Multi-disciplinary teams, VBP, psychiatry and getting things right

Gloria and I had dinner in Preston with Prof John Cox, our out-going external examiner and ex-President of the Royal College of Psychiatry. John is a keen promoter of medicine for the person (and the work of Paul Tournier) and a humane and spiritually aware form of psychiatry. But about such a form of psychiatry, he is very positive. That is, he emphasises the positive virtues of psychiatry so construed rather than, by contrast, taking those broader values to support the end of psychiatry since it has often failed to embrace them in the past. (I say that because I have also heard people argue for the end of psychiatry precisely because they hold some of those same values: about the importance of the person, meaning, recovery etc.)

One reason for that is this. Increasingly in the UK, mental healthcare is provided by other professions (GPs, nurses, clinical psychologists, neurologists) as well as psychiatrists, acting either individually or in multi-disciplinary teams. On John’s view, psychiatrists are uniquely positioned within such teams to provide a broad overview, spanning the biological to the social, evaluative and spiritual. Thus the diminution of the role of psychiatry threatens loss of that overview.

That suggests an underlying question about what one thinks is the nature and aim of discussion in multi-disciplinary team meetings. A first thought is that the different teams are there for a non-accidental reason. As Fulford and Colombo argued some years ago, different roles within mental healthcare typically hold different views about, or models of, the nature of mental illness and the aims of healthcare. So to omit a discipline is to omit an approach or model and thus to miss the understanding of the situation it might bring to bear. Even if one thinks that such approaches or models are merely pragmatic devices – useful rather than true – that provides a rationale for the multi-disciplinary team. A discipline with an overview of the various approaches would have an overview of their pragmatic virtues.

But there is a more metaphysically charged thought also available. One might think that somehow balancing or accommodating the different views could be done ideally so as to lead to the right answer in the circumstances. The right thing to do would be to look at this situation in this! way. This contrasts with an idea – closer to the spirit of Fulford’s values-based practice – that it is not a matter of aiming at a right answer as rather having a good process. On this less charged view, having a good discussion (with a variety of views) just is as good as it can be. Whatever result emerges as seeming right is as right as right gets (to echo a comment of Wittgenstein’s for the opposite purpose).

On the metaphysically charged view, psychiatry is a kind of master discipline which sees best the facts available (with the other disciplines as intellectual prosthetics). On the less charged view, there is no sense of a right answer to be tracked and, in so far as psychiatry has a special role, it is to organise a fair discussion: a kind of choreographer.

So it seems the view that one takes of the role of psychiatry, the nature of multi-disciplinary teams, values-based practice and the metaphysics of what a correct judgement aims at are all deeply tied together. This leaves me wondering: how should we assess the two broad options for thinking about what getting things right involves?

Notes after a SAMI discussion of an idiographic addition to diagnosis

There’s a widespread intuition expressed in frustration by a reviewer of one of my papers (because it was critical of idiographic understanding) that runs as follows:

[T]he real problem in diagnosis comes when the nomothetic is given too much emphasis. Time and time again what is required is something like the idiographic. Time and time again the categorical, pigeon-holing, approach to diagnosis has to be bent in order to accommodate the individual account. The question is merely how to characterise such an account.

The idea that the ‘question is merely how to characterise such an account’ shows that the intuition is more that there must be something distinct from a pigeon-holing approach to diagnosis even if one does not know quite what. The danger, however, is that the intuition may be mistaken and the hope misplaced. That is that ‘idiographic’ is a place holder but nothing can slot into its supposed place.

What would it be for something to meet the felt need? I think three conditions have to be met.

1. It must be a form of understanding, or information, or sensitivity to facts which is distinct from criteriological approaches, understood broadly. ‘Broadly’ because merely adding a new diagnostic category to DSM / ICD would not address the underlying intuition. So it has to be distinct from any innovation within the criteriological approach.
2. It must somehow capture the individuality of individuals.
3. It must be a genuine form of understanding or judgement. That is, it must aim at truth or validity even if only as applied to an individual: the truth about him/her.

With these conditions in place we can look at the clues given in the IGDA document and Jim Phillips paper to see what this form of judgement is.

Class discussion suggested that responding to the uniqueness of each client/patient and their context (in family and society etc) might be a clue. But to understand the movement of an apple juice carton requires relating it to every other object with mass in the universe (ie its context) and that is likely to be a different set of vectors than any other object, as it is in a particular place (hence uniqueness). So the uniqueness and context-dependence of the subject matter does not distinguish idiographic psychiatry from physical science explanation which itself is a form of criteriological / lawlike explanation.

Nor is does the sense of idiographic understanding found in psychology meaning based on qualitative small scale research helpful because it is not distinct. Even criteriological diagnosis concerns individuals. The target is thus small scale. The question remains how is idiographic understanding distinct? How is a focus on individuals achieved?

Hence looking at Windelband. Now there are a number of interesting ideas in his paper, but at no point does he manage to substantiate what he means. There is a key emphasis on the idea that whereas nomothetic understanding concerns generality (eg understanding individuals as instances of generalities) idiographic understanding concerns individuality: individuals as individuals.

In their quest for knowledge of reality, the empirical sciences either seek the general in the form of the law of nature or the particular in the form of the historically defined structure. On the one hand, they are concerned with the form which invariably remains constant. On the other hand, they are concerned with the unique, immanently defined content of the real event… The former disciplines are nomological sciences. The latter disciplines are sciences of process or sciences of the event. The nomological sciences are concerned with what is invariably the case. The sciences of process are concerned with what was once the case. [Windelband 1980: 175-6]

[T]he more we strive for knowledge of the concept and the law, the more we are obliged to pass over, forget, and abandon the singular fact as such… In opposition to this standpoint, it is necessary to insist upon the following: every interest and judgment, every ascription of human value is based upon the singular and the unique... Our sense of values and all of our axiological sentiments are grounded in the uniqueness and incomparability of their object. [Windelband 1980: 181-2]

But this focus is not just on individuals (nomothetic understanding can be applied to just this very apple juice as an example of an object of its general physical properties) but somehow not related to other individuals, cases, the future etc. A completely one-off understanding. And the problem with this is that it is not clear it makes any sense to say that this is a judgement, aiming at truth and validity, at all.

Hence instead following the other clue. Perhaps we need narrative judgement. This looks more promising but still needs to meet the three conditions. Can it? Well we need to say what we mean by ‘narrative’. It can’t mean a particular narrative genre (because that would be unrealistic and restrictive). So I suggest we just mean the form of understanding that places things in a space of reasons, that shows how they make sense. If so on the conditions above:

1. making sense is a normative notion (ie correctness involving) rather than typical / usual and so is distinct.
2. whilst sense-making is a constraint (not everything could make sense even if anything could in the right context), it is a very flexible constraint suited to charting individuals mentality.
3. such understanding does aim at the truth of a person’s reasons.

But is that good enough to meet the underlying intuition? And, more practically, if diagnosis involves both standard DSM criteria and a narrative, won’t the former be the aspect that does all the work?

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

Windelband, W. (1980) ‘History and natural science’ History and Theory & Psychology 19: 169-85.

Reading Michael Williams' diagnosis of scepticism

Scepticism needs an argument. It doesn’t just win because the sceptic wears a stylish black T-shirt. The key argument for external-world-scepticism deploys a ringer. Descartes’ second and third methods of doubt, for example, work by articulating an alternative to our everyday empirical beliefs and perceptions that we cannot distinguish from the everyday cases. Our experiences would seem the same whether we were awake and experiencing the external world or, either, dreaming or subject to a daemon / a brain in a vat. Once such a ringer is in play, it is difficult to rebut the scepticism to follow because no feature within our experience seems capable of determining whether the pre-sceptical conception or the ringer applies. And if that is the case then, even if ringer is actually false, enough has been done to scupper the justificatory element of knowledge and hence knowledge.

But it may be possible to block this argument before it gets started. That, at least, is what Michael Williams attempts. He challenges the ground rules of the sceptical argument. This he offers the following outline of the dreaming scepticism argument:

if we are to know anything about the world, we must sometimes know that we are not dreaming; but we can never know that we are not dreaming; therefore we never know anything about the world.
The first premiss seems hard to deny. And as for the second, if we are ever to know that we are not dreaming, there must be a test that we can, at least in some circumstances, apply to determine whether we are dreaming or not. But now suppose that there were such a test—any test, not just one conforming to foundationalist preconceptions— it will be of use only if we know that we have really applied it and have not just dreamed that we have applied it. That is, it will be of use only if we already have some way of determining that we are not dreaming, which leads us into a regress... [Williams 1988: 436]

But he goes on to offer the following diagnosis of how the argument works: crucially the hidden premiss which is a form of foundationalism.

We can begin with a look at the first premiss, which can be read two ways. On one reading, it is a truism: at least, something I have no wish to dispute. We can concede that the claim that we sometimes have knowledge of the world logically implies that we sometimes know we are not dreaming. Like other logical points, this is epistemologically neutral. It is entirely compatible with our holding that, since we often do know things about the world, we often know that we are not dreaming: we know that we are not dreaming in virtue of what we know about the world, and in this sense there will be tests for whether or not we are dreaming, though not necessarily any single procedure that applies in all situations.
But there is another way to read the first premiss: this is to take it to require that, if we are to know anything about the world, we must be capable of knowing that we are not dreaming: that is, of knowing this in some way that is independent of all knowledge of the world. On this reading, premiss one certainly promises to be useful to the sceptic, but only because it introduces a general and intrinsic dependence of knowledge of the world on whatever knowledge we can have whether or not we know we are dreaming. So premiss one is either trivial and useless or useful but just another way of insinuating a foundationalist constraint on knowledge of the world. Only by oscillating between the two readings can we sustain the illusion of deducing scepticism from a triviality.
Now, it will be said that scepticism is not meant to follow from premiss one alone, but only from premiss one in conjunction with the claim that there could not be a test, foundationalist or otherwise, for determining whether or not we are dreaming. But unless we read premiss one in the second way, the way that presupposes foundationalism, the argument for premiss two will fail. If the dependence of knowledge of the world on knowledge that we are not dreaming is understood in the first, innocuous way, we have no reason for conceding that there could be no test for determining whether or not we are not dreaming. All the argument for premiss two shows, then, is that there is no way of knowing that one is not dreaming that is independent of all knowledge of the world. But this conclusion poses no threat to knowledge of the world unless it is presupposed that such knowledge, by its very nature, stands in need of grounding in some more primitive stratum of knowledge. The argument for premiss two shows that there can be no purely experiential test for determining whether or not we are dreaming, and the epistemological significance of this conclusion derives entirely from the thought that knowledge of the world naturally requires some kind of grounding in experience. Once again, the dreaming argument shows that foundationalist ambitions are likely to be disappointed, but gives no independent reason for entertaining them in the first place. [Williams 1988: 437 italics added]

Elsewhere he summarises this move in in slightly different language:

In effect, what the argument for [scepticism] ... really shows is that there is no way of knowing that we are not dreaming that is independent of all knowledge of the world: there is no purely experiential test by which to exclude the dream possibility. But this conclusion poses no threat to knowledge of the world unless we have already been given reason to think that such knowledge, by its very nature, always requires grounding in some more primitive stratum of knowledge. The argument for there being no test for determining whether or not we are dreaming turns out to be another way of making the point that knowledge of the world cannot be given a ground in experiential knowledge, which is not a step on the road to scepticism unless it has been established that knowledge of the world stands or falls with the possibility of giving it such a grounding. Once again we have an argument that shows that foundationalist ambitions are likely to be disappointed, but gives no particular reason for entertaining them in the first place. [Williams 1996: 87]

So Williams aims to show that the argument for dreaming scepticism can be blocked by showing that it depends on an 'unnatural' assumption that knowledge of the world depends on a substratum of knowledge of experience. Only if the latter can be used to show that there is no general problem with the former are we justified in our everyday beliefs and that is just what scepticism goes on to question (via ringers such as dreaming and the brain in the vat). But Williams argues that that is just an assumption. If it leads to scepticism then so much the worse for that assumption.

He calls the assumption that drives the sceptical argument ‘epistemological realism’. It is the idea that knowledge of the world is a natural kind, a uniform totality, which can be questioned or justified as a whole. That idea is certainly present in Descartes' discussion but it seems, there, to be merely a convenient way of doing the sceptical job quickly. Williams thinks it is more significant than that and actually underpins the sceptical argument.

Does this work?

Williams aims at a theoretical diagnosis of the sceptical argument. He claims that the sceptical argument depends on what seemed merely an accidental feature of Descartes’ method of doubt: treating our knowledge of the external world as a single type of knowledge, sharing a common style of justification (via (our knowledge of) our experience). But the idea that there is such a class as ‘our knowledge of the external world’ is not a natural idea and this category is theoretical and artificial. So once we realise that the sceptic relies on this assumption – for example in the way normal ways of justifying our claim that we are not now dreaming are ruled out because we need to prove we are not dreaming independently of anything else we know about the world – it is equally possible to reject both it and the scepticism it leads to. Further, the very fact it leads to scepticism (which is obvious rubbish) counts against it.

Williams also provides some further comments to try to persuade us that as ‘our knowledge of the external world’ is not a natural idea. His comment that Descartes’ claim that our bodies are external seems spot on.

Is this enough to stop scepticism? Unlike Putnam, he does not claim that the sceptical hypothesis makes no sense. So he does not say that scepticism makes no sense. That may count in his favour (since scepticism seems to make sense). But, unlike Davidson, he does not let the sceptical argument go through. Once it does it seems merely dogmatic to attempt to deny it. Instead, Williams aims to show that scepticism depends on a theoretical view of knowledge which is neither obligatory nor natural.

Still, one might think that the sceptical possibility is the most natural aspect, not of everyday life but certainly, of philosophical inquiry. That is, as soon as one begins to think about knowledge, one realises that there is a central tension in what we take it to be and in our taking ourselves to have it. So in the end, Williams may trade intuitions about what is and is not natural.

If that is how things stack up then one way one might aim to break the deadlock is by considering the plausibility of what Williams opposes to epistemological realism (the view that our knowledge of the external world as a single type of knowledge sharing a common style of justification). What is the alternative? Contextualism.

Epistemological realism takes it that good justifications have a common feature: they start with our experience construed as not presupposing any knowledge of the external world and then work outwards to the external world. What does contextualism take all good justifications to have in common? Nothing (well, nothing substantial). Justification depends on, and varies with, context.

It would be good to learn more of what this involves (see Wittgenstein later). But if contextualism is a better account than epistemological realism (before we consider scepticism) then since scepticism needs a prior assumption of realism, that really would count against scepticism.

“But hang on. If there are two views of knowledge and justification in play: epistemological realism and contextualism (where the former leads to scepticism), then isn't the idea that this blocks scepticism merely dogmatism at one level up. At the ground level, sceptical hypotheses or ringers don't have to be true, they just have to be possible. Their mere undetectable possibility is enough to undermine knowledge - because even if our beliefs about the external world that is mere luck in the face of the ringers - and thus lead to scepticism. So equally at this higher level of abstraction (concerning knowledge of the nature of knowledge rather than trees etc), epistemological realism doesn't have to be true, it just has to be possible, for that fact to undermine, via the standard sceptical argument, ground level knowledge and thus lead to scepticism.”

I don't think so. After the sceptical argument is already up and running, then the fact that we have a stand-off between epistemological realism and contextualism might be enough to hand the victory to scepticism. (First, if we have already granted that we don't know that that! is a tree, then we will not likely know the nature of knowledge either and then, second, if we do not know that contextualism is true then we won't know that that! is a tree: a kind of mutually supportive sceptical collapse.) But Williams contests the argument before the sceptical argument is complete for the first time.

So the stand off between epistemological realism and contextualism is more neutral. It is played out on ordinary pre-sceptical grounds. Only if we have reason to think that epistemological realism is reasonable can the way the sceptic sets up his ringers be reasonable and thus, for the first time, make us concede that we don't have knowledge. But if our response to the sceptic's initial claim - that our knowledge of the world depends on a more certain knowledge of experience - was that that was an absurd idea (because, eg. I only learn to talk about my experiences long after I learn to talk about trees etc), then we would never have been worried about scepticism in the first place. Nothing would follow from the mere existence of sceptical ringers.

Williams, M. (1988) 'Epistemological realism and the basis of scepticism' Mind 97
Williams, M. (1996) Unnatural doubts, Oxford: Blackwell

15th International Philosophy and Psychiatry (INPP) Conference 2012 New Zealand

I see that there is a website for next year's 15th International Philosophy and Psychiatry Conference between 5-7 July 2012 University of Otago, New Zealand.

The introduction reads:

The conference aims to go to the heart of debates about the nature of mental disorder, as it occurs in a multicultural setting. Psychiatric diagnoses, arising as they tend to from Western sources (for example, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders), are often not well suited to the traditions of indigenous peoples. Recent neuroscience is beginning to acknowledge the influence of culture on the development of the brain in ways that can inform our thinking about mental disorders. Leading thinkers from within Māori culture will be among the conference’s keynote speakers, providing a very special opportunity for dialogue and exchange of ideas.

Abstracts must be submitted on the Abstract Submission Form (Oral Presentation / Poster, or Workshop) below. They must be submitted by Wednesday 7 December 2011.

Trying to teach 'Criteria, defeasibility and knowledge'

(This is my attempt to summarise a class discussion of McDowell's 'Criteria, defeasibility and knowledge' though I have to say that, today, I rather felt like a vicar singing the hymn very loudly at the front.)

McDowell’s argument goes deeper and, in the end, concerns the nature of experience. But it is helpful to work up to that from his treatment of other minds. That’s what he does, too.

The problem of other minds starts from the assumption that whilst one can experience another’s behaviour, one cannot experience their mental states. (There is a trivial truth in this claim but it can also be taken to imply a significant epistemological point.) So the challenge is then to answer this question:

How can what we can experience (behaviour) yield knowledge of what we cannot experience (other minds)?

(In the philosophy of mind, this set up is usually accepted and the problem answered in its own terms. But McDowell aims to challenge the terms of the debate, to dissolve the problem before it starts. So I will ignore answers such as ‘the argument from analogy’ or ‘theory theory’.)

Behaviourism
One answer is to say that mental concepts are merely short-hands for behaviour. If so, a judgement about behaviour can support a logical deduction to judgement about mental states: behaviourism. BUT behaviourism is implausible (because of pretence / shamming).

Traditional view of criteria
So the erring Wittgensteinians put forward a weaker version of behaviourism. Mental concepts are not quite short-hands for behaviour but when those concepts are defined they include links to forms of behaviour. That is how little Ludwig learns the concept of pain, for example, by looking at others’ behaviour. So such behaviour is – a priori and by definition – good evidence for mental states. But – learning from the objection to behaviourism – such behavioural ‘criteria’ can be defeated / undermined. The behavioural criteria can be satisfied (that is, the right kind of behaviour can be present) but, for some reason or other, the appropriate mental state is not present (it is merely acting, eg.).

McDowell’s objection to the traditional view of criteria
It cannot give us knowledge of other minds. There is NEVER knowledge, even when there is no acting. Why not? Because if the criteria can be satisfied in the absence of the mental state, then even if all goes well and they are not defeated, still that is merely a matter of luck. All I am aware of is that the criteria are satisfied. But whether the other person really is in the mental state for which her behaviour is a criterion is beyond my ken: beyond anything I can experience.

McDowell’s alternative
The above objection suggests that the only way experience of others’ behaviour can yield knowledge of their mental states is if criteria are NOT defeasible. If they are satisfied, the other person must be in the right mental state.

There’s another consequence of that. Criteria are not types of behaviour at least when specified in non-mind-presupposing terms. If they were, and if they were not defeasible, then that would be behaviourism and we’ve already rejected that.

Two responses to that consequence:
1) a criterion is a criterion only in a context; it is a one-off arrangement of the elements. (This is like Williams’ contextualism but applied to the specific case of justification of knowledge of others’ mental states from behaviour.)
2) But it can be seen as a type as long as it isn’t given in non-mind-presupposing terms. All pain behaviour has the common feature that it expresses pain.

So what is going on?
There’s a positive story and a concession.

The positive story: the original assumption that judgements of behaviour are more secure than judgements of other minds is wrong. Once one has been inducted into a language (a language of other mental states), one can see in others’ behaviour, the expression of their mental states. One categorises the behaviour in terms of the mental states.
This positive story is helped by a historical diagnosis. Philosophers have only ignored the expressive possibility of behaviour because of an objectifying attitude to the body which is itself the result of Cartesianism because Descartes splits the mind off from a merely objective res extensa.

The concession: we do not always get things right. But when we do not that is not because the criteria are satisfied but defeated. But rather, we think the criteria are satisfied though they are not.
But this means that, as long things do not go wrong, what we experience is enough to reach out to (the expression of) other minds. The mistake is to think that there is something common between the cases of things going well or badly: the same behaviour. But there isn’t. In one case the behaviour expresses the mental state and in the other it is not. Thinking that there is means that we never have knowledge of other minds. If there isn’t then we sometimes have knowledge of other minds (when all goes well).

The link to the argument from illusion
The problem of other minds starts by taking behaviour which stops short of mental states to be all that can be experienced. Such behaviour is what is common between cases of things going well or badly.

Scepticism about the external world draws a similar conclusion from cases of illusions. Since we can confuse the experience of an illusion of a dagger and the experience of a real dagger, all that there can be to experience is what is common to both: the highest common factor. But if so, experience can never yield knowledge of the world since, if there is a dagger there, that’s merely a matter of luck.

Just as behaviour can be mind-expressing, so experience can be dagger-involving.