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