Friday 27 July 2012

Values Based Practice, Social Policy and the Service User identity update

Here is an second version of the paper that David Morris and I are writing.

Values Based Practice, Social Policy and the Service User identity


‘Values Based Practice’ (VBP) might be the name of any approach that paid due and serious attention to the role of values alongside facts in good healthcare. But it has also become the name of a particular approach to working with diverse values in healthcare pioneered by the psychiatrist and philosopher KWM (Bill) Fulford. In this paper, we will take it to mean the latter.

Although drawing on a substantial philosophically framework, VBP is, itself in one key respect, theoretically minimalist. That is, aside from some framework values, the violation of which would undermine the very possibility of VBP, the work of managing diverse values is not determined or dictated by antecedent principles. Its ‘principles’ are more pointers or reminders. Nor is it even driven by the goal or telos of a right outcome but is instead guided by the idea of following a good process. The task of managing a legitimate diversity of values is left to a process of discussion by those who have a stake in the outcome, a discussion the shape of which is left deliberately open-ended. Whilst there are some pointers to guide the debate, there are few – though not no – ground rules.

But whilst it is plausible that the application of VBP to clinical decisions with particular identified patients or health service users, and a particular team of health professionals provided by the contingent circumstances of care, can be theoretically minimalist (though whether it can be as minimalist as it is taken by Fulford to be is open to question [see Thornton 2011]), its application to health and social policy cannot escape some substantive antecedent commitments.

A key question concerns the identity of service users in the context of social policy. By contrast with the paradigmatic case of clinical decision making, this identity cannot be taken for granted. But ‘not taking it for granted’ means, in this case, that it cannot be settled prior to some judgements about relevant values, judgements thus prior to and outside the application of VBP. We will use a vignette – the case of Mrs E – to illustrate the possibility that the proper answer to the question ‘Who is the user of a service or policy?’ may be, not an individual or even agglomeration of individuals, but a social network. Neglect of this through assuming that service users are individuals risks neglect of social capital.

We will also caution against conceiving of the service user identity in the policy case on the model of that of paradigmatic clinical decision making. At the risk of slipping into jargon: the service user identity should not be thought of essentially, or exclusively. It is an identity relative to context. But determining who the service user is in any given context depends on a piece of values-based reasoning. So if VBP proper presupposes an answer to this question before it can start such reasoning is not part of VBP but rather something more fundamental.

Values Based Practice and clinical decision making

Values Based Practice stands in opposition to an implicit or inchoate traditional view of the relation of facts and values in medical care. On this traditional view, medical diagnosis is a matter of getting the facts right independent of any values. Values come into play in guiding – alongside good evidence based medicine – treatment and management. And when they do, they are codified in a set of principles, a proper understanding of which form a kind of moral calculus.

VBP rejects both of these aspects of the traditional view. Values are implicated in diagnosis as well as treatment. And any moral principles to which we might appeal are insufficient to guide good practice. The arguments for the first element need not concern us in any detail here [see Thornton 2007: 62-73; Thornton 2011]. But they have to do with the idea that illness in general is an evaluative notion. Illness is bad for the sufferer and that notion of badness is essentially evaluative. (Thus VBP is committed to the failure of programmes to reduce the notion of illness to value-free notions such as a failure of biological or proper function. But, first, there is grave doubt as to whether the pattern of explanation in which functions are deployed really is value-free [See Thornton 2000]. Second, even the foremost contemporary philosopher of psychiatry who defends the use of failure of function to capture the idea of disorder explicitly combines that with the value, harm, to analyse illness and disease [Wakefield 1992, 1999].)

The second step to articulate Values Based Practice is the rejection of both the sufficiency and the fundamental importance of moral principles in guiding medical practice. The first follows from a feature which is present even in Tom Beauchamp and James Childress’s attempt to relate medical ethical reasoning to a set of principles [Beauchamp and Childress 2001].

Principles of Biomedical sets out four general principles to guide medical ethical reasoning: autonomy, beneficence, non maleficence and justice. As is familiar, these four do not derive from any single higher principle and can conflict. Beauchamp and Childress describe two methods for dealing with such conflicts: specification and balancing. Specification is a way of deriving more concrete guidance from the fairly abstract higher level principles. It ‘is a process of reducing the indeterminateness of abstract norms and providing them with action guiding content. For example, without further specification, do no harm is an all-too-bare starting point for thinking through problems, such as assisted suicide and euthanasia. It will not adequately guide action when norms conflict.’ [Beauchamp and Childress 2001: 16]

Balancing and complements specification thus: ‘Specification entails a substantive refinement of the range and scope of norms, whereas balancing consists of deliberation and judgement about the relative weights or strengths of norms. Balancing is especially important for reaching judgements in individual cases.’ [Beauchamp and Childress 2001: 18]

Neither balancing nor specification simply unpacks the content of the principles themselves. Nor, like deductive nomological explanation in the physical sciences, do they combine general principles with particular circumstances in a deductive argument. Both require an extra element of judgement. Thus even according to the Four Principles approach, the four principles are not sufficient for medical ethical judgement.

Values Based Practice goes further than this, however. Although it concedes that there can be sufficient agreement about some values that they can codified to provide the basis for ethical codes and guidelines and other agreed elements for any thinking about healthcare, these remain just a small part of the values that have to be taken account of in guiding medical practice which include individual preferences, desires, wishes, firmly held faith and convictions and so forth.

By stressing this multiplicity, it stresses the standing possibility of disagreements and clashes in thinking about particular circumstances. But if values are ubiquitous and if, agreed framework aside, disagreement is both to be expected and legitimate, how can the process of assessing the competing ‘pulls’ of different values be managed? To repeat, within the framework, guidance by principles is of limited use. There are three key suggestions.

First, rather than aiming to arrive at the right outcome in a conflict, VBP aims instead at there being a good process. That is, it rejects the idea that a particular accommodation of values might be the right result in any particular context in favour of a method. Correctness, if it applies at all, applies to the method followed. Fulford summarises this idea thus: ‘conflicts of values are resolved primarily, not by reference to a rule prescribing a ‘right’ outcome, but by processes designed to support a balance of legitimately different perspectives (the ‘multi-perspective’ principle)’ [Fulford 2004: 206].

Second, ‘communication skills have a substantive rather than (as in quasi-legal ethics) a merely executive role in clinical decision-making (the ‘how it’s done’ principle)’ [ibid: 206]. This again reflects the idea that correctness attaches not to an endpoint but to a process. Thus there is equal stress on methods of raising awareness of values by attention to language use (the ‘values-blindness’ principle) and for improving knowledge of other people’s values (the ‘values-myopia’ principle).

Fulford characterises VBP using ten principles or pointers.

Ten Principles of Values Based Practice

1: All decisions stand on two feet, on values as well as on facts, including decisions about diagnosis (the ‘two feet’ principle)

2: We tend to notice values only when they are diverse or conflicting and hence are likely to be problematic (the ‘squeaky wheel’ principle)

3: Scientific progress, in opening up choices, is increasingly bringing the full diversity of human values into play in all areas of healthcare (the ‘science driven’ principle)

4: VBP’s ‘first call’ for information is the perspective of the patient or patient group concerned in a given decision (the ‘patient-perspective’ principle)

5: In VBP, conflicts of values are resolved primarily, not by reference to a rule prescribing a ‘right’ outcome, but by processes designed to support a balance of legitimately different perspectives (the ‘multi-perspective’ principle)

6: Careful attention to language use in a given context is one of a range of powerful methods for raising awareness of values (the ‘values-blindness’ principle)

7: A rich resource of both empirical and philosophical methods is available for improving our knowledge of other people’s values (the ‘values-myopia’ principle)

8: Ethical Reasoning is employed in VBP primarily to explore differences of values, not, as in quasi-legal bioethics, to determine ‘what is right’ (the ‘space of values’ principle)

9: In VBP, communication skills have a substantive rather than (as in quasi-legal ethics) a merely executive role in clinical decision-making (the ‘how it’s done’ principle)

10: VBP, although involving a partnership with ethicists and lawyers (equivalent to the partnership with scientists and statisticians in EBM), puts decision-making back where it belongs, with users and providers at the clinical coal-face (the ‘who decides’ principle)

Despite these pointers, however, Values Based Practice is theoretically minimalist. That is not to say that it is not based on theoretical considerations. It draws heavily on Fulford’s analysis of the evaluative nature of diagnosis which in turn is based in the ordinary language analysis pioneered in Oxford in the 1950s and 1960s, especially Hare’s early work on the logical properties of value terms [Fulford 1989; Hare 1952]. But that theoretical articulation is used to defend a theoretically-light approach to forming value judgements.

By contrast with what Fulford calls ‘quasi-legal medical ethics’, in which value judgements are derived from a rich body of principles or the equivalent of case law, VBP leaves them to a process of exploration, self- and other-knowledge and discussion. It accepts ‘dissensus’ as a likely outcome. It is a liberal approach to the values in question. Aside from the framework values, all and any values have equal merit prior to the process of local debate.

But that theoretically minimalism is made possible in part by taking one thing for granted. As the fourth pointer says: VBP’s ‘first call’ for information is the perspective of the patient or patient group concerned in a given decision (the ‘patient-perspective’ principle). That principle militates against a slippage of discussion into a paternalist imposition of values on, or against, the patient or service user. But it assumes that the question of who is the patient or service user can be decided independently of the application of VBP to value judgements. This is a reasonable assumption in the paradigmatic case of clinical decision making where the identities of patients, clinicians and other members of a healthcare team are fixed by local contingencies. But things are more complicated in the case of the identity of ‘users’ of a policy.

Values based practice, social policy and service user identity: the underlying logic

In clinical decision making, Values Based Practice can start from the particular patient and his or her clinical team. Thus the question of who is the patient or service user can, to a first approximation, be taken for granted prior to the application of VBP. But that is not true to anything like the same extent in cases to which VBP may be extended and applied: the investigation and evaluation of social policies concerning healthcare.

In the case of the application of Values Based Practice to a particular patient and their pre-existing clinical team, the question ‘Who is the service user?’ is not, typically, a pressing problem. But what of the case of the assessment of existing or the development of new health and social policies?

The problem in a nutshell is this. Any practical health or social care policy has a number of effects or consequences, both positive and negative. A policy designed to reach members of a community unwilling to report their mental health problems, for example, might have such people as its service users. But if it addressed them by addressing families, then healthy family members might also be count as service users. And if the aim were to improve social inclusion within the community, other members of the community might count as service users. Given that VBP prioritises the ‘patient or patient group concerned in a given decision (the ‘patient-perspective’ principle)’ this raises the question: who should count as the patient or service user in such complex cases?

This is not to say that such a question is unanswerable. But answering it will involve assessing the competing claims of different potential groups for priority. Since that is an evaluative (as well as a factual) matter it might have been thought that it could be settled by an application of Values Based Practice. But it turns out that VBP presupposes a prior answer to it. In other words, the question of service user identity is an evaluative matter which, whilst vital, cannot be addressed by VBP as it is applied to clinical decision making.

Although we have outlined the problem as one of principle (VBP both requires but cannot assume an answer to the question of service user identity before its application), there are also practical problems which follow from assumptions which are typically made about the likely identity of service users. One problem is that the potential therapeutic value of social networks in particular go unnoticed and thus their worth is neglected. We will illustrate this through the following detailed vignette (though name s and details have been changed to ensure anonymity).

The case of Mrs E

Consider the case of Mrs E, a woman of 96, living, as she has since 1920, in an un-modernised Edwardian house in inner London. Though she has no significant cognitive impairment or difficulties with communication, Mrs E has breast cancer, diabetes, arthritis and hypertension (resulting episodically in serious nose-bleeds and fainting) for which she requires some eight forms of medication daily. She lives alone having been long widowed and has a daughter of 60 who lives 250 miles away and whose scope for maintaining contact is hampered also by her own health problems. Mrs E’s mobility and hence her self-care is severely limited by her arthritis. She can feed herself but cannot prepare food. She can dress herself but with such difficulty that she usually remains in her night clothes throughout the day. With its original coal fired heating and plumbing system, her only access to hot water in the summer months, when the boiler is off, is by way of a kettle, so she cannot bath or shower for much of the year. Mrs E is frail. Life is a daily struggle to retain independence. That she has retained it in these circumstances is due to the specific and extensive commitment of a neighbour who has provided daily assistance with personal care for some years – and who has de facto become Mrs E’s carer – a number of other neighbours who provide informal support and help with specific tasks as required and two established friends, each of whom visit monthly.  

The members of this network are crucial to Mrs E. They have used their own agency to optimise her resilience, scope for independence and hence agency in two key ways. Firstly, in having been responsible for securing Attendance Allowance, ‘Telecare’ and adaptations to the home environment (including installation of the stair lift by which means Mrs E is able to get to bed) they have articulated and secured otherwise unmet practical needs and financial entitlements. Secondly, they have established a form of social engagement based on shared identity. One of the two established friends is, as Mrs E herself has always been, a keen gardener and so shared gardening narratives have become a critical aspect in shaping over time a form of support which is reciprocally informative, appreciative and, therefore, sustainable. In addition, through the multiple dimensions of shared experience associated with their engagement with Mrs E and each other, this network has generated new and diverse forms of knowledge and accordingly, collective identity. In addition to being the group of individuals who support Mrs E, they might be considered with Mrs E to constitute a form of neighbourhood capital both with continuing potential for mutual support based on the needs of Mrs E herself, and, in the context of what may be thought of as the ‘core economy’ [Cahn 19**] of the locality, with emergent potential for the wellbeing of other members of the community and therefore, the community itself. 

In relation to Mrs E though, while this network has therefore been instrumental in enabling her independence, it has reached the limits of its capacity to meet a level of personal need that deepens a little each week and has sought advice from the local Adult Social Care Department. Until this point, the only health or social care service which Mrs E had received was that provided, as required, by her GP and a Community Nurse working from the Practice. The Social Worker who visits Mrs E is experienced and specialises in older people. She sees her role as one of assessing the individual needs of Mrs E, as a putative service user, against a criterion framework for service entitlement. In part because of the effectiveness with which she has utilised the network interventions to date, Mrs E fails to meet any of the criteria for a service to be provided. Moreover, the social worker’s professional modus operandi provides no space for an account either of the impact of the decision on the network or of its contribution to date and in the future. Fidelity to an individualised or personalised definition of who the service user is has eliminated the need to understand the problem systemically as one in which a number of people are, in effect, joined to the challenge of meeting individual need. In excluding any evaluation of the inter-dependency impact that these relationships, for all their complexity, might represent, we see an approach to seeking to protect individual independence which contains the means for its own failure, with all that this entails for the costly and inevitable demise of Mrs E’s health and wellbeing.    

To privilege the identity of an individual community member as service user as the key organising principle in the design of services that incorporate a values perspective may be necessary to reframing the way in which power is seen and used in the relationship between professional service provider and recipient. It is certainly the sine qua non for a service seeking to be consonant with the precepts of contemporary policy on personalisation. As the example has shown, however, it can also reinforce a conceptualisation of this relationship as bilateral: one in which some nominal redistribution of power takes place between two players in a clinical engagement rather than one that draws on the rich capital that a systemic approach can engender if it brings to bear instead the ‘real life’ analysis of social possibility revealed in the multiple identities of people who may – or may not use services.

The case of Mrs E reveals one danger in a too hasty assumption about the identity of the users of a health or social policy. A typical focus on individuals neglects the importance, and value, of social networks which might properly be thought of as users of services. Such networks, however, need not themselves be mere agglomerations of individuals but may be structured and supported by social relations.

Such a case contrasts with the paradigmatic view of VBP applied in a clinical setting in which the question of who is the service user seems, at least, more clear cut. That is not true, we have suggested, of the policy case. But it might be assumed that identifying service users in the latter case can be modelled on the former through a slippage between the idea of identifying service users to the idea of a service user identity. (Think of the difference between using the word ‘identity’ to mean having an answer to the question ‘Who is the tallest person in the room?’ and using it to mean the self-conception that someone might have. The tallest person may not think of themselves as the tallest person, their height may be of no importance to them.) So it might be thought that there is a shortcut to picking out who the service users are of a mental health policy, eg., from the community of service users, those who take on that as their identity. There are, however, reasons to be wary of the very idea of a service user identity which we will now outline.

The contingent perils of a service user identity

We will outline four reasons to be cautious of the idea that a community of service users can be picked out through a service user identity.

First, the very idea of a service user identity, based on shared experience could, ironically, limit relationships with other disadvantaged communities whose own complementary claims could be an resource. To privilege the collective voice of common interest over other perspectives and communities may encourage such communities to turn inwards.

Second, it circumscribes the context within which individual capabilities can be understood and appreciated. Behind the case for equity of opportunity is an implicit argument for the recognition of capability. The right to participate is driven by an assertion of personal capability to participate. A categorical approach to defining community may place limits on the way in which its members and their diverse capabilities, both individual and shared, will be expressed and perceived externally, thereby limiting the effect of that aspect of empowerment concerned with the proper recognition of what people can do. This links to the third problem.

Third, in practice, the right to be equally valued irrespective of difference is likely to be realised only in a social context in which the capabilities of people with disability are recognised and the potential for defining people principally in terms of disability are eradicated. The positive perception of disability necessary to actions that support empowerment are associated with the idea that the nature and value of an individual’s activity should be seen as a function of their multiple identity. A service response to the needs of people with disability which incorporates their role as citizens with contributory assets alongside that of service users with needs, is conditional on the notion of multiple identity being understood by public agencies. This understanding may not be best served by retaining, as the basis for service organisation, a model of community characterised by a singular definition of membership especially in a service environment governed by a contemporary concern with community health and civic engagement.

Fourth, the potential for individual recovery, whether defined at the level of the individual or at a population level, is usually calibrated against an assessment of the response of other people. For example, how successful a person with a mental illness might be in holding down a job in an open plan office  is likely to depend on an  assessment made of the anticipated or actual response of office colleagues (‘the work community’), while policy on employment for people with mental health problems is likely to take this into account, deploying study data (or not!) in which examples of such individual experience is aggregated as an evidence base for the existence, and therefore policy relevance, of stigma and discrimination as factors to be considered in service model development.   It is important therefore to give these external social accounts some descriptive weighting in order to advance social recovery prospects and, to the extent that such discourse is conducted within the conceptual framework of ‘the community’ (which is the case for policy and practice in public mental health as well as that for services), it is important to provide for an understanding of community perspectives associated with ‘the other’ that has some equivalence to those associated with that of illness experience.

Service user centrality and theoretical minimalism

As we outlined in the first section, when Values-Based Practice is applied to individual clinical cases, it is theoretically minimalist. With the parties to a clinical decisions identified, VBP imposes a background of shared values – necessary for it to function at all – but then leaves the management of rational and legitimate disagreement about values to a discussion in which highlighting the values involved, including hidden and implicit values and communication skills play a central role. By adopting a form of theoretical minimalism, VBP can avoid having to settle contentious global debates about competing moral theories and approaches. Providing that there is sufficient agreement about framework values, VBP can leave the discussion of competing values to a local context. The particular participants can examine their values relevant for the particular decisions concerned.

Such discussion is not, however, entirely free. A safeguard against paternalism is the ‘patient-perspective’ principle: the ‘first call’ for information is the perspective of the patient. But, as we have argued, the combination of this principle and theoretical minimalism cannot be carried over in to the context of health and social policy.

Identifying the claims of groups to count as service users, to count as having more say than others, cannot be taken for granted. If not, it must itself be subject to a value-laden debate and judgement. If VBP is identified with a minimalism, then this issue cannot be settled by VBP alone. If it is not so identified, then the application of VBP to policy debate will call for a more structured approach to weighing the opinions and values of those who may be affected. The cost of the application is giving up minimalism. Some values will have more values than others.

There is, however, a benefit from this cost. We will illustrate this by refrring back to two earlier sections. First, in the discussion of Mrs E, we highlighted the danger of assuming that the proper answer to the question ‘Who is the service user?’ picks out an individual or even an agglomeration of individuals. In some cases, at least, a better answer may be that a social network or community is the service user (where one distinction between an agglomeration and network is that individuals can enter or leave the latter without changing its identity).

Second, in the penultimate section, we drew attention to some contingent but typical dangers from approaching the question of the identity of service users in the policy case with the same simple mindedness which seems to work for the paradigmatic clinical case. If one thinks of service users as those picked out by having a service user identity – as a particular community fixed prior to potential policy developments – then this will encourage the isolation and permanence of that community. But if instead, identifying the service user community or communities depends on the policy under scrutiny and its particular consequences, these dangers can be diminished.

To count as a service user – relative to a particular policy – will depend on fitting a role, or characteristic. This follows from the idea that so counting will flow from an argument which will have to be couched in general terms such as why having such and such a role puts one in a position to have an expertise in so and so. Thus a sufferer from a mental illness may also be a tax paying citizen, a family member, a carer, a member of a particular ethnic grouping etc. Thus the individual can properly count as a member of any number of differing communities relevant to a policy initiative and thus merit a number of different voices.

Thus service user identity may include social networks as well as individuals and can be shifting and multiple rather than fixed and single. Neither of these corrections to the paradigmatic case is inconsistent with the main thrust of VBP: with the claim that values play a key role in debate about health and social care in a way that reists codification in ethical principles. But since both kinds of debate about identity are grounded in reasoning  concerning the, sometimes competing, values in play, they are inconsistent with the assumption that service user identity can be assumed before VBP is put into play.


Beauchamp, T.L. and Childress, J.F. (2001) Principles of Biomedical Ethics Oxford: Oxford University Press

Cahn **

Fulford, K.W.M. (1989) Moral Theory and Medical Practice Cambridge: Cambridge University Press

Fulford, K.W.M. (2004) Ten Principles of Values-Based Medicine. in Radden, J. (ed) The Philosophy of Psychiatry: A Companion New York: Oxford University Press, 205-34

Hare, R.M. (1952) The Language of Morals Oxford: Oxford University Press

Thornton, T. (2000) ‘Mental Illness and Reductionism: Can Functions be Naturalized?’ Philosophy, Psychiatry and Psychology 7: 67-76

Thornton, T. (2006) Judgement and the role of the metaphysics of values in medical ethics. Journal of Medical Ethics, 32, 365-370

Thornton, T. (2007) Essential Philosophy of Psychiatry Oxford: Oxford University Press

Thornton, T. (2011) ‘Radical liberal values based practice’ Journal of Evaluation in Clinical Practice 17: 988-91

Wakefield, J.C. (1992) ‘The Concept of Mental Disorder: On the Boundary Between Biological Facts and Social Values’ American Psychologist 47: 373-88

Wakefield, J.C. (1999) Mental disorder as a black box essentialist concept. Journal of Abnormal Psychology 108: 465-472

Wednesday 25 July 2012

Norman Malcolm's "lady-philosopher" and Sliding Doors

In the Brewery Arts Centre last night with friends, I had a vague pretext to tell the story of Wittgenstein’s worry and then relief when Norman Malcolm (pictured) didn’t marry a ‘lady philosopher’. All ended happily, I reported, thinking of Wittgenstein, Malcolm and the non-philosopher Mrs Malcolm acting out the moon, earth and sun’s paths through the cosmos on Jesus Green.

But this morning I had a follow up email:

How do you know that it all worked out fine with the philosopher not getting himself a philosopher-wife? Or what I mean to say is: How do you know it wouldn't have been fine if he had gotten her? Isn't there some kind of philosophical construct that describes the certainty of uncertainty to any situation that could have several endings or more simply put just like in 'sliding doors' with Gwyneth Paltrow?
Laura x

So here is a bad reply to a question that that question at least presupposes.

Suppose you make a life changing decision (you do, or you don’t, marry a lady philosopher, you do, or don’t, change jobs or move country etc) and then wonder whether you made the right decision. What sense attaches to that question?

In some cases, it seems that we do have a fairly clear idea. Last Saturday at Pizza Express I had the Etna having deliberated for a little while as to the rival merits of the old American Hot. If I were to ask, at the time, whether I’d made the right choice I might mean something like: if I had had the American Hot, would I have liked it more than I do like this Etna? I compare the counter-factual taste with the actual taste.

This is a fairly sophisticated use of ‘compare’. I cannot actually compare a real pizza with an unreal one (the one I didn’t order and thus didn’t cause to be made and thus didn’t exist). But we can extend the idea of actual comparisons of actual pizza. Imagine if like Prince Charles having 12 different eggs each cooked for longer and longer times to find the perfect soft boiled egg every morning I ordered both pizzas and ate the one I preferred. Now we just skip the actual other pizza and ask whether I would have preferred it. We can teach small children to do this and thus save on the restaurant bill.

But suppose that had I had the American Hot – in that possible world – by chance or by some complex causal chain, the waitress would have dropped it on my lap or a light fitting would have fallen on my head, killing me. Would I have preferred that to the Etna I actually had with no such upset? That seems the wrong question. I want to know which I would have preferred it all other things being equal. Hold everything else constant in the actual and the possible world and compare only the different pizza experiences. That is, I think, what we normally mean if we ask whether we’ve made the right choice in the ‘Express.

What if the American Hot always causes me, or would cause me, an allergic reaction? That might factor into an assessment of what is to be compared or not. If the deliberation is practical, it should include the predictable consequences of the competing choices. But sometimes I might wonder whether, aside from allergic reactions, I would have preferred it. We can think either way.

But in complex cases, this whole approach does not seem possible. Changing partners, jobs, countries etc changes lots of things (such as the friends one ends up with) in unpredictable ways and these other things may matter enormously to an assessment of how and why one is as happy, or not, as one is. So the idea that one can compare the actual case with something else is put under threat. Who knows what significant factors would have changed had I taken, or not taken, that job? What friends, what exercise regime, what diet, what state of health? Unlike the convergence in the film Sliding Doors, it seems to me that the differences, given a different initial major choice, get bigger and bigger very quickly. So even if one undertakes to try to think about another choice all other things being equal, it is unclear that that phrase has, in this context, a clear meaning. I could not have that job in Otago and live in Kendal eg. But what are the limits to what has to stay fixed and what change?

That thought also puts another one under threat: did one make the right choice? Without the possibility of asking whether the other choice would have been better there is now also no sense equivalent to the pizza case of having chosen correctly.

But there is at least one other way of approaching that idea. Here is an analogy based on an idea from Crispin Wright (though I doubt he would approve the extension!). These days we all know that colour is a complicated business. Colours are related to light but not simply to some wavelengths. There is no pink or brown in the spectrum, eg. Facts about the eye play a role also. One response to this is to think that colour is not real and in the world in the way that length or mass is. Instead, to be green is to be judged to be green on a summer's afternoon by someone with statistically normal vision. So the judgement that x is green fixes the facts about that bit of the world. Well, roughly. It's like the euthyphro paradox: do the gods love what is good because it is good? Or is it good because the gods love it? The sketch of a view of colour links it to the second option.

That is not, however, to say that such judgements cannot go wrong. The lighting may be wrong or the colour vision defective. But ultimately what is right or wrong does not depend on independent facts about colour. The facts about colour depend, ultimately, the other way round on judgement. So we might try to save the idea of a correct choice in complex cases by a similar move: if one followed the right procedures and made no procedural errors, then that is the notion of correctness in play. The standard of correctness just is making the judgement in the right way. If we want to, we can then milk a notion of the alternative having been worse from that to say, if the choice were made correctly and took into account the appropriate factors, then the alternative would have been worse: that is what correctness in such a choice amounts to. (But like the colour case, the facts about the other case depend on, rather than disciplining, the correct judgement.) On reflection, pizza choice is probably Iike that too.

So given that listening to what Wittgenstein said was always the right thing for his disciples, the real Mrs Malcolm was bound to be better than the hypothetical lady-philosopher Wittgenstein feared.

Monday 23 July 2012

Postdoctoral Research Fellow in Philosophy, Durham University, UK

Applications are invited for the position of Postdoctoral Research Fellow in the Department of Philosophy, Durham University. The post is associated with a three-year research project entitled “Hearing the Voice”, which is supported by a Strategic Award in the Medical Humanities from the Wellcome Trust. The project will investigate the phenomenon of voice-hearing (hearing a voice in the absence of any speaker). Usually interpreted as a sign of severe mental illness, voice-hearing figures in the experience of a wide range of people, including many who do not seek psychiatric help. The Hearing the Voice project aims to achieve the fullest possible account of this experience by examining it from a range of perspectives including philosophy, literature, theology, psychology, cognitive neuroscience, psychiatry and the medical humanities. The project involves researchers from all three faculties of Durham University, along with clinicians, academics and experts-by-experience from national and international partner institutions.

This post, one of a number associated with the project, will be tenable for three years, from 1st October 2012. Working closely with Professor Matthew Ratcliffe, the post-holder’s principal responsibility will be to research the phenomenology of voice-hearing and address associated philosophical issues, in ways that engage with neuroscience and other disciplines. The research fellow will produce high quality philosophical publications on voice-hearing and closely related topics, most of which will be interdisciplinary and/or collaborative. He/she will also attend a regular project reading group, present papers at project events, and work with several other members of the research team to organize events, co-edit publications, and assist in the development of on-line resources.

For further details:

PhD studentships in health at UCLan

Project Title – Improving Access to Health and Healthcare
Reference Number: RB-12-HEA1
Project Title – Developing Evidence for Practice
Reference Number: RB-12-HEA2
Project Title – Understanding Service User Perspectives
Reference Number: RB-12-HEA3
Project Title – Can We Trust Internet Surveys and Social Networking Sites to Capture The Views of People With Cancer?  
Reference Number: RB-12-HEA4

Thursday 19 July 2012

Oxford Handbook of Philosophy and Psychiatry Section VII draft introduction

Section VII Explanation and understanding

For much of its history, the pairing of explanation and understanding has been taken to express an opposition between natural science and human science or interpersonal understanding more broadly. Further, the opposition was taken to express the limits of both. The kind of insight offered by one was impossible to achieve by the other. This was Jaspers’ view. Whilst psychiatry should contain both approaches, and whilst the very same events could be approached using either (he thought that every event could, in principle be explained and, more surprisingly, all could also be understood), concentration on only one risked diminishing the insight.

Given that understanding is an implicit thread through much of the rest of this handbook, this section concerns not what cannot but rather what can be studied scientifically. On the assumption that psychiatry is based, in part at least, on natural science, what is the nature or the general shape of that science? Some of the chapters aim at getting right the nature of component parts of a scientific world view. What, for example, is the nature of causation and its connection, if any, to the existence of mechanisms? If psychiatry rests on a taxonomy of mental disorders, what kind of kinds does that involve? If they merit the title ‘natural kinds’, what exactly are those? Should taxonomy aim at reliability and validity and are these in tension?

Others concern potentially fruitful scientific approaches. One chapter addresses not a priori arguments against the identity in principle of mind and brain but rather what concretely can be learnt about the mind from sub-personal brain mechanisms studied using contemporary imaging techniques. Another addresses how phenomenology – the philosophical approach with which Jaspers was familiar – can be combined with neurology to produce a unified discipline which augments both.

The overall moral of the section is that psychiatry can properly claim to contain – if not be restricted to – a scientific discipline but one which requires a twenty first philosophy of science. The conception of science which dominated philosophy at the start of the twentieth century assumed that things were much simpler than they have proved to be. That conception was a poor fit for a discipline facing the empirical and conceptual challenges that psychiatry has taken on. Once, however, one realises that there can be different kinds of (natural) kinds; that causal links need not be restricted to well behaved levels of explanation but can cross levels (if, indeed, such talk of levels fits actual findings); that there are varieties of validity and reliability with opposing virtues etc. then one has a more appropriate understanding of the nature of science to shed light on psychiatric practice.

Chapter summary

In ‘Causation and mechanisms in psychiatry’, John Campbell returns to a theme he has been developing in a number of recent papers on psychiatry and psychology. Taking the question of whether poverty causes mental illness as a first example, he argues against some assumptions that have been taken to constrain causation and then for a positive view. There is no need to assume that only particular kinds of cause can have particular kinds of effects belonging to the same ‘level of explanation’. Second, although we find it natural and fruitful to look for them, there need be no mechanisms mediating cause and effect. But third, causation can be thought of in the light of potential interventions. In the example given, if intervening on poverty has effects on mental illness then poverty – possibly brutely – causes mental illness.

Rachel Cooper argues in ‘Natural kinds’ that debate about whether mental disorders can be natural kinds has been distorted by assuming that such kinds have to be like the kinds picked out by the Periodic Table in chemistry. There are, however, different views of kinds in different natural sciences (eg kinds of rock in geology). In consequence, Cooper argues for a relaxed view in consequence: natural kinds are kinds picked out by the sciences. Such kinds, of whatever sort, can ground explanations and predictions. Thus, although kinds of mental disorder differ from the kinds recognised by sciences such as chemistry in various ways, they may yet be natural kinds.

The first challenge Dominic Murphy addresses in ‘The medical model and the methods of cognitive neuroscience’ is to characterise what the ‘medical model’ might mean especially in the context of psychiatry. He distinguishes a minimalist from a stronger version. The former adopts appropriate empirical methods, such as epidemiology or evidence of dose-response relationships for drugs and is ‘recognisably medical in terms of the information it collects, the concepts it employs and the practices it supports’. But it makes few, if any, commitments about what is really going on with the patient’. By contrast a stronger version adds to this a commitment that disease is a breakdown in normal functioning due to a pathogenic process unfolding in some bodily system. The chapter then explores how such a view of psychiatry as an instance of cognitive neuroscience concerned with the sub-personal causes of psychiatric signs and symptoms can address issues such as the proper level of explanation and or the value-based nature of illness..

Ken Schaffner’s ‘Reduction and Reductionism (in Psychiatry)’ is still to come...

In ‘Reliability, validity, and the mixed blessings of operationalism’ Nick Haslam starts by providing careful overview of the various concepts of reliability and validity and explores their interrelation. He then uses this to assess the benefits and the costs of the reliability inspired turn to operationalist diagnosis begun in DSM III. Although nuanced, he argues that whilst it may have helped to explore the relationships between diagnoses and other relevant clinical phenomena and also improved communication across theoretical and cultural divides, it may also have contributed to the proliferation of mental disorders, the resulting problem of comorbidity, and a distorted conception of some forms of psychopathology where its focus on observable features may have led to a systematic neglect of others.

J.D. Trout and Michael Bishop’s ‘Diagnostic Prediction and Prognosis: Getting from Symptom to Treatment’ looks first at diagnosis and then prognosis and treatment. The first half provides an overview of the evidence concerning the effectiveness of a variety of approaches to diagnosis starting with subjective methods, semi-structured and structured clinical interviews and Statistical Prediction Rules (SPRs). It transpires that the last approach trumps all others: when based on the same evidence, the predictions of well-constructed SPRs are at least as reliable, and are often more reliable, than the predictions of human experts. The second half of the chapter discusses assessment of the effectiveness of treatments including a discussion of what counts as a placebo control in the case of talking therapies.

Tim Thornton’s chapter ‘Clinical judgement, tacit knowledge and recognition in psychiatric diagnosis’ takes Michael Polanyi’s famous slogan that ‘we know more then we can tell’ and his discussion of knowledge of anatomy to assess the role of tacit knowledge in psychiatric diagnosis. Against a view of tacit knowledge as context-dependent and practical, it argues for its ineliminable role in diagnosis even in cases of very thorough phenomenological description.

Two chapters, in different ways, sketch the possibilities for particular scientific approaches to the study of mind. Nicholas Shea argues in ‘Neural mechanisms of decision making and the personal level’ that more general philosophical arguments concerning the relation between personal and sub-personal level descriptions (eg Davidsonian arguments that personal level descriptions cannot be reduced to sub-personal level descriptions) leave open the possibility that light can be shed on the nature of human experience through neural imaging work. He outlines one particular study of neural basis of reward-guided decision making in which imaging suggests that a particular psychological approach or model is realised in the imaged brain activity. Shea goes on to outline how such an approach might also shed light on addiction and schizophrenic delusions.

In ‘Psychopathology and the enactive mind’ Giovanna Colombetti sketches account of recent enactivist approaches to the mind, which draws on the phenomenology of Merleau-Ponty but also neuroscience. Specifically, she outlines the interplay of three key themes in enactivism: the ‘neurophenomenological’ integration of first- and third-person data concerning lived experience and physiological activity for the study of consciousness; its emphasis on the integration of cognition and emotion and the direct bodily and affective nature of intersubjectivity.

The final chapter of the section, Michael Lacewing’s ‘Could psychoanalysis be a science?’ addresses its titular question. Although the particular issues outlined concerning the characteristic forms of psychoanalytic theory and practice and the way evidence for it can be marshalled both on its own terms and in combination with other approaches are distinctive, the chapter also serves as a microcosm for the issues that face psychiatry more broadly when critics ask about its scientific status.

Wednesday 18 July 2012

PhD Bursary on Scientific Self-Knowledge and Moral Agency

Project Title: Scientific Self-Knowledge and Moral Agency
University of Central Lancashire - School of Education & Social Sciences
Reference No RB-12-ESS2

Applications are invited for a full-time bursary available in the School of Education & Social Science The bursary is tenable for up to 3 years for a PhD (via MPhil route) [subject to satisfactory progress] and is open to both Home, EU and International students.  The bursary will cover the cost of tuition fees at the Home/EU rate.  International students will be required to fund the difference between the Home/EU and International fee rate.  The successful applicant will commence on 1 January 2013.  Please note deferred starts from this date will not be permitted.

Project description
The tensions between adopting a scientific conception of the self, and retaining a conception of oneself as a moral agent, are well recognised.  In the face of these tensions, philosophers have sometimes been content to employ alternative vocabularies for dealing with moral appearances on the one hand, and bio-psycho-social realities on the other.  However, this strategy looks untenable in cases in which the very characterisation of a moral challenge requires the adoption of a scientific vocabulary (for example, with the challenges thrown up by new biotechnologies).  The aim of this project is to consider whether any notion of moral agency can be rendered consistent with a scientific conception of the self.

Specific project themes might include:
Whether recent forms of moral naturalism have the potential to reconcile moral realism with scientific realism.
Whether bioscience reveals, or could reveal, that moral agency is a myth.
Whether the retention of a viable notion of moral agency would impose principled limits on the epistemic authority of the sciences.
Whether the adoption of a bio-scientific self-conception promises to bolster, or undermine, moral autonomy.
Whether the adoption of a scientific self-conception has moral significance in and of itself, apart from its potential consequences.

Applicants should have, or expect to receive a minimum of UK 2:1 honours degree (or equivalent) in a relevant subject area.   
Informal project related enquiries may be directed to Dr Peter Lucas email  Tel 01772 892548

Application Forms can be found at:
Completed application forms should be emailed to
The closing date for applications to the Graduate Research School Office:
Thursday 13 September 2012 12 Noon British Summer Time
Please note incomplete applications will not be processed

Thursday 12 July 2012

Wittgenstein naturalism and the supernatural

Two emails landed yesterday discussing Wittgenstein’s philosophical method. One, from Ben Smith, reported that after giving a paper on Wittgenstein’s naturalism he had come under fire from members of the audience who were flabbergasted that ‘naturalism’ and ‘Wittgenstein’ could be used in the same sentence because any kind of naturalism is anti-supernaturalism and, since Wittgenstein is not happy to reject religious supernatural thought and discourse, he can’t be a naturalist. Thus describing him as a naturalist would be to attribute inappropriate metaphysical views to him.

The other was from Michael Atkinson, who is following my philosophy and mental health course and who is proposing a dissertation looking at how Wittgenstein’s metaphilosophical views would impact on thinking about mental illness. He commended §254 and this fits my reaction to Ben’s email also.

The substitution of “identical” for “the same” (for instance) is another typical expedient in philosophy. As if we were talking about shades of meaning and all that were in question were to find words to hit on the correct nuance. That is in question in philosophy only wherewe have to give a psychologically exact account of the temptation to use a particular kind of expression. What we ‘are tempted to say’ in such a case is, of course, not philosophy; but it is its raw material. Thus, for example, what a mathematician is inclined to say about the objectivity and reality of mathematical facts, is not a philosophy of mathematics, but something for philosophical treatment. [Wittgenstein 1953 §254]

Here the suggestion seems to be that whilst what mathematicians say and do when they are doing mathematics is fine, their inchoate philosophising about the underpinnings of maths isn’t all right but rather the subject for philosophical therapy. The next paragraph says something about the nature of that and hence the status of the inchoate philosophising:

The philosopher’s treatment of a question is like the treatment of an illness. [Wittgenstein 1953 §255]

Taken together and with the surrounding paragraphs, this suggests the following response to Ben’s audience. It is only easy to say what is supernatural if one has a prior theory of nature and hence the limits of nature. Thus, eg., if one is a physicalist, one believes that nature is exhausted by the physical before one does any further piecemeal philosophy. Anything non-physical (including anything which cannot be reduced to the physical) is supernatural. (See, for example, my favourite quotation from Fodor:

I suppose that sooner or later the physicists will complete the catalogue they’ve been compiling of the ultimate and irreducible properties of things. When they do, the likes of spin, charm and charge will perhaps appear upon their list. But aboutness surely won’t; intentionality simply doesn’t go that deep. It’s hard to see, in face of this consideration, how one can be a Realist about intentionality without also being, to some extent or other, a Reductionist. If the semantic and intentional are real properties of things, it must be in virtue of their identity with (or maybe of their supervenience on?) properties that are neither intentional nor semantic. If aboutness is real, it must be really something else. [Fodor 1987: 97])

But Wittgenstein does not hold any such prior view because he does not privilege any particular ‘discourse’ or language game. So, for example, talk of numbers might not fit physicalism strictly (or rather, physicalists might need, like Quine, some sort of argument to fit them into a physicalist picture of nature, the sort of argument undermined by Hartry Field’s book Science without Numbers) but if mathematicians talk of numbers in their practice (rather than down the pub) then Wittgenstein is fine with numbers. There is no view from outside, no policing by philosophy. The limits of the objectivity of numbers is fixed by the prior mathematical talk not the pub philosophy, however. Given this approach then nature might well contain lots of things that a priori metaphysicians - eg physicalists - would call supernatural.

Reading Wittgenstein, we might still want to describe some argumentative moves as the rejection of the supernatural. But that, I suggest, is because the mark of the supernatural is what doesn’t belong to any well formed language game rather than to a specific - eg scientific - language game. It is, I fear, difficult to say how we can draw the distinction between what the mathematicians say at the blackboard and what they say in the pub. But if we can, then nature is fixed by the flexible limits of all blackboard talk, that is all talk with well formed ways of going on. Talk of the supernatural is not, as it were, what lies beyond the boundary of the natural but rather beyond a limit of good sense when venturing out in search of further, but needless, foundations.
PS: By chance, after a graduation drink with departing undergraduate philosophers, I found myself in conversation with a couple of UCLan colleagues (Robert Lee (a senior lecturer in Deaf Studies and researcher in Deaf Studies and Linguistics) and Isabel Donnelly (newly appointed Dean of School of Languages)) about linguistics. In the company of experts it seemed worth getting a brief overview of Chomskyan linguistics having failed so badly to learn much from Juan Uriagereka’s award winning course book Rhyme and Reason: An Introduction to Minimalist Syntax. Thus I was treated to a delightful impromptu representation of the use of tree structures to depict surface grammatical structure using the various empty glasses on the table.

But I was also intrigued to know what it was that the structure they were describing was thought to be a structure in or of. Given talk of ‘the sentence’, I wondered what their underlying ontological commitments. What, really, was the substrate?, I wanted to know. (If, eg, language then what sort of a thing is language, in their view). What was delightful was that they were utterly deaf to my Mephistophelian temptations. Each time I asked the question (perhaps adding different contrast cases: “If not a structuring of neurological states ...” “If not the structuring of Platonic Thought....”) I was treated to a further ten minutes of increasing detailed description of internal disputes about the precise nature of particular structures and never the kind of stepping back that I really wanted. Like virtuous people who simply cannot see the temptations of evil, they could not even understand my confusion.

But of course, I should not have wanted that. As my colleague Peter Lucas pointed out, I should have been happy simply with the descriptions they so patiently offered. The question I was trying to ask about the ‘real’ underlying nature of the substrate of the structure was exactly the kind of thing that might come out in that location – down the pub – but as an ex Wittgensteinian, I should not have been asking for it.

Fodor, J. (1987) Psychosemantics: the problem of meaning in the philosophy of mind, Cambridge, Mass.: MIT Press
Uriagereka, J. (1998) Rhyme and Reason: An Introduction to Minimalist Syntax. Cambridge, Mass.: MIT Press.
Wittgenstein, L. (1953) Philosophical Investigations, Oxford: Blackwell

PhD Studentship on the contribution made by service users to the learning opportunities for nursing students

PhD Studentship University of Central Lancashire - School of Health
Reference Number: RS/12/05

Applications are invited for this PhD studentship which has been funded by the Higher Education Academy and The School of Health. The studentship is tenable for up to 3 years for a PhD (via MPhil route) subject to satisfactory progress. The studentship will cover the cost of tuition fees for UK/EU residents plus a maintenance grant of £13,590. The successful applicant will start on 1 October 2012.

International applicants may apply but will be expected to pay the difference between the UK/EU and International Fee Rate.

Project Title: Shifting Perceptions, Developing Dialogues and Relationships: an appreciative exploration of the tripartite relationship (student-lecturer-service user) and the particular contribution made by service users to the learning opportunities for nursing students

Project Description: The shift to involve service users in the education of nursing students is generally seen as a positive move. However, there is insufficient good quality evidence that robustly examines and problematizes service user engagement and its impact on the three key stakeholders (students, service users and lecturer/mentor). The aim of this study is to appreciatively explore the tripartite relationship (student-lecturer/mentor-service user) central to the learning opportunities for nursing students and examine whether this does shift perceptions, develop dialogues and relationships. The study will be situated in the School of Health at the University of Central Lancashire and in particular will focus on undergraduate pre-registration nursing programmes. This study will use a mixed methods approach underpinned by the principles of Appreciative Inquiry. The study will involve: (1) a series of appreciative workshops - at the start and at the end of the fieldwork - with students, staff and service users; (2) Observation of learning and teaching; (3) Interviews with a selection of the students; and (4) Design and implementation of new model(s) of service user engagement. The study will involve working with a small steering group of stakeholders. Analysis and interpretation of data will draw on thematic analysis and narrative analysis.

Informal enquiries about the posts can be made to Professor Bernie Carter, email tel: 01772 893720

Applicants should have or expect to receive first degree (Honours) in a relevant subject (for example, Nursing, Health, Education, Social Sciences) at 2.1 or above. Particular consideration will be given to candidates with a Master's degree in a relevant subject. Requests for an application pack (quoting the reference number RS1205) should be directed to the Graduate Research School Office. Tel: 01772 895082 or email: Closing Date: 27 July 2012 Proposed Interview Date: 16 August 2012

Friday 6 July 2012

Lastly, from INPP 2012

Picking up some other themes from the conference, in no particular order.

Louis Charland announced that he was a lonely fan of the role of passions, rather than emotions, in the philosophy of mind. On his account, passions play a structuring role in shaping changing emotions and sentiments. So a passion for collecting can structure a life. (Collecting can be a passion.) Or jealousy, also a passion he thinks, can structure the feelings experienced in response to the events of a week. He told us that a piece of research with Tony Hope and Jacinta Tan on anorexia as a passion had just been accepted for publication. (For the moment, to read more of his general view, see his piece in the Goldie edited OUP collection or the Emotion Review special issue.)

Steve Rosenmann pressed a critique of the idea that the role that culture plays in psychopathology is in merely shaping the expression of universal underlying forms of pathology. His view, partly based on the poor correlations across cultures of, eg., mood disorder and suicide, was that there was nothing culturally invariant. I wasn't sure, and must ask, how wide he took this to be: did it merely apply to pathology? (A reason to think he took it to be broader was an analogy with the impossibility of translating such notions as 'shaking off the blues', grasp of which requires sharing a whole form of aesthetic life.) Are there no culturally invariant experiences or concepts? The worry would be an implausible (and un-Davidsonian) picture of untranslatable island world-views. But how could one stop short of that?

Werdie van Staden argued that there was an incompatibility between the very idea of a long standing search for a cause of schizophrenia and the fact that a cause seems to be ruled out by its very definition. He took this as a focus for a more general worry about how causal notions are involved in the definition of various disorders and he went on, the brave chap, to propose the broad outline of an architecture for an alternative psychiatric taxonomy.

Derek Bolton sketched a kind of portrait of London (in the context of a conference in which the attachment of Maori identity to land, or place, or even a particular mountain has been much mentioned) and then an overview of last summer's riots. Against a background of Wittgenstein's comment that disputes do not break out among mathematicians, that they don't come to blows, he outlined some of the factors that might encourage the rioters into violence by contrast with conversation.

I was not entirely sure whether he aimed to make an intervetion in an understanding of the events or rather, one level up, to comment on the conditions of possibility of such an enterprise. A hint of the former was his stress on general social and financial deprivation. Had the rioters been able to steal a place in a better more equal society then they would have taken that rather than training shoes, he suggested. One point from the floor struck me. Mohammed Rashed expressed unease at calling the London riots 'political' in any sense similar to that of describing recent events in Egypt 'political'. Why, he asked, had no one raised a placard or banner in London? Without that, to what extent was it motivated by political considerations?

This morning I am listening to a helpful history of the Maori as a precursor to discussion of Maori mental health. In my naive way, I have been struck by the connection, mentioned above, of the connection between identity and place. One of my conference colleagues, who announced her own Maori identity, asked Prof Sir Mason Durie what advice he would give to young Maoris in the light of both this importance of place but also the threat of maintaining the existing connections to it because of a variety of development pressures. He replied, if I followed, that like everyone, the Maori population would in the future, no doubt, move about more, be less fixed, but that other connections (such as to language, culture and societal links) would take over the sustenance of identity. I was not sure how welcomed this answer was.

Later, having given my own talk about the Beltane Fire Festivals, I chatted to a NZ psychiatrist who had been brought up in Northern Ireland and who said that Wittgenstein's comments about the terribleness in the surface of the fire festivals applied equally to the parades of his youth. He seemed to suggest, however, that despite still retaining some element of Northern Irish identity (alongside an adopted NZ identity), that he had had no difficulty in giving up his prior particular connection to that place. I suppose the limit of that process is the (southern) Irish identity of so many non-passport holding Americans. Some connection between identity and place might merely require a conception of a place and not an actual physical relation. At the same time, I will only feel I have properly arrived home when I have been for a (jet-lagged) run on my adopted Scout Scar. (But there is a difference: it sheds light on me precisely because I have chosen it. It instances my explicit values. The same young Maori speaker said that to understand her one needed to understand her relation to a C16 ancestor simply, I think, in virtue of having him. That seems an odd view of things to me.)

I have thoroughly enjoyed the conference here. It has been quite intimate (though I understand financially fine) and quite coherent. The five person local organising committee has been both visible enough to help emphasise the themes, and the local character of this INPP conference, without being dominant. Well done them! It is a great pity if there is no INPP 2013.

Thursday 5 July 2012

At the INPP 2012, Dunedin

The INPP conference began, properly, today with what the programme described as a Maori 'welcome ceremony/ritual of encounter'. The programme described the morning thus:

Arai te Uru Marae Thursday 5 July Pöwhiri – welcome ceremony/ritual of encounter A Pōwhiri encapsulates the formal welcome ceremony onto the marae (traditional meeting place), starting with the initial karanga (call) from the tangata whenua (people of the land, the hosts) right up to the sharing of kai. This process also removes the tapu (sacredness) from the manuhiri (visitors), who are referred to as waewae tapu (literally, sacred feet) if they are first-time visitors to that particular marae.

This marae’s kawa is that shoes are removed before entering the wharenui (meeting house) and they would be removed outside the door. Whaikōrero or formal speech making follows the karanga.    A waiata or song is sung after each whaikōrero by the group the orator represents. Koha – a gift, generally an envelope of money, is laid on the ground by the last speaker for the manuhiri (visitors). A local kuia (female elder) may karanga as an expression of thanks. A male from the tangata whenua will pick up the koha.

Whaikōrero or formal speech making follows the karanga.    A waiata or song is sung after each whaikōrero by the group the orator represents. Koha – a gift, generally an envelope of money, is laid on the ground by the last speaker for the manuhiri (visitors). A local kuia (female elder) may karanga as an expression of thanks. A male from the tangata whenua will pick up the koha.

Hongi – the pressing of noses signifies the joining together of tangata whenua and manuhiri. Tangata whenua invite the manuhiri to come forward to shake hands (hariru) and hongi. Hākari – the feast, a meal is then shared. This usually signifies the end of the pōwhiri.

Thus we took a bus to what I learnt as an unusually urban version of a marae to wait in the carpark until called by song to enter a building, women first. There then followed a set of apparently challenging ritual greetings in, obviously enough, a foreign, to me, tongue and thereafter, in English, friendly greetings and tea. I think that this says more about my own inadequacies than the nature of the encounter but I found the experience strangely disturbing. Whilst I could be sure that no harm would come to me, the otherness of the challenging encounter couldn't be entirely eased by such rational reassurance. Still, all this, coupled with a helpful later explanation of what had gone on by Prof Sir Mason Durie, was rather helpful for my own plenary lecture when we returned to the University. Prof Durie's account traded on exactly the kind of normative notions of what was the right thing to do that I sought to extract from Wittgenstein's discussion of Frazer.

Since I am writing this before the public lecture a the end of the day, I can't comment on that yet. But one thing did strike me from another fine joint presentation by a group of ex Kings students. The final paper, partly prepared by the absent Natalie Banner, considered various competing definitions of mental disorder up to and including the draft DSM V. It took homosexuality as a litmus test. On the assumption that it is not a disorder, do the various definitions successfully manage to exclude it? If not, so much the worse for them.

In the discussion that followed, one thing began to strike me. It would be possible to take the inference the other way. (One person's modus ponens is another's modus tollens.) If the DSM V definition implies that homosexuality is a disorder, one might conclude, instead, that the definition is fine and that homosexuality is, indeed, a disorder. In the face of such a response, what are the options for replying?

One might attempt to appeal to some grounding facts about the real status of homosexuality to apply pressure back, again, the other way, against the definition of disorder. That would accord with the history of trying to offer a correct or true account of the nature of disorder, for example, of whether it is purely factual or partly evaluative. The analysis itself aims at factual correctness. But it isn't clear what those grounding facts might be in the context in which the nature of disorder in general is up for grabs. The way the discussion after the paper in fact seemed to go was that it was better, more desirable, to take homosexuality to be the litmus test it had been assumed to be. In other words, the status of analysis of disorder was a matter of value, not fact: analysis aimed at what was good, not what was true.

Wednesday 4 July 2012

Theology and mental health workshop prior to INPP 2012

I spent the second day before the INPP conference at an associated workshop on theology and mental health organised by the Centre for Theology and Public Issues at the University of Otago. As one of today's speakers, Dr Richard Egan, pointed out there is a peculiar conflict between two growing intellectual trends in mental health care. On the one hand, a stress on the underlying biological science of psychiatry. On the other, a growing emphasis on the role of spirituality in mental health care. As he pointed out, the spirituality special interest group of the Royal College has 2,000 members.

Despite this, and despite being part of a Glasgow-based research group on transcultural psychiatry which has taken spirituality as an important thread, I have never known quite how to approach this tension. Lacking faith with a capital F, I have merely faith in the Enlightenment and hence some unease about forms of spirituality tied to religion and theology especially if one is encouraged to take supposed religious experiences at face value. (This leaves me the worry: to what extent can one not take a view on whether an apparent such experience is revelatory of theological facts? Why should psychitary be more relaxed on this than the Catholic Church, for example, for whom not every supposed experience is genuine?)

Given this, I was the wrong audience member for some of the papers which - quite reasonably, of course - concerned practical matters of how the Church should approach those either mentally ill or disabled. (Nor could I easily grasp the suggestion that mental disability is a divine blessing.) But two papers did leave me with more tractable thoughts.

Rev Dr Lynne Baab began by outlining the recent history of the bereavement exclusion from DSM IV and discussionabout it for DSM V. She bemoaned a failure to grasp the possibility of long standing non-pathological sadness giving the example of a colleague who had assumed he was ill when in fact he had suffered bereavement and both work and spiritual challenges.  Rejecting the appropriateness of medical care in such a case (though not in others)  Rev Dr  Baab went on to outline the possibilities of therapeutic resources drawing on the Christian tradition, including, eg., psalms of lament.

I wondered, and asked, about the relation of these two themes:  the rejection of the medicalisation of everyday suffering and the usefulness of religious resources in the face of suffering. Would it matter whether or not suffering were pathological for the relevance of spiritual resources? The parallel is wondering whether one needs to restrict pharmacology to pathological suffering if everyday healthy sadness is both unpleasant and might be eased? Her answer was helpful: what she really wished to resist was a whole mindset which did not value the positive possibilities of suffering. The Christian tradition to which she referred was not merely a reassurance, a kind of resource, but a better way of conceptualising the relation of flourishing and suffering. (In other words, medicalising everyday suffering and not seeing a religious response as relevant were two sides of the same coin.)

Andrew Bradstock dicussed the problem of suffering from OCD when one also has a religious faith.  Both Luther and Bunyan, for example, felt tempted to blaspheme in ways characteristic of OCD. (The latter was subject to 'floods of blasphemous thoughts' about whether the Koran might have just as great a merit as the Bible.) Such cases, far from uncommon, raise the question of how to distinguish conscious real thoughts (I think the phrase he used) from those attributable merely to an illness.

He pointed out that traditional approaches at cure may require sufferers to agree to their thoughts whilst resistingthe compulsions and this can seem irreligious to them. Such exercises are, though, to break the power of the compulsion. But awareness of that may be no help with religious guilt. In fact, reason, rather than training, may not bring relief to the sufferer. They may be told and in some sense accept that their thoughts are the result of an illness and thus not sinful but they may not be able to accept that thought - a second order thought after all - in the face of the ground level thought.

This left me wondering whether the issue of sin really changed the question of responsibility beyond, say, empirical or worldly legal matters? Or did it just change it as far as the sufferer is concerned? Prompted, Andrew suggested the latter but it seems to me that the nature of authorship relevant to sin might actually make a difference, at least against an assumption, briefly, that there really is such a possibility. (That is, that one can sin as opposed to merely thinking one can sin.) But that goes to heart of my general worry here: can we take a view of religion and mental illness which is neutral with respect to theology?