Thursday 20 November 2014

Pro-social behaviour

One of the presentations I heard at a graduate psychology conference at Durham this week (to which I had been generously invited to give the closing lecture) concerned an investigation of the factors that encourage pro-social (the antonym of anti-social) behaviour in some example universities. The potential impact of the research was that it might indicate how to make universities better but in particular more harmonious places especially important in the light of the rise of tuition fees in the UK and the need for high student satisfaction scores.

One stage of the research concerned self assessments of instances of pro-social behaviour undertaken by individuals themselves identified via questionnaires. A further stage included objective external measures including both experimental and descriptive data gathering. So for example, for the latter, total quantities of recycling might be weighed for particular student groups. For the former, students might be asked to throw some paper away being offered, without comment, both recycling and non recycling rubbish bins. Both self assessment and more objective measures required, however, some identification of what counted as pro-social behaviour. And this was picked out, not by a priori experimenter imposition, but by preliminary research of what students themselves thought of as pro-social with then some editing out of idiosyncratic outliers.

I was struck by the fact that recycling was used as an example of what is pro-social. This, it seems to me, is obviously a good thing. But it isn't clear why it counts in this case, as pro- social as opposed to pro- some other good (eg future generations, the good of the planet, ecology etc) especially given the link made in the presentation to social harmony. Of course, if everyone in the community agrees on this value then subscribing to it will count as pro-social and non recyclers will look disruptive of harmony but it seems interestingly contingent that this value, the value of recycling, promotes harmony. In communities elsewhere, or in the past, the ardent recycler will be / was a thorn in the side of the harmonious wasteful consumers.

This struck me as an interesting feature of the research because of an event a couple of weeks ago. Working one evening in my room in college, in a castle in Durham, I was disturbed by odd noises from the stairwell outside. There, I found a group of young men undertaking a drinking rite, one sitting in the dungeon like basement on a chair being cheered, or perhaps jeered, on by an audience as he drank quantities of beer. When I asked - like you do - whether they were OK or were killing one another, everyone insisted they were fine including the victim (I was reminded of the cheery wave of the man being beaten up in the children's cartoon pastiche of the TV series Life on Mars) and a quick informal assessment of capacity suggested I should leave them alone. Later, when I left the building, I warned them I was off out and thus no longer able to get help should it be needed, but they still seemed to have capacity though by now there was a 20 foot tube down the stairs feeding the beer into the mouth of the (now different) victim from above. I left in a strangely bad mood but they were doing nothing worse than many other adult students across the UK and across time. Further, unpleasant though the scene seemed to me, such behaviour no doubt survives from generation to generation precisely because of its function in sustaining and underpinning a kind of social harmony in the groups concerned.

But when I asked my psychologist researcher, she assured me that such behaviour had not featured in her research into what is pro-social. I suspect an implicit normative control was in place. That doesn't look good when it comes to thinking about harmonious university life in the era of high tuition fees.

Call for papers: moral and legal responsibility in the age of neuroscience

23-25 SEPTEMBER 2015


 The focus of this conference will be moral and legal responsibility in people who have been diagnosed with mental disorders. This is an exciting area in which recent developments in policy and research are casting a new light on old problems.

The conference is not confined to psychiatrists and is open to anyone with an academic, professional or personal interest in this area. We hope to bring speakers from different backgrounds together with the aim of promoting an eclectic, multi-professional approach to this area. We would welcome submissions from patient, offender and victim advocacy groups.

Suitable topics would include the following but submissions in any other related area of scholarship will be considered:
Neuroscience and criminal responsibility
Autonomy and suicide
Recent developments in legal mitigation e.g. ‘loss of control’ defence and diminished responsibility
Agency and responsibility in personality disorder
Assessment of legal capacity
Deprivation of liberty in patients who lack capacity
Responsibilities of clinicians and service users
Responsible research and policy
Psychiatry and political violence

Submissions for oral and poster presentations are invited. Speakers will have 30 minutes for their presentations.

A summary no longer than one side of A4 should submitted to the conference organiser, Dr John Callender by 31 January 2015. Please submit by e-mail to or

Tuesday 18 November 2014

Psychiatric diagnosis, tacit knowledge and criteria

A third draft paper written whilst a fellow of the Institute for Advanced Study, University of Durham.

For the last 50 years, both of the major psychiatric diagnostic systems – DSM and ICD – have aimed at reliability at the potential cost of validity. They have done this by codifying diagnosis in the form of criteria, influenced by operationalism from the philosophy of physics and down playing aetiological theory. It is an empirical question whether DSM-III, -IV and now -5 and the parallel ICD classifications have achieved this aim overall.
There have been criticisms, however, that the explicit criteria under-determine the diagnoses made by skilled clinicians. That is, the criteria themselves have a vagueness for which experienced psychiatrists have to compensate in diagnostic judgements in response to particular patients expressing particular signs and symptoms. The overall top-down or gestalt judgement is more precise than the component criteria on which it is supposed to be based.
The aim of this chapter is not to address whether this is so but rather how it could be so. In doing so, I will make two suggestions. First, diagnosis may involve an important tacit element. As a recognitional judgement, it may share characteristics of an uncodifiable form of know-how. Second, the postulation of criteriological intermediaries between the skilled clinician and their patients’ or clients’ actual conditions may distort the recognitional process. Judgement of the underlying mental states of patients and clients may be more secure than the operationalised criteria.
Background: the rise of criteriological diagnosis
Over the last half century, there has been a concerted effort to improve the reliability of psychiatric diagnosis by pruning the two main diagnostic systems of possibly over hasty aetiological theory and stressing instead more directly observational features of presenting subjects. Two main factors explain this. (For a fuller account, see [Fulford et al 2005].)
First, on its foundation in 1945, the World Health Organisation set about establishing an International Classification of Diseases (ICD). The chapters of the classification dealing with physical illnesses were well received but the psychiatric section was not widely adopted. The British psychiatrist Erwin Stengel was asked to propose a basis for a more acceptable classification. Stengel chaired a session at an American Psychological Association conference of 1959 at which the philosopher Carl Hempel spoke. As a result of Hempel’s paper (and an intervention by the psychiatrist Sir Aubrey Lewis) Stengel proposed that attempts at a classification based on theories of the causes of mental disorder should be given up (because such theories were premature), and suggested that it should instead rely on what could be directly observed, that is, symptoms.
In fact, Hempel’s paper provided only partial support for the moral that was actually drawn for psychiatry. He argued that:
Broadly speaking, the vocabulary of science has two basic functions: first, to permit an adequate description of the things and events that are the objects of scientific investigation; second, to permit the establishment of general laws or theories by means of which particular events may be explained and predicted and thus scientifically understood; for to understand a phenomenon scientifically is to show that it occurs in accordance with general laws or theoretical principles. [Hempel 1994: 317]
These two requirements – that terms employed in classifications should have clear, public criteria of application and should lend themselves to the formulation of general laws – correspond to the aims of reliability and validity respectively. But it was the former that was adopted by psychiatry as the key aim at the time. With respect to it, Hempel claims that
Science aims at knowledge that is objective in the sense of being intersubjectively certifiable, independently of individual opinion or preference, on the basis of data obtainable by suitable experiments or observations. This requires that the terms used in formulating scientific statements have clearly specified meanings and be understood in the same sense by all those who use them. [ibid: 318]
He commends the use of operational definitions (following Bridgman’s book The Logic of Modern Physics [Bridgman 1927]), although he emphasises that in psychiatry the kind of measurement operations in terms of which concepts would be defined would have to be construed loosely. This view has been influential up to the present WHO psychiatric taxonomy in ICD-10.
The second reason for the emphasis on reliability and hence operationalism was a parallel influence within American psychiatry on drafting DSM-III. Whilst DSM-I and DSM-II had drawn heavily on psychoanalytic theoretical terms, the committee charged with drawing up DSM-III drew on the work of a group of psychiatrists from Washington University of St Louis. Responding in part to research that had revealed significant differences in diagnostic practices between different psychiatrists, the ‘St Louis group’, led by John Feighner, published operationalised criteria for psychiatric diagnosis. The DSM-III task force replaced reference to Freudian aetiological theory with more observational criteria.
This stress on operationalism has had an effect on the way that criteriological diagnosis is codified in DSM and ICD manuals. Syndromes are described and characterised in terms of disjunctions and conjunctions of symptoms. The symptoms are described in ways influenced by operationalism and with as little aetiological theory as possible. (That they are neither strictly operationally defined nor strictly aetiologically theory free is not relevant here.) Thus one can think of such a manual as providing guidance for, or a justification of, a diagnosis of a specific syndrome. Presented with an individual, the diagnosis of a specific syndrome is justified because he or she has enough of the relevant symptoms which can be, as closely as possible, ‘read off’ from their presentation. The underlying syndrome is connected to more accessible, epistemologically basic signs and symptoms.
An objection to criteriological approaches
Although the rationale for a criteriological, or bottom up, approach to diagnosis seems clear, it has not escaped criticism. The charge is that combining individual symptoms understood initially in isolation from context and only assembled in the conjunctions that add to diagnosis is vague.
In a paper called ‘Phenomenological and criteriological diagnosis: different or complementary?’ Alfred Kraus, professor of psychiatry at Heidelberg, argues that diagnostic systems such DSM and ICD miss out an important element of psychiatric diagnosis [Kraus 1994]. Because they assume that diagnoses are built up from a number of individual and conceptually independent symptoms they cannot capture top-down and holistic elements of diagnosis.
One key criticism that Kraus makes of what he calls this criteriological approach to diagnosis, is that rather than providing a reliable foundation, the connection between individual symptoms and conditions lacks specificity. There remains widespread disagreement about the correlation between individual symptoms and underlying syndromes. By contrast, according to Kraus, a top-down holistic model is more specific because it allows a correlation between schizophrenia and particular kinds of catatonia or delusional structure. Correlations are not between schizophrenia and delusions in general. Such a connection is vague. Specificity attaches to the link between schizophrenia and delusions with a specific schizophrenic colouring. But this connection can only be established with a top-down rather than criteriological model of diagnosis. The bottom up approach is vague whilst the top down approach is more specific.
Kraus also argues that in the bottom-up model, symptoms can only be added together through conjunction. But no mere conjunction of individual symptoms—a ‘Chinese restaurant menu’ approach—can capture the psychological integrity up to which the individual parts add. For that, one again needs a holistic approach. This is not to say, however, that particular elements cannot be identified in a holistic diagnosis. It is just that the individual elements have a different logic.
One way of marking this distinction (although not Kraus’ own) is to contrast parts that are independent pieces and parts that are essential aspects. The pieces of a jigsaw add up to a whole, but each piece can exist independently of the others. By contrast a musical note has both a tone and a pitch, but neither aspect can exist independently of the other. Thus, according to a holistic approach, psychological symptoms are interdependent aspects of a psychological unity.
Kraus combines with these two comments on the limits of a criteriological model of diagnosis with a further philosophical explanation of the difference in approach. This is why he contrasts the criteriological with a phenomenological rather than merely a holistic model. This concentrates not on psychiatric diseases but on the mode of being of whole persons, the ‘whole of the being in the world of schizophrenics or manics’. Thus the phenomenologically based diagnosis of schizophrenia turns on an overall assessment of the patient—a ‘praecox feeling’—as having a very different form of ‘being-in-the-world’. But whether or not that more general view is correct, the criticism suggests that the operational structure of psychiatric manuals contributes to the vagueness of diagnosis strictly based on them.
Mario Maj makes a similar criticism. Again taking the example of schizophrenia, he argues that:
One could argue that we have come to a critical point in which it is difficult to discern whether the operational approach is disclosing the intrinsic weakness of the concept of schizophrenia (showing that the schizophrenic syndrome does not have a character and can be defined only by exclusion) or whether the case of schizophrenia is bringing to light the intrinsic limitations of the operational approach (showing that this approach is unable to convey the clinical flavour of such a complex syndrome). In other terms, there may be, beyond the individual phenomena, a ‘psychological whole’ (Jaspers, 1963) in schizophrenia, that the operational approach fails to grasp, or such a psychological whole may simply be an illusion, that the operational approach unveils. [Maj 1998: 459-60]
In fact, Maj argues that this shows the weakness of the operational approach. He argues that the DSM criteria fail to account for aspects of a proper grasp of schizophrenia: for example, the intuitive ranking of symptoms (which have equal footing in the DSM account). He suggests that there is, nevertheless, no particular danger in the use of DSM criteria by skilled, expert clinicians for whom it serves merely as a reminder of a more complex prior understanding. But there is a problem in its use to encode the diagnosis for those without such an additional underlying understanding:
If the few words composing the DSM-IV definition will probably evoke, in the mind of expert clinicians, the complex picture that they have learnt to recognise along the years, the same cannot be expected for students and residents. [ibid: 460]
Maj’s criticism that the DSM criteria do not capture a proper, expert understanding of the diagnosis of schizophrenia raises the question of how or why that could be the case. If the criticism is right, is it that the wrong criteria have been used: either the wrong symptoms and / or the wrong rules of combination? Or is there something more fundamentally wrong with the criteriological approach as applied to psychiatry?
Josef Parnas suggests the latter. In a paper describing pre-operational approaches to taxonomy and diagnosis as a ‘disappearing heritage’ he comments on an underlying difference in attitude towards signs and symptoms of schizophrenia.
When the pre-DSM-III psychopathologists emphasized this or that feature as being very characteristic of schizophrenia, they did not use the concept of a symptom/sign as it is being used today in the operational approach. This latter approach envisages the symptoms and signs as being (ideally) third person data, namely as reified (thing-like), mutually independent (atomic) entities, devoid of meaning and therefore appropriate for context-independent definitions and unproblematic assessments. It is as if the symptom/sign and its causal substrate were assumed to exhibit the same descriptive nature: both are spatio-temporally delimited objects, ie, things. In this paradigm, the symptoms and signs have no intrinsic sense or meaning. They are almost entirely referring, ie, pointing to the underlying abnormalities of anatomo-physiological substrate. This scheme of ‘symptoms = causal referents’ is automatically activated in the mind of a physician confronting a medical somatic illness. Yet the psychiatrist, who confronts his ‘psychiatric object’, finds himself in a situation without analogue in the somatic medicine. The psychiatrist does not confront a leg, an abdomen, not a thing, but a person, ie, broadly speaking, another embodied consciousness. What the patient manifests is not isolated symptoms/ signs with referring functions but rather certain wholes of mutually implicative, interpenetrating experiences, feelings, beliefs, expressions, and actions, all permeated by biographical detail. [Parnas 2011: 1126]
The claim here is that the criteriological approach has the wrong model of psychiatric symptoms and signs in two respects. Just as smoke can mean fire or tree rings the age of a tree, the criteriological approach takes signs to be free standing items which causally indicate underlying states. Furthermore, these relations are independent of one another: they are atomic. By contrast, Parnas suggests, psychiatric signs and symptoms are both essentially meaning-laden rather than brutely causal and also mutually interdependent wholes. It is the latter claim which plays the more important role in his criticism.
One argument for their interdependence is that it is only in particular contexts that symptoms are reliable. Thus, for example, mumbling speech is comparatively widespread (Parnas estimates 5% of the population) but in – and only in – the context of other features such as ‘mannerist allure, inappropriate affect, and vagueness of thought, it acquires a psychopathological significance’ [ibid: 1126]. So the effectiveness of the sign is context-dependent. In some contexts it is indicative and in others not. Excluded from context – as it is in the criteriological context – it is vague. But it is precise in context. Parnas goes further by suggesting a more than merely additive view. Grasp of psychiatric symptoms is likened to seeing the figure of the duck-rabbit first as a rabbit and then suddenly as a duck: seeing the signs and symptoms under an overall aspect or gestalt.
A Gestalt is a salient unity or organization of phenomenal aspects. This unity emerges from the relations between component features (part-whole relations) but cannot be reduced to their simple aggregate (whole is more than the sum of its parts)... A Gestalt instantiates a certain generality of type (eg, this patient is typical of a category X), but this typicality is always modified, because it is necessarily embodied in a particular, concrete individual, thus deforming the ideal clarity of type (universal and particular). [ibid: 1126]
So the model of diagnosis is one in which the skilled clinician grasps the right diagnosis as an integrated whole in which different aspects can be seen as abstractions from that whole rather than as its basic building blocks. Such a view would accommodate Kraus’ rejection of a ‘Chinese restaurant menu’ approach and Maj’s suggestion that criteriological elements serve as reminders for already skilled clinicians. They do – on this view – in the sense that, after the fact, such articulations of the overall picture are possible, as a musical note may be divided into its pitch, tone and duration whilst it cannot be built up from those as independent building blocks. But that does not imply that the expert judgement of the whole could be built up from the individual criteria understood in isolation.
Diagnosis and tacit knowledge
This criticism of the criteriological approach prompts two further questions. The bottom up codification of diagnosis through simpler, more basic signs and symptoms suggests an explanation of how complex diagnostic judgement is possible. It is possible because it is based on simpler more epistemically accessible building blocks. The first question concerns the nature of an overall ‘gestalt’ judgement if that explanation is rejected. On what is top-down judgement based and what is its relationship to the criteriological approach? In this section, I will suggest an analogy with context-dependent tacit knowledge to try to make this seem a less puzzling possibility [for a more detailed discussion see Thornton 2013]. But it will also help highlight how the move from context-dependent recognition to explicit criteria introduces vagueness into psychiatric diagnosis.
Second, if diagnostic judgement is not based on more observational features of a clinical encounter, how can it yield knowledge of underlying mental states. In the final section, I will suggest an analogy with the more general ‘problem of other minds’ and outline what may initially seem a counter-intuitive view outlined by the philosopher John McDowell which inverts the epistemic priority of judgements about behavioural signs and symptoms and judgements of underlying mental states. Again it will suggest that reliance on basic criteria comes at the cost of introducing vagueness into diagnosis.
I suggested at the start that the development of the theoretically minimal criteriological approach to diagnosis in psychiatry was partly influenced by operationalism in the philosophy of science in the first part of the twentieth century. The aim was to minimise uncodified elements in psychiatric diagnosis so as to maximise reliability. But there was, in the second half of the century, a contrasting view about the nature of scientific knowledge: the chemist turned philosopher Michael Polanyi’s arguments for the importance of tacit knowledge. (Polanyi himself talks of tacit knowing rather than knowledge. I will, nevertheless, use ‘knowledge’ whilst talking about his views but will return to emphasise the practical dimension to what is tacit.) Top-down or gestalt judgement in psychiatry can be thought of as an instance of tacit knowledge.
Polanyi gives the following example:
We know a person’s face, and can recognize it among a thousand, indeed among a million. Yet we usually cannot tell how we recognize a face we know. So most of this knowledge cannot be put into words. [Polanyi 1967b: 4]
This is an instance of what he takes to be a general phenomenon. Indeed, he begins his book The Tacit Dimension with the following bold claim:
I shall reconsider human knowledge by starting from the fact that we can know more than we can tell. [Polanyi 1967b: 4]
The broad suggestion is that knowledge can be tacit when it is, on some understanding, ‘untellable’. ‘Tellable’ knowledge is a subset of all knowledge and excludes tacit knowledge. But the slogan is gnomic. Does it carry, for example, a sotto voce qualification ‘at any one particular time’? Or does it mean: ever?
The very idea of tacit knowledge presents a challenge: it has to be tacit and it has to be knowledge. But it is not easy to meet both conditions. Emphasising the tacit status, threatens the idea that there is something known. Articulating a knowable content, that which is known by the possessor of tacit knowledge, risks making it explicit. There is a second strand through Polanyi’s work which helps address this problem. At the start of his book Personal Knowledge in which he says:
I regard knowing as an active comprehension of things known, an action that requires skill. [Polanyi 1958: vii]
These two features suggest a way to understand tacit knowledge: it is not, or perhaps cannot be made, explicit and it is connected to action, the practical knowledge of a skilled agent. The latter connection suggests a way in which tacit knowledge can have a content: as practical knowledge of how to do something. Taking tacit knowledge to be practical suggests one way in which it is untellable. It cannot be made explicit except in context-dependent practical demonstrations. It is not that it is mysteriously ineffable but that it cannot be put into words alone.
Psychiatric diagnostic judgement can be thought of as an example of such a skill: the ability to recognise in context the manifestation of psychiatric illness. Polanyi also compares recognition to a practical skill, likening it to bicycle riding:.
I may ride a bicycle and say nothing, or pick out my macintosh among twenty others and say nothing. Though I cannot say clearly how I ride a bicycle nor how I recognise my macintosh (for I don’t know it clearly), yet this will not prevent me from saying that I know how to ride a bicycle and how to recognise my macintosh. For I know that I know how to do such things, though I know the particulars of what I know only in an instrumental manner and am focally quite ignorant of them. [ibid: 88]
In both cases, the ‘knowledge-how’ depends on something which is not explicit: the details of the act of bike riding or raincoat recognition. Whilst one can recognise one’s own macintosh one is, according to Polanyi, ignorant, in some sense, of how. Thus how one recognises it is tacit. Polanyi makes the same claim for linguistic labelling generally.
[I]n all applications of a formalism to experience there is an indeterminacy involved, which must be resolved by the observer on the ground of unspecified criteria. Now we may say further that the process of applying language to things is also necessarily unformalized: that it is inarticulate. Denotation, then, is an art, and whatever we say about things assumes our endorsement of our own skill in practising this art. [ibid: 81]
Polanyi seems here to say that explicit recognition of something as an instance of a type is based on the implicit recognition of subsidiary properties of which one is focally ignorant. To recognise a feature one must a) always recognise it in virtue of something else (subsidiary features) of which b) one is focally ignorant. But it is not clear that either part of this claim is true.
To consider the claim, it will help to make clearer what Polanyi means by focal attention and subsidiary awareness. Elsewhere he uses the sample of pointing to something using a finger.
There is a fundamental difference between the way we attend to the pointing finger and its object. We attend to the finger by following its direction in order to look at the object. The object is then at the focus of our attention, whereas the finger is not seen focally, but as a pointer to the object. This directive, or vectorial way of attending to the pointing finger, I shall call our subsidiary awareness of the finger. [Polanyi 1967a: 301]
In looking from the finger to the object, the object is the focus of attention whilst the finger, though seen, is not attended to. It is not invisible, however, and could itself become the object of focal attention. This suggests that the first part of the general claim that Polanyi needs itself faces an objection based on a regress. The recognition of an instance of a type or kind depends on subsidiary awareness of something else which could have been the object of focal awareness and thus would have depended on subsidiary awareness of something else.
This is a potential rather than a vicious regress. (It is not that in order to have subsidiary awareness of something one must already or actually have had focal awareness of it or anything else. Combined with Polanyi’s general claim, that thought would have generated a vicious regress.) Nevertheless, even the potential regress suggests something implausible about Polanyi’s general claim. It does not seem reasonable to think that it is always the case that recognition depends on subsidiary awareness of something else. Take the case of the direct perceptually based recognition that a part of a wall is red. Surely that turns on the focal awareness of the colour independent of subsidiary awareness of anything else?
Polanyi seems to assume that the question of how one recognises something as something always has an informative answer and then to cover cases where it is not obvious what this is he suggests it can be tacit. But whilst it sometimes may have an informative answer, there is no reason to think that it always has. What of the second aspect: that one must be focally ignorant of the subsidiary features?
Even in cases where one recognises a particular as an instance of a general kind in virtue of its subsidiary properties and cannot give an independent account of those properties, it is not clear that one need be focally ignorant of them. It may be, instead, that the awareness one has of the subsidiary properties is simply manifested in the act of recognition. I might say, I recognise that this is a, or perhaps my, macintosh because of how it looks here with the interplay of sleeve, shoulder and colour even if I could not recognise a separated sleeve, shoulder or paint colour sample as of the same type. Whilst it seems plausible that one might not be able to say in context-independent terms just what it is about the sleeve that distinguishes a or my macintosh from any other kind of raincoat (one may, for example, lack the vocabulary of fashion or tailoring) that need not imply that one is focally ignorant of, or not attending to, just those features that make a difference. Recognition may depend on context-dependent or demonstrative elements, such as recognising shapes or colours for which one has no prior name. But if anything, that suggests one has to be focally aware, not focally ignorant, of them.
Thus Polanyi’s own account of the tacit nature of recognition faces some key questions. But, in setting out the issues, a more minimal account of tacit knowledge has already been suggested. Recognition is tacit because it is a skill – for example, developed through repetition and critical practice and demonstrated in applications – and because it can thus be articulated only in context-dependent terms such as ‘like this!’. It cannot be explicated in words alone independently of additional practical demonstrations in context.
If the skilled diagnostic judgement described in the previous section by Kraus, Maj and Parnas is thought of as tacit knowledge as just explicated then it can be contrasted with criteriological diagnosis in the following way. The criteria set out in ICD and DSM are an attempt to make psychiatric diagnosis explicit. They attempt to set out context-independent descriptions of psychiatric syndromes.
Such an attempt is akin to attempting to model an ability to recognise colours and shades on general knowledge of the names for colours that ordinary people have. For most people, the ability to recognise, think about and recall (at least for some period) particular shades of colour goes beyond what they can make explicit linguistically. The ability can instead be manifested by pointing to particular instances of colour themselves. By contrast with the fine discriminations that can be made in context, colour vocabulary is generally vague.
Similarly, by contrast with the context depending discriminations of skilled clinicians, the criteria set out in diagnostic manuals are vague and imprecise. Because they are context-independent, the criteria in DSM and ICD are portable. There is an advantage in communication of a linguistic codification of diagnosis that floats free of particular contexts. But it is bought at the cost of precision. By contrast, the features that play a role in the top-down diagnoses of skilled clinicians are identified in the context of a particular patient’s or client’s psychological whole. Such recognition cannot be captured in words alone.
Criteria and other minds
In the previous section, I suggested that tacit knowledge can be used to shed light on the idea that an overall top down or gestalt diagnostic judgement could be more specific than a diagnosis based on general but vague criteria. A skilled clinician has a recognitional skill which can only be exemplified in context-dependent judgements about particular patients or clients. That is to approach the problem from an epistemological perspective: what it is to have knowledge in this way. In this section, I will complement that by taking an ontological view. What could the relation be between the underlying mental states and conditions amounting to mental illness or disease syndromes and the more epistemically accessible criteria set out in DSM and ICD?
To outline an answer to this question I will outline a debate from the philosophy of mind that our knowledge of other minds in general is based on behavioural criteria. Although the argument against that view that I will outline does not directly carry over to the case of psychiatric diagnosis, it does suggest why criteriological diagnosis is vague compared to top-down or gestalt judgement.
The concept of a criterion was introduced into the philosophy of mind as a solution to the problem of other minds by followers of the philosopher Ludwig Wittgenstein. The influential Wittgenstein exegete PMS Hacker, writing in the Oxford companion to philosophy, defines a criterion thus:
A standard by which to judge something; a feature of a thing by which it can be judged to be thus and so. In the writings of the later Wittgenstein it is used as a quasi-technical term. Typically, something counts as a criterion for another thing if it is necessarily good evidence for it. Unlike inductive evidence, criterial support is determined by convention and is partly constitutive of the meaning of the expression for whose application it is a criterion. Unlike entailment, criterial support is characteristically defeasible. Wittgenstein argued that behavioural expressions of the ‘inner’, e.g. groaning or crying out in pain, are neither inductive evidence for the mental (Cartesianism), nor do they entail the instantiation of the relevant mental term (behaviourism), but are defeasible criteria for its application. [Honderich 1995]
Key features of this definition are that the criteria of, for example, an ‘inner’ state like pain are fixed by convention and are partly constitutive of what we mean by the word ‘pain’. Thus groaning and crying out are not mere symptoms but rather part of what we understand by pain, connected by definition not induction. At the same time, however, the criteria of pain are defeasible.
The reason for this qualification is the following intuition. Whilst, in general, pain behaviour is the expression of underlying pain, on occasion behaviour which resembles pain behaviour in every detail is not the expression of pain. It may be the result of acting or pretence. (And equally, genuine underlying pain may sometimes be stoically kept from expression.) As a result, the criterial support that apparent pain behaviour gives for a judgement that someone is in pain is taken to be defeasible. It can, on occasion, be overturned.
The idea that criteria give only defeasible support for a claim is combined with a further assumption which the philosopher John McDowell, in his criticism of this very notion, describes thus: ‘if a condition is ever a criterion for a claim, then any condition of that type constitutes a criterion for that claim, or one suitably related to it’ [McDowell 1982: 462-3]. In other words, criteria are types. Whilst on most occasions, when instances of some general type of criterion are satisfied the underlying fact for which those instances are criteria also obtains, on some occasions the type of criterion is satisfied (by some particular circumstances) but the fact does not obtain. In such cases, the criterion is satisfied but is nevertheless also defeated.
This suggests that there is an essential vagueness in the support that criteria, so understood, provide for judgements about mental states. In any particular case, some expression, some sign or symptom of pain for example, may or may not actually mean that the person expressing it is actually in pain.
This worry provides the basis for McDowell’s criticism of the use of criteria, understood in this way, to explain how knowledge of other minds is possible. On the assumption that it is sometimes, at least, possible to know someone else’s mental state, McDowell asks how such knowledge is supposed to be based ‘on an experiential intake that falls short of the fact known... in the sense [of]... being compatible with there being no such fact’ [McDowell 1982: 459].
The worry is this. If one knows something, then it cannot be the case that - ‘for all one knows’ - things may be otherwise. That possibility is ruled out precisely because one knows what is the case. But if criteria fall short of implying the fact that they are supposed to enable one to know, then they cannot themselves rule out the possibility that the fact does not obtain. So if our everyday concept of knowledge does rule this out then such knowledge cannot be based on perception that the criteria for some mental state are satisfied. A possible alternative view in which the perceived the criteria is supposed merely to be enough to satisfy linguistic conventions for the ascription of knowledge would also not address this objection, either.
If experiencing the satisfaction of ‘criteria’ does legitimise (‘criterially’) a claim to know that things are thus and so, it cannot also be legitimate to admit that the position is one in which, for all one knows, things may be otherwise. But the difficulty is to see how the fact that “criteria” are defeasible can be prevented from compelling that admission; in which case we can conclude, by contraposition, that experiencing the satisfaction of ‘criteria’ cannot legitimize a claim of knowledge. How can appeal to “convention” somehow drive a wedge between accepting that everything that one has is compatible with things not being so, on the one hand, and admitting that one does not know that things are so, on the other? [McDowell 1982: 458]
Imagine that there are two observers who both see that the behavioural criteria, so construed, for two other people being in pain are satisfied but that only one of them really is in pain: the other is pretending. If the observers’ experiences are the only grounds for them knowing the mental state of their respective subject and if their perceptions are the same in both cases (seeing that the criteria for pain are met) then how can one observer know their subject’s mental state and the other observer not? Surely, neither has knowledge even if one has, by chance, a true belief. It seems merely a matter of luck that one observers’ experience is of undefeated criteria whilst the other’s is of defeated criteria, that in one case the observed subject really is in pain and in the other merely pretending. The luckier observer has done nothing extra to earn the right to knowledge.
There is, however, an alternative view of criteria and of knowledge of other minds based on them. Rather than assuming that, in the case of pretence, the criteria for mental states are satisfied but are also defeated - by the fact that it is a case of pretence - one can instead construe it as a case of the criteria only appearing to be satisfied. This is a rejection of the idea that criteria are defeasible types of situation. Instead, McDowell presses the idea that, when criteria are satisfied, one’s experience does not fall short of the facts. So there cannot be cases where the criteria are satisfied without the fact for which they give criterial support also holding.
McDowell supports this interpretative possibility by considering a passage in which Wittgenstein discusses criteria in a non-mental context.
The fluctuation in grammar between criteria and symptoms makes it look as if there were nothing at all but symptoms. We say, for example: “Experience teaches that there is rain when the barometer falls, but it also teaches that there is rain when we have certain sensations of wet and cold, or such-and-such visual impressions.” In defence of this one says that these sense-impressions can deceive us. But here one fails to reflect that the fact that the false appearance is precisely one of rain is founded on a definition. [Wittgenstein 1953 §354]
Wittgenstein rejects the temptation to say that both the fall of a barometer and also sensations of wet and cold (or visual impressions) are mere symptoms of rain. Instead, and by contrast with the barometer fall, the connection between the sensations (or the visual impressions) and rain is definitional or criterial. They are used in an explanation of what ‘rain’ means. This thought can, however, be interpreted in two ways.
Commentators often take this to imply that when our senses deceive us, criteria for rain are satisfied, although no rain is falling. But what the passage says is surely just this: for things, say, to look a certain way to us is, as a matter of ‘definition’ (or ‘convention’... ), for it to look to us as though it is raining; it would be a mistake to suppose that the ‘sense-impressions’ yield the judgement that it is raining merely symptomatically - that arriving at the judgement is mediated by an empirical theory. That is quite compatible with this thought... when our “sense-impressions” deceive us, the fact is not that criteria for rain are satisfied but that they appear to be satisfied. [McDowell 1982:466]
Someone who steps outside their house when the lawn sprinklers are switched on may think that by having experiences of wet and cold they have experienced the criteria for rain, albeit on this occasion defeated. After all, when being taught about rain they may have been taught it through practical definitions involving experiences that felt similar. But the experiences used in the practical definition were not just any experiences of wet and cold but wet and cold experiences of rain falling. Similarly in the case of criteria for mental states, pretence can make it seem that the criteria for pain, for example, are satisfied when, in fact, they are not
Taking the criteria to be merely any experience of wet and cold (for rain) or any experience of high pitched cries (for pain) makes them too vague to sustain knowledge. Correcting this requires rethinking the generality and the descriptive nature of criteria. If the criteria for pain are given in both general and also behavioural terms, they are too vague to underpin knowledge. So one might think of them as particular though still behavioural. If so, only particular instances of behavioural criteria (particular instances of crying out and rubbing knees etc) are valid guides to underlying pain. Such a suggestion maintains the behavioural character of criteria for mental states but denies their generality. The alternative is to maintain (something of) their generality but deny the restriction to merely behavioural signs and symptoms. On such an account, the criteria for pain do not have in common anything that could be given in mind-free behavioural terms. Rather they share the essentially mind-involving generality of being expressions of pain.
McDowell offers a philosophical diagnosis of why such a view of criteria seems to go unnoticed which goes back to the influence of Cartesian dualism. If one starts from that basic picture then it invites a contrast between the behavioural states of other people to which one can have direct perceptual access, and mental states, which are, in some sense, hidden behind them. According to Descartes, they even exist in different kinds of space (res cogitans and res extensa). Cartesian dualism suggests an alienated picture of human behaviour in which all that anyone else can ever see is bodily movement which is only contingently associated with minds. Because perception of, and judgements about, such ‘behaviour’ is taken to be unproblematic whilst access to other people’s mental states is taken to be problematic, a route is needed from one to the other. Thus it seems plausible to think that judgements about mental states have to be grounded in independent judgements about behaviour. The alienated picture of human behaviour survives in approaches to the philosophy of mind which have long since rejected Descartes’ conception of the mind as res cogitans (or thinking stuff) existing in a different dimension to matter (res extensa).
This picture of the relation of mind and body is neither obligatory nor natural, however. One can instead think of mind and body as more closely linked. What one says and does expresses what one thinks and feels. Whilst one person’s mental states do not themselves fall within the direct experience of another their expression of their mental state does. Such expression is not one that is consistent with the absence of the inner state. So McDowell replaces an account in which all that is visible to an observer is another person’s intrinsically brute or meaningless behaviour, standing in need of further interpretation and hypothesis, with one in which that behaviour is charged with expression.
By denying that our ‘access’ to the minds of others must proceed through a neutrally described behavioural intermediary (their behaviour), McDowell can offer a much less technically charged account of criteria which he summarises thus:
I think we should understand criteria to be, in the first instance, ways of telling how things are, of the sort specified by “On the basis of what he says and does” or “By how things look”; and we should take it that knowledge that a criterion for a claim is actually satisfied - if we allow ourselves to speak in those terms as well - would be an exercise of the very capacity we speak of when we say that one can tell, on the basis of such-and-such criteria, whether things are as the claim would represent them as being. [McDowell 1982: 470-1]
Knowledge of other minds depends on what people say and do. It does not require a kind of direct mind reading. The judgement is based on, emerges from, what they say and do. But the conceptualisation of what they say and do need not be couched in mind-independent neutral terms. As Dowell comments:
This flouts an idea we are prone to find natural, that a basis for a judgement must be something on which we have firmer cognitive purchase than we do on the judgement itself; but although the idea can seem natural, it is an illusion to suppose it is compulsory. [McDowell 1982: 471]
It may be easier to see patterns and generalities in behaviour construed as essentially expressive of minds than in neutrally described bodily movement. So even though judgements about others’ minds may be based on their behaviour, the description of the behaviour may be less secure than the description of what it expresses.
I have set out two contrasting accounts of criteria from the philosophical discussion of the problem of other minds to shed light on the more specific issue of mental illness diagnosis. There are, however, two related important differences between the two cases which need mention.
First, the application of the idea of criteria in the more general problem of other minds and in the case of psychiatric diagnosis differ in one clear respect. It is merely a theoretical idea in the former case but set out in practical detail in recent editions of the DSM and ICD in the latter case. Second, and related to this, is an important difference in the dialectical context of criticism of behavioural criteria in the two cases. The argument above assumes that it is possible to have knowledge of other minds. Since the standard model of criteria (as defeasible behavioural types) makes knowledge impossible, it cannot be the basis of our knowledge of other minds.
But one might object that psychiatry does not aspire to knowledge when it comes to diagnosis but some weaker state such as a belief with a particular degree of probability. And hence an argument which shows that knowledge cannot be based on criteria, so understood, need not undermine that project. Such an objection carries risk, however. Since psychiatry is a practical discipline, diagnoses form the basis for action (concerning treatment and management). Thus clinicians need more than merely having beliefs with a particular (suitably high) probability of being true, they need to know that they do.
Nevertheless, even if psychiatric diagnosis need not aspire to knowledge itself but merely to some known probability of being correct, it could be based on criteria understood as behavioural types (ie the target of the criticism of this section). Providing that there are other methods of arriving at diagnoses, such as the considered judgement of skilled clinicians or longitudinal studies, it would be possible to make an assessment of the sensitivity and specificity – in probabilistic terms – of types of behavioural criteria. The dialectical context differs for defenders of defeasible criteria for knowledge of other minds because they assume that there is no more fundamental way of having such knowledge and hence no independent test of the construct validity of the criteria.
Despite these differences, McDowell’s discussion of the two accounts of criteria and the role, in the account he defends, of the idea that behaviour can be more than mere behaviour but rather expressive mental states sheds light on the possibility, at least, of the relative vagueness of criteriological diagnosis compared to the specificity of gestalt judgement. Both the DSM and ICD stress operationalised descriptions as opposed to more essentially psychiatric descriptions couched in aetiological terms. They do this in an attempt to provide secure foundations for diagnosis. But that very strategy makes the criteria mere approximations of the underlying psychopathological states they aim to capture. As Kraus, Maj and Parnas suggest, precision requires thinking of psychiatric symptoms as abstractions from a diagnostic whole rather than built up from neutral – or more neutral – criteria whose obtaining does not strictly imply the presence of the psychiatric syndrome for which they are supposed to be signs.
An alternative view of diagnostic criteria, drawing on McDowell’s account and influenced by the empirical claims of Kraus, Maj and Parnas would stress the specific schizophrenic colouring of particular delusions, for example. It may seem that this carries the risk that identifying that a patient or client is experiencing such a delusion is riskier than the vaguer claim that they are experiencing some sort of delusion or other. But this may not be so in context. In particular cases, the justification for thinking that the delusion carries a specific schizophrenic colouring may be what warrants the more general claim that they are thus experiencing some more general category of delusion.
I have considered the charge made against criteriological models of diagnosis that, compared with the gestalt judgement of a skilled clinician, they are essentially imprecise and vague. I have argued that two independently plausible considerations help explain how this could be so. Epistemologically, such diagnosis could be akin to the kind of context-dependent practical skill that underpins one model of tacit knowledge. Such skill resists codification in general context-independent terms akin to the DSM and ICD’s diagnostic criteria but is nevertheless a form of conceptually structured knowledge. Ontologically, the diagnostic criteria of the DSM and ICD may be merely more or less behavioural abstractions from underlying psychological reality. Skilled clinicians need not rely on neutral criteria but on the direct expression of complex psychological wholes.
This chapter was written whilst a fellow of the Institute for Advanced Study, University of Durham. My thanks both to the IAS, Durham and the University of Central Lancashire for granting me research leave.
Bayer, R. and Spitzer, R.L. (1985) ‘Neurosis, psychodynamics and DSM-III’ Archives of General Psychiatry 42: 187-96
Bridgman, P.W. (1927) The Logic of Modern Physics, New York: Macmillan
Fulford, K.W.M., Thornton, T. and Graham, G. (2006) The Oxford Textbook of Philosophy and Psychiatry Oxford: Oxford University Press
Hempel, C.G. (1994) ‘Fundamentals of taxonomy’ in Sadler, J.S. Wiggins, O.P. and Schwartz, M.A. (eds) Philosophical Perspectives on Psychiatric Diagnostic Classification, Baltimore: Johns Hopkins: 315-331
Honderich, T. (1995) Oxford companion to philosophy, Oxford: Oxford University Press
Kraus, A. (1994) ‘Phenomenological and criteriological diagnosis: different or complementary?’ In Philosophical Perspectives on Psychiatric Diagnostic Classification (ed. J.S. Sadler, O.P.Wiggins, and M.A. Schwartz) Baltimore, MD: Johns Hopkins University Press, pp. 148–162.
McDowell, J. (1982) ‘Criteria, defeasibility and knowledge’ Proceedings of the British Academy 68: 455-79
Maj, M. (1998) ‘Critique of the DSM-IV operational diagnostic criteria for schizophrenia’ The British Journal of Psychiatry 172: 458-460
Parnas, J. (2011) ‘A Disappearing Heritage: The Clinical Core of Schizophrenia’ Schizophrenia Bulletin 37: 1121–1130
Polanyi, M. (1962) Personal Knowledge, Chicago: University of Chicago Press
Polanyi, M. (1967a) ‘Sense-giving and sense-reading’ Philosophy 42: 301-325
Polanyi, M. (1967b) The Tacit Dimension, Chicago: University of Chicago Press
Ryle, G. (1949) The Concept of Mind, London: Hutchinson.
Ryle, G. (1945) ‘Knowing How and Knowing That’ Proceedings of the Aristotelian Society, 46: 1-16
Shorter, E. (1997) A History of Psychiatry, New York: John Wiley and Sons
Thornton, T. (2013) ‘Clinical judgement and tacit knowledge’ for Fulford, KWM (Bill) et al (ed) Oxford Handbook of Philosophy and Psychiatry, Oxford: Oxford University Press
Wittgenstein, L. (1953) Philosophical Investigations, Oxford: Blackwell.

Friday 14 November 2014

On the therapeutic status of McDowell's representationalism

I gave a talk in the Durham Philosophy Deportment which could, I realise in retrospect, have been significantly simplified. The key point, really, was that the move from the representationalism (by which I mean a view of experience as itself a content-laden state) of Mind and World to that of 'Avoiding the myth of the given' and after involved key changes which, rather than merely a matter of degree, change the point and nature of the account.

In the earlier picture, both a partial respect for the coherentism in Davidson's slogan that nothing can count as a reason for a belief except another belief (whilst trying to reject mere frictionless spinning in the void that coherentism might otherwise suggest) and a kind of Sellarsian innocence go hand in hand. The innocence is that, following Sellars' Myth of Jones, it is unproblematic to think of mental states as carrying - because modelled on - the same kind of claims as judgements. In Mind and World, the very same contents can be asserted in judgement, can be carried in the experiences that invite such judgement and can make up part of the world itself, understood as the totality of true Fregean Thoughts. A key passage runs:

In a particular experience in which one is not misled, what one takes in is that things are thus and so. That things are thus and so is the content of the experience, and it can also be the content of a judgement: it becomes the content of a judgement if the subject decides to take the experience at face value. So it is conceptual content. But that things are thus and so is also, if one is not misled, an aspect of the layout of the world: it is how things are. Thus the idea of conceptually structured operations of receptivity puts us in a position to speak of experience as openness to the layout of reality. Experience enables the layout of reality itself to exert a rational influence on what a subject thinks. [McDowell 1994: 26].

The twofold retreat in AMG (and there is a third more recent retreat with the idea that the content of good and bad disjuncts in the underlying disjunctivism is the same; it is merely the way such content is had that differs) runs thus.

I used to assume that to conceive experiences as actualisations of conceptual capacities, we would need to credit experiences with propositional content, the sort of content judgements have. And I used to assume that the content of an experience would need to include everything the experiences enables its subject to know noninferentially.
But both these assumptions now strike me as wrong.
[Lindgaard 2008: 3]

This helps illustrate the previous Sellarsian innocence. In response to the question: which concepts structure experience?, the Mind and World McDowell would have replied: all the concepts that the experience non-inferentially warrants. Not any longer.

But, now, there is no longer an easy transition from world, via experience to judgement. The middle step in that chain is mediated by an entirely different kind of content: intuitional rather than propositional. So there is no longer a simple appeal to experience carrying the same kind of content. (This makes his appeal to a Sellarsian thought in his response in the Lindgaard collection to Bill Brewer's objection from the Muller Lyer lines odder, I have to confess.)

Further, the partial role for the Davidsonian slogan is further reduced since experiences no longer share even the form of beliefs. If the world imposes rational friction on judgement in such a way that preserves a common form (since the world is made up of true Thoughts) the connection via two further links - true Thought to intuitional content, and from intuitional content to true Thought - is no longer clear. In the latter case, we are told that bits of intuitional content can be carved up and reassembled as propositional content but since the concepts articulating intuitional content are a subset of those available non-inferentially, many judgments are based on intuitional content only via recognition.

Gosh that is still too long a summary. But my key thought was this. If the assumptions that hold all this in place, that need to be balanced in such a way to reduce felt tensions, can tolerate the double deployment of carving of and recognition from intuitional content, why not cut out the middle man? Carve up and recognise worldly states of affairs. Why, in other words, isn't McDowell Charles Travis? He has already given up the kind of clarity about rational relations that insisting that the relata are conceptual seemed designed to underpin. Who is to say, a priori, therapeutically, how the same concepts in different forms licence rational transitions in the space of reasons?

(No one who wants a theory of experiential content will be tempted by Travis' minimalist work. But McDowell does not explicitly want any such thing. He just wants to reconcile the felt tensions surrounding judgement's responsibility to its subject matter with something like a partial respect for Davidson so that one seeks justificatory links not mere exculpating.)

In questions, Rachael Wiseman suggested that McDowell and Wittgenstein have a different attitude to the first move in philosophy, the one Wittgenstein characterises thus:

How does the philosophical problem about mental processes and states and about behaviourism arise?——The first step is the one that altogether escapes notice. We talk of processes and states and leave their nature undecided. Sometime perhaps we shall know more about them—we think. But that is just what commits us to a particular way of looking at the matter. For we have a definite concept of what it means to learn to know a process better. (The decisive movement in the conjuring trick has been made, and it was the very one that we thought quite innocent.)—And now the analogy which was to make us understand our thoughts falls to pieces. So we have to deny the yet uncomprehended process in the yet unexplored medium. And now it looks as if we had denied mental processes. And naturally we don't want to deny them. [Wittgenstein 1953 §308]

Whilst Wittgenstein doubts that first move and calls us back to the zeroth move, the description of the phenomena, Rachael suggested that McDowell seems much happier to accept philosophical summarising as a kind of first move for subsequent analysis. And hence, she suggested, his less critical deployment of McDowellian metaphors. Such first moves merely call for some holistic pruning. Not all survive. I have not thought in such terms but it seems right. It marks that other curiosity. McDowell thinks that therapeutic dissolution can still - innocently - appeal to the philosophical canon.

(PS: There is a development of some of these thoughts here.)

Thursday 6 November 2014

Why 'In the Space of Reasons'?

In response to a question from someone reading philosophy but not a philosopher (better: a poet).

The phrase comes from a paper (now published as a short book) called ‘Empiricism and the Philosophy of Mind’ by Wilfrid Sellars, the mid C20 American philosopher. One question he addresses is whether knowledge has a foundation. His answer is that it does, it can be grounded in perceptual reports, but that these do not have a property sometimes expected of epistemic foundations: that they can be made independently of holistic considerations. They are not brute data in that sense. That, he suggests, is the ‘Myth of the Given’.

In building to that claim he comments:

The essential point is that in characterizing an episode or a state as that of knowing, we are not giving an empirical description of that episode or state; we are placing it in the logical space of reasons, of justifying and being able to justify what one says. [Sellars EPM §36 italics added]

Sellars claims here that knowledge has an essentially normative status. It belongs to Reason. This contrasts, for example, with those who argue that knowledge is ‘a true belief arrived at by a reliable process’. But it also suggests that holism of conceptual connections which contradicts previous versions of foundationalism (The Myth…). In a little more detail, he attempts to find a middle position between coherence and foundationalism. If something is to count as a perceptual report it must meet 2 conditions:
1) It must be reliable.
2) The subject who makes it must know it is reliable. Otherwise, trained parrots would count as making perceptual reports. But parrots are not justified in their ‘utterances’.

But answering 2) means that a subject must think of her reports as reliable. So she must have a conception of how the world works and how her reports work, under suitable conditions. But if that is the case, this is not a form of the Myth of Given because perceptual reports are now fallible. If her world view is wrong, that will infect her perceptual reports. So neither mere coherence (because perceptual beliefs are not inferred from anything else) but not foundationalism (since perceptual reports are fallible and can be undermined by failures of the world-view).

In Mind and World, John McDowell extends this picture beyond states of knowledge to any state that has empirical content, is about part of the world (whether or not meeting the additional requirements for knowledge). The very idea of mental states having content – intentionality in traditional philosophical vocabulary – requires their rational friction (so not merely causal contact) with the world. But then our only understanding of rational relations requires both relata have conceptual structure. Since experience provides the friction but experience is - for reasons McDowell develops elsewhere - a kind of direct openness to the world (by contrast, eg., with an internal structure in the veil of ideas) then the world itself must have conceptual structure. (McDowell here acknowledges a debt to German Idealism, Kantianism without the ineffable noumenal world, Hegel.) So there is nothing beyond the conceptual realm. There is nothing outside the space of reasons. That space has limits but no externally imposed limitations.

So my blog’s title is supposed to flag the importance of normative connections, of reasons or Reason, whilst at the same time hinting that there’s nothing unavailable to such a perspective. (That said I don’t actually accept the argument to German Idealism. One reason is this.) Given that there is some discussion on it from time to time of psychopathological states, of understanding within mental healthcare, this raises some tensions.

Tuesday 4 November 2014

Transcultural psychiatry, cultural formulation and validity in DSM-5

(This is a second draft paper written whilst my mind has been dominated by feelings of dullness and misery. I have at least found trying to concentrate on philosophy some consolation.)

Transcultural psychiatry, cultural formulation and validity in DSM-5
DSM-5 puts greater emphasis than previous editions non-Western cultural idioms of mental distress but without making explicit the relation between these and the psychiatric scientific aspirations, such as for their reliability and validity, of the rest of the taxonomy. The first section of this chapter outlines three possible views of the nature of transcultural psychiatric taxonomic concepts: a two factor view of underlying pathology overlain by a cultural shaping presupposed by one view of the role of cultural formulation and two versions of a one factor view, radical and conservative. But I argue in the second section that establishing the correctness of any one is none too easy. Two influential approaches to the nature of the concept of disorder – Wakefield’s harmful dysfunction analysis and Fulford’s failure of ordinary doing – can be pressed with only minor tweaking to support any of the a priori models of transcultural concepts. In the final section I examine one such idiom: khyal cap or wind attacks, a syndrome found among Cambodians. I argue that this does not fit any of the ways of domesticating variation from standard DSM-5 categories and that this suggests that the very idea of transcultural psychiatric diagnostic concepts fits uneasily with the rest of DSM-5.

Introduction: cultural factors in DSM-5
DSM-5 introduces a more explicit treatment of cultural factors in psychiatric diagnosis than previous editions of the DSM. In Section III, there is a discussion of the role of what is called a ‘Cultural Formulation’ including a semi-structured interview to help investigate cultural factors. In the Appendix, there is a ‘Glossary of Cultural Concepts of Distress’ which describes nine common conditions (though see below). In the Introduction, a number of suggestions are made as to how cultural factors might affect diagnosis and prognosis and thus should be investigated in a cultural formulation [APA 2013: 14]. Culture may affect:
·         The boundaries between normality and pathology for different types of behaviour.
·         Vulnerability and suffering (by amplifying fears that maintain panic disorder).
·         The stigma of, or the support for, mental illness.
·         The availability of coping strategies.
·         The acceptance or rejection of a diagnosis and treatments, affecting the course of illness and recovery.
·         The conduct of the clinical encounter itself thus affecting the accuracy of diagnosis, acceptance of treatment, hence prognosis and clinical outcomes.
The Introduction also summarises (in fact at greater length than the later discussion of the cultural formulation in the main text) three distinct ways that culture can impact on diagnoses. The single idea of culture-bound syndromes from DSM-IV is replaced by three notions: cultural syndromes, cultural idioms of distress and cultural explanations (or perceived causes) of illnesses (or symptoms). It is worth quoting the summary in full:
1. Cultural syndrome is a cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community, or context (e.g., ataque de nervios). The syndrome may or may not be recognized as an illness within the culture (e.g., it might be labeled in various ways), but such cultural patterns of distress and features of illness may nevertheless be recognizable by an outside observer.
2. Cultural idiom of distress is a linguistic term, phrase, or way of talking about suffering among individuals of a cultural group (e.g., similar ethnicity and religion) referring to shared concepts of pathology and ways of expressing, communicating, or naming essential features of distress (e.g., kufiingisisa). An idiom of distress need not be associated with specific symptoms, syndromes, or perceived causes. It may be used to convey a wide range of discomfort, including everyday experiences, subclinical conditions, or suffering due to social circumstances rather than mental disorders. For example, most cultures have common bodily idioms of distress used to express a wide range of suffering and concerns.
3. Cultural explanation or perceived cause is a label, attribution, or feature of an explanatory model that provides a culturally conceived etiology or cause for symptoms, illness, or distress (e.g., maladi moun). Causal explanations may be salient features of folk classifications of disease used by laypersons or healers. [ibid: 14]
Although the authors distinguish between these different ideas, they concede that the same elements may play a role in all three categories. For example, in the West, depression is used as an idiom of distress whether of an illness or pathology or of mere normal but significant sadness. But it is also recognised as a mental illness syndrome gathering together a number of symptoms. Finally, it is taken to be the cause of those symptoms. Just as depression can play the role of syndrome, idiom of distress and explanation, so can other concepts local to other cultures. Given this complication, although the ‘Glossary of Cultural Concepts of Distress’ describes nine common culture-bound syndromes, the concepts described may also play a role as idioms of distress and purported explanations or causes of experiences. The cultural concepts described are khyal attacks or khyal cap, ataque de nervios (‘attack of nerves’), dhat (‘semen loss’), kufungisisa (‘thinking too much’ in Shona), maladi moun (‘humanly caused illness’) nervios (‘nerves’), shenjing shuairuo (‘weakness of the nervous system’ in Mandarin Chinese), susto (‘fright’), taijin kyofusho (‘interpersonal fear disorder’ in Japanese). Each is related to similar but different concepts found in other, including Western, cultures. Khyal cap, for example, is linked to panic disorder.
But given that, in the years leading up the publication of DSM-5, much emphasis was placed on the attempt to increase the validity of psychiatric diagnostic categories, by contrast with their reliability which had already been increased by the stress on aetiologically minimal operationalised criteria, what stance does DSM-5 have to the content of the cultural concept? Are they, too, supposed to possess validity, to be genuine descriptions of real features of mental pathology? Or does the cultural sensitivity aimed at in a formulation and the semi-structured interview protocol require the adoption of a kind of anthropological relativism? Can the aim of cultural sensitivity and the articulation of non-Western idioms go hand in hand with the scientific ambitions of twenty-first century western psychiatry? Or does it require a kind of liberal irony towards the rest of the diagnostic manual?
In the next section I will outline three general ways of thinking about the cultural dependence of mental illness categories and hence the possible role of cultural formulations. Then in the subsequent section I will explore the merely loose connection between these and two broad approaches to the concept of mental illness. In the final section, I will return to reconsider the status of the cultural concepts actually listed in DSM-5 through consideration of one of them: khyal cap.

Three models of cultural concepts of distress
A two factor model of cultural variation
One way to understand how culture affects mental illness would be to think of the expression of mental illness as the result of two factors: an invariant endogenous factor and a cultural shaping. On such a view, mental illnesses either are, or are underpinned by, pathologies of some sort of universal substrate such as an essential human nature. This is the first factor.
Perhaps the most obvious candidate for such a substrate is human biological nature. This would fit a common emphasis within mental healthcare on the centrality of biological psychiatry especially for accounts of the aetiology of mental illness. It would also be consistent with Jerome Wakefield’s analysis of the concept of disorder as a harmful dysfunction (although the next section argues against any close connection or implication) [Wakefield 1999]. Setting aside the role of the value term ‘harm’ for the moment, the first factor in a two factor account of culture-bound syndromes might be a biological dysfunction picked out or explained in evolutionary terms.
Whilst biological nature is the most obvious candidate for the first factor, others are also possible. Consider Louis Sass’ account of Schreber’s delusions in Paradoxes of Delusion [Sass 1994]. The main claim of the book is summarised in an early passage thus:
[Schreber’s] mode of experience is strikingly reminiscent of the philosophical doctrine of solipsism, according to which the whole of reality, including the external world and other persons, is but a representation appearing to a single, individual self, namely, the self of the philosopher who holds the doctrine… Many of the details, complexities, and contradictions of Schreber’s delusional world… can be understood in the light of solipsism. [ibid: 8]
But the elucidation or understanding that Sass seeks isn’t merely aimed at one particular delusional experience or even at all of Schreber’s experiences considered as a whole. It is meant to shed light more generally on the nature schizophrenia itself. The reason it can (according to Sass) is that the experiences that characterise schizophrenia derive from a general and abstract feature of rationality:
[Madness] is, to be sure, a self-deceiving condition, but one that is generated from within rationality itself rather than by the loss of rationality. [ibid: 12]
So one might take the first factor of a two factor theory of cultural psychiatry to be an invariant feature of human mindedness whether unified as a biological dysfunction or more generally characterised in mental terms: in Sass’s case as a feature of rationality. It might, in other words, attach to the nature of rational subject-hood however that is (biologically) realised or underpinned. This would form the basis or underpinning of mental illness across cultures and not specific to any one of them.
Cultural variation enters this (two factor) picture only with the second factor. Culturally invariant pathologies of underlying human nature are overlaid by local cultural variation in how they are expressed. ‘Expressed’ could carry either of two meanings. First, it might mean that standing possibilities for biological dysfunction or failings of rational subjectivity might be differently prompted by different social or geographical contexts. This would be akin to akin to variation in heart disease rates and causes in different cultures and hardly merits the label ‘cultural concept’. (I will return to this possibility a little later and will suggest it is better thought of as a one-factor model.)
The more interesting idea is that variation in ‘expression’ picks out the way in which underlying pathologies might be plastic to the different self-interpretations that different people in different cultures come to possess and thus the way the pathologies are experienced and avowed. This would be an example of a cultural idiom of distress in the vocabulary of the DSM-5. But whereas for physical illness, how one understands one’s illness might be thought to be an accidental superficiality compared with the real underlying condition (as understood, perhaps, by the medical profession), one might argue that for mental illness its esse is percipi: how it is perceived at least partly constitutes it. Thus in the case of Sass’ account of schizophrenia, a two factor model would be premissed on the idea that cultural variation might make it difficult to realise that the symptoms reported in different cultures resulted from something like the same failure within rationality. Identifying the common element would require significant interpretative work reflected in a cultural formulation.
I suggested earlier that on a two factor model, mental illnesses either are, or are underpinned by, pathologies of some sort of universal substrate. The difference between these options is the difference between thinking that the alloy of an invariant underlying pathology and a varying cultural overlay itself comprises what we mean by mental illnesses themselves. One might think, for example, that khyal cap and panic disorder have the same underlying biological mechanism but that the characteristic way in which the former carries its own ontology (ie that subjects think of their distress through the conceptual lens of a wind-like substance) is sufficient to mark it off as a different kind of mental illness. Biological dysfunction is then the common cause of two distinct illnesses depending on cultural context. On the other hand, one might think that the real illness is whatever is common to khyal cap and panic disorder. It is merely that the form that that single illness takes can vary.
Whichever view is taken of whether the first factor is the illness or merely the common underpinning of different illnesses, a two factor view of cultural concepts of mental illness suggests a particular view of the aim of a cultural formulation in psychiatric diagnosis. It is a way of reverse engineering, from locally divergent symptoms, the common underlying nature or the underlying causes of mental illness. The aim of sensitivity to cultural difference would be to find a way to penetrate beneath it to a common substrate appropriate for scientific psychiatric research.
This seems to be the view of the ex-president of the World Psychiatric Association Juan Mezzich et al. in their discussion of ‘Cultural formulation guidelines’ when 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. [Mezzich et al 2009: 390]
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]
These passages suggest that there is a division between how an illness is enacted and expressed and the underlying framework set out by Western psychiatry. The former is locally culturally shaped. The latter is invariant. On Mezzich et al’s  account, the only positive role cultural factors can then play is as a source of contingent health promoting 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]
In other words, ‘culturally salient themes’ do not reveal the shape of mental illnesses in themselves but can, contingently, be used to promote health because of their effects on how people understand their own illnesses. All this suggests that this underlying view of the role of a cultural formulation is determined by a two factor view. Such a view is, however, merely one of several possible. I will argue that it is a half way house between two more radical views of the possibilities for cultural psychiatry both of which of versions of a single factor which I will now outline.
Two versions of a one factor model of cultural variation
A two factor model of the nature of transcultural psychiatry requires a distinction between surface appearance and underlying pathology. But it might be that this distinction cannot be drawn. The various ways one might attempt to flesh out the contrast between underlying pathology – for example as biological or some other underpinning notion of universal human nature – and surface appearance might fail.
Consider the two versions of the first factor outlined above: biological dysfunction cashed out in accord with evolutionary theory and a pathology of the structure of rationality as such. In the first case, drawing a distinction between surface form and underlying invariant function or dysfunction might seem unproblematic for physical illnesses. But in the case of mental dysfunctions there may be no principled way of drawing a distinction between ways of thinking, for example, that are problematic within a particular culture and some underlying cognitive function underpinning several different forms. The surface form may simply be the dysfunction. Why? Whilst it is unlikely that there is no such thing as biological human nature and hence some shared biological underpinnings for human mentality it might not, unaided, determine mental pathology because it might not – without education and enculturation, for example – determine the kind of mindedness that mental illness threatens. Mental illness might be a feature of what McDowell calls our ‘second nature’, or, in German, bildung by contrast with biological first nature [McDowell 1994: 183]. Perhaps learning a language is necessary for some, at least, forms of mental illness such as thought disorder. Perhaps there is no principled way to factor conditions like depression into those aspects that require conceptual thought or language and mere biological underpinnings.
A one factor model need not imply that there is any cultural variation of mental illness. It might be that our second nature, or rather that aspect of it relevant for the formation of mental illnesses, is universal. If so, mental illness would be akin to heart disease, varying only in external features such as rates and superficial and unimportant local understandings of it. Any apparent deeper variation would be a mark of our ignorance, our misdiagnosis. So a conservative version of the one factor model likens mental illness to heart disease with no significant space for cultural variation and no need for a cultural formulation to extract or excavate the underlying commonalities because they are open to view.
But it is also possible that, because second nature depends on enculturation and because cultures vary, second nature also varies. If so, the richer notion of human nature, beyond mere biology and sufficient for a conception of mental illness, might not be universal. Cultural variation might go ‘all the way down’. Genuinely different forms of mental illness would emerge from different ways of living in different societies.
To flesh this example out it will be helpful to consider again but in more detail Sass’ account of schizophrenia according to which it is a failure of rationality from within, or driven by, rationality itself rather than a mere absence of rationality. The symptoms of schizophrenia are a kind of lived experience of the philosophical theory or stance of solipsism according to which only the subject of experience – for me: I – exists. Everything else is merely an idea (for me: one of my ideas). Solipsism is thus idealism whose implicit consequences have been explicitly adopted since if everything that exists is merely an idea only the first person subject of thought (for me: I) can have those ideas. But as Wittgenstein argued, solipsism is then strictly nonsensical because it presupposes a contrast between self and other (in the claim that everything is merely an idea) which it cannot consistently draw (since everything is an idea) [Wittgenstein 1929]. Sass, controversially, embraces this further feature of solipsism – that it is nonsense – to shed light on the pathological status of schizophrenia with the hope of solving ‘simultaneously for understanding and strangeness’ in Naomi Eilan’s useful phrase [Eilan 2000: 97]. (For criticism of just this point see [Read 2001; Thornton 2004].)
Such an account can be used to illustrate both the conservative and the radical version of the one factor model of cultural concepts. If one thinks that the history of Western philosophy merely illustrates and unpacks conceptual connections implicit in the rationality of any possible thinker then solipsism is also a standing possibility for any thinker and hence, on Sass’ account, so is schizophrenia as its lived version. That would be a conservative one factor model. Any apparent culturally determined local variation in the experience of schizophrenia, such as the specific contents of delusions by contrast with invariant forms, would be merely superficial, requiring no great cultural sensitivity to detect. (It is the thought that it is merely or trivially superficial which distinguishes this from a two-factor model with its demand for a cultural formulation to penetrate surface features.)
If, on the other hand, one thinks that Western philosophy has been driven not merely by the abstract demands of rationality but by historically contingent assumptions about the nature of subjectivity and the connection of mind and world then the temptation towards solipsism will seem to be a merely local cultural matter. At the risk of being glib, had Descartes not existed, there would have been no such thing as schizophrenia.
This version of the one factor model is more radical than the two factor model even though both agree on the need for some sort of cultural formulation. A radical one factor model of a cultural formulation is more radical because it does not enable one to dig beneath surface difference to find underlying common pathologies but would instead be an articulation of the genuinely different ways people can be ill in different cultures. According to it, there are genuinely different forms of mental illness which need have nothing substantial in common across different cultures.

The loose connections between different models of cultural idioms and rival accounts of mental disorder
Prima facie a two factor model and two versions of a one factor model – according to one of which (the radical version) there is radical cultural variation all the way down and according to the other (the conservative version) there is no cultural variation, akin to heart disease – are all possible approaches to the role of culture in psychiatric diagnosis. Given that the one factor model is coherent, at least, is there any reason to think the two factor model holds good, as Mezzich et al seem to assume in their account of the purpose of a cultural formulation? To repeat, the two factor model postulates a set of invariant underlying pathologies which are overlaid by cultural variation in the way they are expressed. What independent support can be given to that notion?
Given that I have illustrated the two factor approach, above, by appealing to Jerome Wakefield’s harmful dysfunction analysis, it might be hoped that settling on a satisfactory understanding of the concept of illness or disorder will also determine the correct view of transcultural psychiatry. But although there are connections, they are not as simple as they might at first appear. I will explain this by sketching the implications of two rival models of (mental) illness.
According to Wakefield, a disorder is a harmful dysfunction, where a dysfunction is picked out, it turns out, in accordance with evolutionary theory. (I say ‘it turns out’ to mark the fact that function is supposed to be a ‘back box concept’.) Evolutionary theory specifies the biological functions of the traits of the human mind and body. On this picture, there are evolutionary facts about mental function, from which deviations are failures of function, and these facts should hold universally. This approach might thus support the universal substrate necessary for a two factor model.
But, on reflection, it need not. It will only support a two-factor model if the underlying dysfunctions – identified via failure of biological functions – can also be culturally moulded or shaped. Suppose that there is no way to separate an underlying mental function or dysfunction from its surface appearance. One reason for thinking this might be a commitment to a difference of kind between the personal level and the sub-personal combined with the idea that there is no depth dimension to the personal or mental. If so, such a view does not fit a two factor model. How might this be? Consider the following description of a symptom (typical of psychotic conditions) in DSM-5.
Disorganized thinking (formal thought disorder) is typically inferred from the individual's speech. The individual may switch from one topic to another (derailment or loose associations). Answers to questions may be obliquely related or completely unrelated (tangentiality). Rarely, speech may be so severely disorganized that it is nearly incomprehensible and resembles receptive aphasia in its linguistic disorganization (incoherence or "word salad"). Because mildly disorganized speech is common and nonspecific, the symptom must be severe enough to substantially impair effective communication. The severity of the impairment may be difficult to evaluate if the person making the diagnosis comes from a different linguistic background than that of the person being examined. Less severe disorganized thinking or speech may occur during the prodromal and residual periods of schizophrenia. [APA 2013: 88]
Influenced by Wakefield, derailed switching from one thought to another could reasonably be construed as a failure of biological function: a function of the cognitive system. But it is not clear that it is susceptible to any significant cultural shaping. Whilst the subject matter, for example, of jumbled thoughts will depend on the circumstances, including broader cultural circumstances, of the person who experiences them, that seems to be a merely superficial surface colouring of the condition. So in the case of this symptom, the harmful dysfunction model of disorder seems to support a conservative one factor model of cultural psychiatry.
Could the harmful dysfunction analysis of illness be used to support the third option: the radical one factor view according to which mental illnesses are cultural shapings ‘all the way down’? Not, I think, on Wakefield’s own approach which is founded on a historical biological conception of function and dysfunction. But only two changes are necessary to fit that model. First, it requires changing the underlying analysis of function from a historical approach following Wright to a present functioning account following Cummings [Wright 1973, Cummins 1975]. Second, the context of such functions would have to be widened to take account of social functioning. Taken together, such a modification would suggest the possibility of conditions which impaired the local social functioning of individuals. Furthermore, both modifications seem plausible in the light of existing criticism of Wakefield’s precise view [eg Bolton 2008].
The harmful dysfunction account of disorder is consistent with all three models of cultural concept. Thus a defence of harmful dysfunction as a general analysis of mental disorder does not itself determine a view of cultural psychiatry. Wakefield’s position contains a value-free core. There are opposing views that hold that mental illness is evaluative through and through. Can such a ‘values-in’ view determine the correct account of cultural concepts in psychiatry?
On Bill Fulford’s version of a ‘values-in’ theory, illness corresponds to an endogenously caused failure of ordinary doing, an inability to do the sort of things that one should just be able to get on and do [Fulford 1989]. The analysis aims to capture both mental and physical illness. Both are value-laden. Fulford thus challenges an assumption about physical illness shared by both Thomas Szasz and Robert Kendell [Szasz 1960; Kendell 1975]. But he also stresses a contingent difference between mental and physical illness which is relevant here. We typically disagree about the values relevant to mental illness, and hence of the sort of impediments to ordinary doing, whilst we typically and contingently agree in the case of physical illness. We agree about the contribution of a heart to healthy ordinary doing, and hence about heart disease, but not mental flourishing and hence mental illness.
If Fulford is correct about that difference and its significance then his account might seem to undermine the universality of the underlying pathology necessary for a two factor model. (I suspect that that is what Fulford himself would think.) There would be no underlying universal substrate of pathologies because different cultures would have different values and thus quite different ways of failing to be able to act. This would support the radical version of the one factor model.
But that model of cultural psychiatry is not a necessary consequence of a ‘values-in’ view of mental illness. One might think that mental illness and mental health are essentially evaluative notions but that, on a proper view, the values involved are (that is, ought to be) universal. On such a view, there is a rich value-laden notion of the proper way for a human to be, for human flourishing, and deviations from it are value-laden mental illnesses. This might amount to either a two factor or a conservative one factor model. The difference depends on whether one thinks that the kinds of actions one should ordinarily be able to do can be common components within importantly different broader culturally determined contexts (the two factor model) or whether one thinks that the same basic actions, undermined by illness, are visible across different (the conservative version of the one factor model). On the former view there is a need for a cultural formulation to investigate common factors within apparently different practices whilst on the latter the commonalities are clear and hence there is no such need.
My aim so far has been to investigate different possible views of trans-cultural psychiatry. Three different views seem to make sense, each with different implications for the need for a cultural formulation. But there do not seem to be close connections between general accounts of the nature of mental illness and disorder and any one of the three. In other words, there do not seem to be very strong a priori arguments for any particular view. Given this, the only alternative is to look to the actual examples in DSM-5 and examine which model they fit and hence the implicit view of transcultural psychiatry.

The status of Khyal cap
Having sketched some abstract models of ways to understand cultural concepts of mental distress and their merely loose connections to rival accounts of mental disorder in general, I will now turn to one particular example from DSM-5 to see which model applies.
Khal cap is described in the following way. (It will be helpful to quote this one example in full to suggest the kind of description offered in the other cases too).
Khyal cap
‘Khyal attacks’ (khyal cap), or ‘wind attacks,’ is a syndrome found among Cambodians in the United States and Cambodia. Common symptoms include those of panic attacks, such as dizziness, palpitations, shortness of breath, and cold extremities, as well as other symptoms of anxiety and autonomic arousal (e.g., tinnitus and neck soreness). Khyal attacks include catastrophic cognitions centered on the concern that khyal (a windlike substance) may rise in the body—along with blood—and cause a range of serious effects (e.g., compressing the lungs to cause shortness of breath and asphyxia; entering the cranium to cause tinnitus, dizziness, blurry vision, and a fatal syncope). Khyal attacks may occur without warning, but are frequently brought about by triggers such as worrisome thoughts, standing up (i.e., orthostasis), specific odors with negative associations, and agoraphobic type cues like going to crowded spaces or riding in a car. Khyal attacks usually meet panic attack criteria and may shape the experience of other anxiety and trauma- and stress or related disorders. Khyal attacks may be associated with considerable disability.
Related conditions in other cultural contexts: Laos (pen lom), Tibet (srog rlunggi nad), Sri Lanka (vata), and Korea (hwa byung).
Related conditions in DSM-5: Panic attack, panic disorder, generalized anxiety disorder, agoraphobia, posttraumatic stress disorder, illness anxiety disorder. [ibid: 834]
I raised the question at the start of the chapter of whether cultural sensitivity requires the adoption of a kind of anthropological relativism or whether it is consistent with the privileging of a particular cultural standpoint: that of twenty-first century western psychiatry?
In this case, at first sight no such relativism seems necessary. Khal cap can serve as an ‘idiom of distress’: the conception of an experience had by a subject. If someone describes their experience as the rising up of a wind-like substance then that is simply an anthropological fact about the culture. It can serve as a ‘cultural explanation’ because, again, that is a fact about how a culture explains particular experiences without implicit endorsement of that theory of aetiology by the ascriber. But, by the standards of twenty-first century western psychiatry, it can even be described as a ‘cultural syndrome’ since that is defined as ‘a cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community, or context’. If, for whatever reason, the symptoms described co-occur then it is reasonable to call them ‘khal cap’. In other words, the sincere use of ‘khal cap’ by a transcultural psychiatrist need not cause any intellectual difficulty.
But such a reading of the description carries some implications when it comes to understanding the nature of culturally sensitive psychiatry. If the concept of a khyal attack is only ever used within the (intensional) context of what someone from that culture believes – his or her conception of the nature and explanation of their experiences – rather than as an objective description of what is really causing the attack, then that suggests a distinction of kind between cultural concepts (or culture-bound syndromes) and the main elements of DSM-5’s taxonomy.
Consider the question asked from a traditional Western psychiatric standpoint: ‘But from what are they really suffering?’. The description above suggests a ready answer selected from the list of related conditions in DSM-5: ‘Panic attack, panic disorder, generalized anxiety disorder, agoraphobia, posttraumatic stress disorder, illness anxiety disorder’. Such a response suggests that a culturally sensitive psychiatry might be merely a sensitivity to other cultures’ errors: the truthful ascription of a false belief about the causes of abnormal experiences.
With that worry in the background, I can approach the example of khyal attack through the range of options explored above. Recall Mezzich et al’s suggestion that the role of a cultural formulation is to ‘map what he or she has learned about the patient’s illness onto the conceptual framework of clinical psychiatry’. I suggested that this reflected a two factor model. If so, the underlying invariant factor is whatever is picked out by ‘panic attack, panic disorder, generalized anxiety disorder, agoraphobia, posttraumatic stress disorder, [or] illness anxiety disorder’. The varying local cultural shaping is the ‘catastrophic cognitions centered on the concern that khyal (a windlike substance) may rise in the body’.
The example fits the two factor model. But if so there remains an asymmetry between khal cap and panic attack because, from the perspective of the rest of the DSM, the former involves an error about the real aetiology of the condition. Dividing the condition between two factors does nothing to change this perspective.
Nor does it help to adopt the conservative one factor model. That presents a stark choice for any putative newly discovered mental illness. On this conservative view, culture-bound syndromes such as khyal cap can have either of two statuses. They are either really other names for universal conditions also picked out by the vocabulary of Western psychiatry such as ‘panic disorder’. Or they do not exist. For example, if it is an essential part of the theoretical apparatus of khyal cap that it is caused by the rising up of a wind-like substance then given that on our best account of physiology there is no such substance then, equally, there is no such condition. Those who self-report it, or its characteristic symptoms, are in some sense in error about their own conditions.
Could khal cap be understood in accord with the radical one factor model? Again, it seems not. That would require thinking of it as a genuinely different way of being ill resulting from being in a different culture. One way that might come about (influenced by the harmful dysfunction approach to disorder) is if it impedes a social function which has no echo in Western society. Or, drawing on Fulford’s work, it might be that there are local standards for what counts as ordinary doing and hence novel possibilities for endogenously caused failures of such doing. But khal cap does not seem to differ from health in respect of any novel social function or ordinary doing. It does not fit this more radical idea of transcultural psychiatry.

This chapter was written whilst a fellow of the Institute for Advanced Study, University of Durham. My thanks both to the IAS, Durham and the University of Central Lancashire for granting me research leave.

One of the criticisms of western psychiatry has been its cultural narrow mindedness, reflecting only a particular socio-cultural perspective [eg Watters 2010]. Thus the idea that DSM-5 contains a wider range of cultural idioms of mental distress than previous editions might suggest progress has been made in addressing this criticism.
Further, there are ways in which the existing DSM diagnostic categories could be augmented by other culturally-specific concepts. On a two factor model, the same underlying illnesses – or the same underlying causes of illness – might be experienced in different ways in different societies. Perhaps the disturbances of self that underpin schizophrenia with its characteristic delusions might be experienced differently in a culture not so influenced by the individualism imparted to the west by Descartes. On a radical one factor model, genuinely distinct conditions might be possibilities in virtue of different conceptions of flourishing, or ordinary actions, or societal functions (depending on the view taken of the concept of disorder). A compendious version of the DSM might chart conditions whether or not they were possible in every society.
However, the conditions set out in DSM-5, exemplified by khyal cap, do not fit either of these possibilities in a way that suggests cultural even handedness. If khyal cap is understood in accord with a two factor approach, the second factor nevertheless involves a kind of mistake. And it does not fit the radical one factor model.
This result is, perhaps, unsurprising. Although these cultural concepts of distress are flagged in the Introduction and discussed in the main body of DSM-5, their articulation and description is restricted to an appendix. They do not form a part of the taxonomy of mental illnesses proper, the taxonomy whose aims included validity. The very idea of transcultural psychiatric diagnostic concepts does not fit easily into DSM-5.

Bolton D. (2008). What is mental disorder? An essay in philosophy, science and values, Oxford: Oxford University Press
Cummins, R. (1975) ‘Functional Analysis’ Journal of Philosophy 72: 741–65
Eilan, N. (2000) ‘On understanding schizophrenia’ In D. Zahavi (Ed.), Exploring the self. Amsterdam: John Benjamins
Fulford, K.W.M. (1989) Moral Theory and Medical Practice, Cambridge: Cambridge University Press
Kendell, R.E. (1975) ‘The concept of disease and its implications for psychiatry’ British Journal of Psychiatry 127: 305-315
Mezzich, J.E., Caracci, G., Fabrega Jr., H. and Kirmayer, L.J. (2009) ‘Cultural formulation guidelines’ Transcultural Psychiatry 46: 383-405
Read, R. (2001) ‘On approaching schizophrenia through Wittgenstein’ Philosophical Psychology 14
Sass, L.A. (1994) The Paradoxes of Delusion, New York: Cornell
Szasz, T. (1960) ‘The myth of mental illness’ American Psychologist, 15: 113-118
Thornton, T. (2004) ‘Wittgenstein and the limits of empathic understanding in psychopathology’ International Review of Psychiatry 16: 216-224
Wakefield, J.C. (1999) ‘Mental disorder as a black box essentialist concept’ Journal of Abnormal Psychology 108: 465-472
Watters, E. (2010) Crazy like us: the globalization of the American psyche, New York : Free Press

Wright, L. (1973) ‘Functions’ Philosophical Review 82: 139–68