past and later selves, the present self being unable to dissolve it. Had I decided merely a day or so after signing up to pull out, that would have been fine. But having lived with the decision for a while – the very reason we’ve been running so much in Lois’ post-script thought – it seems to establish an independent or autonomous obligation not to be dissolved, even if to be outweighed, through later rational deliberation.

International Journal of Person-Centered Medicine, again

I see that the International Journal of Person-Centered Medicine (Int J Pers Cent Med) has now published a large number of short papers: here.

The collection includes my own co-authored paper with Ken Schaffner (pictured). I’m sure Ken won’t mind me saying that I viewed our co-production with some anxiety. We were, in effect, instructed by Juan Mezzich to co-author a piece on philosophy of science relevant to the Program on Psychiatry for the Person but also given a tiny word limit.

This presented two problems: we would have to select a single idea or problem area rather than attempt to summarise everything that might be of relevance. It seemed to me that the most obvious philosophy of science issue connected to this programme rather than any other area of psychiatry was the relation of understanding and explanation. But this prompted the second problem: Ken and I have entirely different underlying assumptions about this.

I take it that it marks the distinction between the normative space of reasons and something with an entirely different explanatory logic, perhaps subsumption under laws.

Ken does not start from that assumption. He assumes a much more pragmatic view that there are different conceptual tools for different jobs. (I first met him at a WPA conference and pressed him on how he proposed to accommodate the normativity of person-level explanations in his multi-level model. He looked at me quite blankly. On that day, it simply wasn’t in his mind. (That is not to say he is not fully up to speed on the debate as seen from the normativist side even if he disagrees with us.))

Still, in my old age, I have ended up with a view which is much closer to that than I would have thought when writing my PhD. I don’t think that we should assume that there cannot be local liaisons between elements in both schemes. And I don’t think that we should aim at a single stereoscopic view (in Sellars’ phrase). So perhaps this ends up looking rather pragmatic. But the underlying view is that there is a distinct kind of logic. Does that starting difference matter if it becomes disguised or ameliorated by some additional thoughts? I am inclined, still, to think it does or should.

In the end, however, our piece is so short that all we can do is flag the issue and flag different approaches to dealing with it. I hope that, perhaps for psychiatrists, there is some value in that.