Mezzich et al (2009) ‘Cultural formulation guidelines’

Also for the MHRNS transcultural psychiatry group I’ve looked at

Mezzich, J.E., Caracci, G., Fabrega Jr., H. and Kirmayer, L.J. (2009) ‘Cultural formulation guidelines’ Transcultural Psychiatry 46: 383-405

I have never really known what the point of a cultural formulation was. But, a priori, two possibilities strike me depending on one’s view of how deep or how shallow one thinks the relation between culture and mental illness.

1) It might be that one thinks of mental illnesses as pathologies of aspects of an essential human nature such as biological nature or essential features of our rationality or mindedness. If so, cultural variation would overlie this and lead to local differences in the way that such fundamental pathologies are expressed. And then a cultural formulation would be a way of reverse engineering, from locally divergent symptoms, the common underlying causes.

This seems to be the view of Mezzich et al. they say:

The cultural formulation of illness aims to summarize how the patient’s illness is enacted and expressed through these representations of his or her social world. [ibid: 390]

and

Performing a cultural formulation of illness requires of the clinician to translate the patient’s information about self, social situation, health, and illness into a general biopsychosocial framework that the clinician uses to organize diagnostic assessment and therapeutics. In effect, the clinician seeks to map what he or she has learned about the patient’s illness onto the conceptual framework of clinical psychiatry. [ibid: 391]

The only positive role cultural factors can then play are as contingent resources:

The aim is to summarize how culturally salient themes can be used to enhance care and health promotion strategies (e.g., involvement of the patient’s family, utilization of helpful cultural values). [ibid: 399]

But there might be a more dramatic view of the role of culture in influencing mental illness.

2) It might be that the distinction between surface appearance and underlying pathology cannot be drawn. That is, the various ways one might want to flesh out the underlying notion – for example as biological or some other underpinning notion of universal human nature – might fail. It is unlikely that there is no such thing as biological human nature but it might not, unaided, determine mental pathology because it might not – without education and enculturation, for example – determine mindedness. (Learning a language, for example, seems to be key.) By contrast, a richer notion of human nature, beyond mere biology, may simply fail to be universal.

If so, the two factor model of the first option would fail. A cultural formulation would not merely enable one to dig beneath surface difference to find common pathologies but would be an articulation of the genuinely different ways people can be ill in different cultures. There’s no sign of that in Mezzich’s view.

The competition between the metaphysics of mental illness of positions 1 and 2 merits discussion, at least.

Vaillant, G.E. (2012) ‘Positive mental health: is there a cross-cultural definition?’

I’ve been reading

Vaillant, G.E. (2012) ‘Positive mental health: is there a cross-cultural definition?’ World Psychiatry 11: 93-99

and it suggests a general dilemma for any cross-cultural definition of mental health.

Vaillant outlines seven different empirical models of mental health.

First, mental health can be conceptualized as above normal, as epitomized by a DSM-IV’s Global Assessment of Functioning (GAF, 6) score of over 80. Second, it can be regarded as the presence of multiple human strengths rather than the absence of weaknesses. Third, it can be conceptualized as maturity. Fourth, it can be seen as the dominance of positive emotions. Fifth, it can be conceptualized as high socio-emotional intelligence. Sixth, it can be viewed as subjective well-being. Seventh, it can be conceptualized as resilience. [Vaillant 2012: 93]

He says that he contrasts them. But in fact there is no critical assessment of them. Instead:

To avoid quibbling over which traits characterize mental health, it is helpful to adopt the analogy of a decathlon champion. What constitutes a “track star”? A decathlon star must possess muscle strength, speed, endurance, grace and competitive grit, although the combinations may vary. Amongst decathlon champions, the general definition will not differ from nation to nation, or century to century. The salience of a given facet of a decathlon champion, or of mental health, may vary from culture to culture, but all facets are important. [ibid: 93-4]

That is, also, pretty much all says about the question of whether any or all of the approaches might serve as cross cultural definitions. But the paper implicitly raises a few questions about the very idea of this.

First, there is the distinction between a definition of mental health and an instance of the definition. Are the brisk accounts offered supposed to be definitions of what mental health is? Or are they supposed to be examples of the way in which mental health might be instanced or realised or brought about in particular cases? The former claims generality. The latter may be 7 from a potentially infinite list. Vaillant’s relaxed attitude to lumping them together suggests the latter but if so there’s no attempt at the definition promised in the title.

Second, the obvious worry about a cross-cultural definition of mental health is parochialism. One may draw up an account that presupposes or expresses merely a local view of what matters. This worry is increased the more substance there is to it. Roughly, the more one says, the more likely it is to draw on a local view. But if one avoids this through greater abstraction, the risk is that of vacuity. One will end up saying very little about what mental health is.

Third, one might succeed in arriving a cross-cultural definition which is merely contingently cross-cultural. One way of doing that would be to take as many locally specific conceptions of mental health as there are cultures and construct a disjunction of them all (that is, link them all together with the word 'or' between each). That would then be a cross-cultural account (akin to a Tarskian enumeration of truths) but (like Tarki’s account) would be subject to the counter-factual worry that had there been a further community it would not have been covered by the enumeration. (The enumeration offers no inductive warrant for further extension.)

Given these points, and given the title of the article, I would expect Vaillant to offer some sort of theoretical backing for the substance he offers. For example, if one connected a concept of mental health to mental functioning underpinned by evolutionary theory, one would have the start of an account of what was essential (that is, on the temporary assumption that one get a non-question-begging account of human mental functioning from evolutionary theory: an assumption I do not share).

Failing that Nature’s eye perspective, how else might one attempt such a justification? One possibility would be to offer a conception of human flourishing without appeal to a reductionist base. So one might offer a richly normative account of how humans ought to function in the way that Aristotle does (and Vaillant mentions). But now the worry returns that this is merely a local perspective. Let me sketch just one example of this from Vaillant’s paper, not his Aristotle section in truth, but his sketch of Erikson’s model of maturity.

In Erikson’s model, adult maturity is achieved over time through the mastery of the four sequential tasks of “identity”, “intimacy”, “generativity”, and “integrity”.

Identity is not just a product of egocentricity, of running away from home, or of marrying to get out of a dysfunctional family. There is a world of difference between the instrumental act of running away from home and the developmental task of knowing where one’s family values end and one’s own values begin...

Next, young adults should develop intimacy, which permits them to become reciprocally, and not selfishly, involved with a partner. Living with just one other person in an interdependent, reciprocal, and committed fashion may seem neither desirable nor possible to a young adult. Once achieved, however, the capacity for intimacy may seem as effortless and desirable as riding a bicycle... Career consolidation is a task that is usually mastered together with or that follows the mastery of intimacy...There are four crucial developmental criteria that transform a “job” into a “career”: contentment, compensation (i.e., useful to others, not just a hobby), competence and commitment. Failure to achieve career consolidation is almost pathognomonic of severe personality disorder.

Mastery of the fourth task, generativity, involves the demonstration of a clear capacity to care for and guide the next generation. Existing research reveals that sometime between age 35 and 55 our need for achievement declines and our need for community and affiliation increases.

The penultimate life task is to become a “keeper of the meaning”. This task, often part of grand-parenthood, involves passing on the traditions of the past to the future. The focus of a keeper of the meaning is on conservation and preservation of the collective products of mankind. Generativity and its virtue, care, requires taking care of one person rather than another. In contrast, keeper of the meaning and its virtues of wisdom and justice are less selective; for justice, unlike care, means not taking sides.

The last life task is integrity, the task of achieving some sense of peace and unity with respect to both one’s own life and the whole world, and the acceptance of one’s life cycle as something that had to be and that, by necessity, permitted of no substitutions. [ibid: 95-6]

This seems a plausible account of the stages that instance good mental health in the UK in the C21 but also seem tied to biological underpinnings and the nature of societal living (shades of Aristotle). But at the same time, one can easily imagine someone for whom these stages of family, career and elder statesman seem a bourgeois straight-jacket and that other ways of going on would be more life affirming. Even if this does, as a matter of fact, instance good mental health for many of us now, there seems no reason to think it defines it. Especially for mental health, rational disagreement and new ways of living seem ongoing possibilities.

In other words, there seems no obvious way of balancing the requirement of substance and non-contingent universality.

Summer School in Philosophy of Psychiatry: Mind, Value and Mental Health

I have been sent the following notice:

Summer School in Philosophy of Psychiatry: Mind, Value and Mental Health

14 – 19 July 2013 University of Oxford

It is with great pleasure that we announce this one-week accredited summer school.  Presented by the Faculty of Philosophy and the Department for Continuing Education, this event will explore the areas in which the philosophy of mind and ethics or the philosophy of value come into contact with issues about mental health.

The intensive programme will be delivered by renowned experts in the field through keynote lectures and seminars offering opportunities for substantial dialogue between philosophers, scientists and mental health practitioners.

The summer school will be led by members of the Faculty of Philosophy:

Professor Martin Davies (Wilde Professor of Mental Philosophy, Corpus Christi College)

Professor Bill Fulford (Emeritus Professor of Philosophy and Mental Health, University of Warwick, and Member of the Philosophy Faculty, University of Oxford)

Dr Edward Harcourt (University Lecturer (CUF) in Philosophy, Fellow and Tutor in Philosophy, Keble College)

International guest speakers include:

Professor George Graham (A.C. Reid Professor, Wake Forest University)

Professor Terence Irwin  (Chair of the Faculty Board and Professor of Ancient Philosophy, Keble College)

Professor Chris Frith (Emeritus Professor, Wellcome Trust Centre for Neuroimaging at University College London. Neils Bohr Visiting Professor, University of Aarhus, Denmark)

Professor Giovanni Stanghellini (Professor of Social Psychopathology, Post-graduate School of Psychiatry, University of Florence)

This event will take place at St Catherine’s College, Oxford and includes social activities and plenty of networking opportunities. Residential and non-residential options are available.

Further details available: www.conted.ox.ac.uk/PoP

To register your interest in this summer school, please email conferences@conted.ox.ac.uk

Valutazionismo o oggettivismo: nell’analisi della malattia mentale abbiamo a che fare con una questione di fatti o di valori?

I have just been posted a copy of the latest issue of Rivista Sperimentale di Freniatria. which has a paper of mine - 'Valutazionismo o oggettivismo: nell’analisi della malattia mentale abbiamo a che fare con una questione di fatti o di valori?'  - generously translated into Italian. For those who can speak Italian (sad to say not me which is why I am not such a regular reader of Rivista Sperimentale di Freniatria), the abstract is as follows.

Abstract:
Il livello di comprensione della natura della malattia mentale che le neuroscienze sono in grado di offrire dipende dalla natura della stessa malattia mentale: si tratta, cioè, di un’essenza oggettiva intrinseca oppure di qualcosa di valoriale e socialmente determinato? Il dissenso a questo riguardo è di lunga data. Al fine di gettare qualche luce sul dibattito, l’Autore utilizza, rielaborandolo, lo schema suggerito da Zachar e Kendler per riflettere sulla tassonomia psichiatrica. Secondo Thornton, un approccio radicalmente esternalista della malattia mentale (un esternalismo costitutivo valutazionista) invalida il ruolo svolto dalle neuroscienze. Tuttavia, la divergenza tra una tale posizione valutazionista e il suo opposto oggettivista può riguardare non solo la natura della malattia mentale, ma altresì i termini del dibattito medesimo. Il valutazionista può, infatti, asserire che lo stesso dissenso non è una questione fattuale, ma al contrario valoriale.

Learning from artificial cases?

As part of a more general training programme I took part in a session by Miles Peacocke of Real Results (a colleague of whom conducted another session I’ve previously remarked on). It involved an exercise, or game, the rules of which I will not describe as not knowing about it in advance seems to be an important element of it (that seems true even if the purpose of the exercise remains opaque to me) and colleagues may well encounter it themselves. We were told that it involved co-operation and it began with the distribution of a set of cards containing a variety of forms of content though until I’d seen the cards it wasn’t clear to me whether it really was wholly cooperative. I hope I don’t give too much away to say it involved acting on and ordering the cards under time pressure.

As it turned out, we – members of UCLan’s research active staff – successfully completed it in good time (much to Miles’ apparent surprise) without the imposition of any top down structure. Suggestions were made – I made some myself – but no one exercised any great authority and we collectively allowed the necessary order to evolve out of initial disorder through a variety of distinct local strategies. Not everybody did the same thing with their cards, for example. But it seemed clear to me, early on, that this would not matter (though in other games it might).

Afterwards, Miles asked what we’d done well, what we’d improve and what we thought would change if we did it again. And at this point I realised how difficult it is to learn anything general from such commercial training exercises. In this particular game, a bottom up evolution was a safe strategy insofar as no one started off in a better epistemic state. Best therefore to hear all suggestions. But not all the games in his little box might have worked that way. Nor was that something that we had ‘done’ in the sense of an intentional shared action: that would require exactly the kind of prior view we lacked. That it had happened was retrospectively a good thing but it might not in other cases. So it made little sense to resolve to act in the same way or differently for an arbitrary choice of game (and there’s no point in asking about the same game now we knew how it worked). I predicted that we would, as a matter of fact, act in pretty much the same way whether or not we should.

In other words, we probably hadn’t learnt anything easily generalisable except, perhaps, that academics are less rubbish at such things than one might expect. That was, perhaps, a pleasing result but not obviously what the session had taken as its aim (and a dangerous aim at that!). The universe of possibilities of any such exercise is just too large and its connection to aspects of life outside such exercises too much subject to interpretation to draw robust lessons about when such ways of acting would be effective strategies and when not. Too much is contextual.

On the other hand, everything can form the basis for some sort of analogical thinking and, by strange coincidence, as I cycled back to the station I encountered just such a possible instance. The traffic lights which control an off-set four way road junction of two dual carriageways had broken and cars were making their ways gingerly across it. With no top down control, responsibility had fallen to individual drivers who were exercising a degree of courtesy so that even on a bike it did not seem too dangerous. So bottom up order from chaos worked. But did it work better than traffic lights? And would it work for other junctions? Hard to generalise from that particular case.