Delusion and disjunctivism

I realise that sitting in conferences on mental illness and madness, I’m aware of a lack of general awareness of something like the power of disjunctivism to undermine the argument from illusion. That might seem an odd segue but it comes naturally to me when presented with a worry from Thomas Szasz that there’s something odd about a diagnosis of mental (by contrast with physical) illness in that it turns on a disagreement between clinician and patient. The worry starts from the practical asymmetry in that situation and then presses the question: but who is to say that the clinician is right? And it can seem that since the main thing that holds the practical asymmetry in place is a social power relation - where one side can access the police and law easily while the other cannot - then that is also all the asymmetry can comprise, too. The difference is merely one of power.

My naive response, when I hear this worry expressed, that the clinician is obviously right and her patient wrong if the latter says (today) he is Napoleon (to take an example from Szasz) is usually greeted with a raised eyebrow and the question: but how do we know that? And once one begins to press this worry, it can seem that this meta-level asymmetry, which now has me and the hypothetical clinician, with perhaps other members of society, on the one hand and the supposed patient and possibly my more open-minded interlocutor (“Perhaps he really is Napoleon, travelled through time!”) on the other hand, itself only comprises difference in numbers.

I suspect that this is a case where the obvious and naive thought is given up not because it ceases to ring true, but because of an intuitive philosophical argument. The ‘who is to say?’ question is a philosophical question and seems to drive a conclusion that - like much philosophy - goes against what we had taken to be obvious. If that is so, it is a pity that disjunctivism isn’t more widely available since the worry Szasz implicitly trades on a form of the argument from illusion. I’d like to print out these passages from Sebastian Rodl’s book and hand them to all and sundry:

The argument (from illusion) is: Whenever I seem to know something (on the basis of perceptual. experience), I might have been fooled. Had I been fooled, I would not have known that I was. I would not have been able to tell my situation apart from one in which I am not fooled. This shows that my grounds do not place me in a position to exclude that I am in such a situation. They do not enable me to exclude that I am fooled. —The argument supposes that, had I been fooled, I would have believed the proposition in question on the same grounds on which I believe it now that I am not fooled. This straightforwardly entails that these grounds do not establish the truth of what I believe and therefore do not provide me with knowledge.
But when I know something on the ground that, say, I perceive it to be the case, then I would not, had I been fooled, have believed it on this ground, for, had I been fooled, I would not have perceived it to be the case. Hence, when I am not fooled, my grounds exclude that I am fooled: when I perceive how things are, I am not fooled with regard to how they are. One might object that this grants me grounds that rule out error at the price of making it impossible for me to know whether my belief is based on such grounds. For, when I am fooled, I do not know that I am fooled. So I can never know whether I am not fooled and my beliefs are based on grounds that [establish] their truth, or whether I am fooled and such grounds are unavailable to me.
This objection repeats the mistake: from the fact that, when I am fooled, I do not know that I am, it does not follow that, when I am not fooled, I do not know that I am not. When I know that p as I perceive it to be the case, then I know that I perceive that p. Thus I am in a position to distinguish my situation from any possible situation in which I would be fooled, for, in any such situation, I would not perceive that p, while in the given situation I do. [Rodl, S. (2007)Self-Consciousness, Cambridge, Mass.: Harvard University Press pp 157-8]

This is a good summary of disjunctivism in epistemology: the view that the epistemic significance of an experience is not restricted to what would be the highest common factor shared between a veridical experience and a mere illusion. There can be more to an experience than just an appearance, construed as merely as how things seem. It can be a matter of drinking in an aspect of the world itself. Rather than being limited to the highest common factor, experiences come in two distinct forms: Either, when all goes well, a taking in of how the world is. Or, when things go badly, a mere deceptive appearance. Hence ‘disjunctivism’. In the former case, experience is relational: a feature of the world itself forms part of the subject’s state.

Rodl’s passage makes two key points. First, in the good disjunct, one knows how one knows and hence, in the good disjunct, one can know that one knows (since how one knows is good enough because necessarily world-involving). Of course, had one been in the bad disjunct, one would have thought that one knew how one knew and that one knew but one would have been wrong on all counts: wrong that one knew (whatever fact about the world) and hence how one knew (it) and hence that one knew that one knew (it).

But, second, the fact that, in the bad disjunct, one does not know has no effect on the good disjunct. ‘[F]rom the fact that, when I am fooled, I do not know that I am, it does not follow that, when I am not fooled, I do not know that I am not’.

Disjunctivism helps highlight the real asymmetry in the case above. It is not that both clinician and patient have the same sort of cognitive state with the fact about Napoleon’s identity being an inaccessible extra. The real asymmetry in the case of the sane clinician and deluded patient is that one is right and the other wrong about who is and isn’t Napoleon.

How is experience supposed to be a positive reason for belief in Mind and World?

I’ve been working on final edits to the second edition of my book on McDowell and I’m increasingly confused by something that, surely!, should have bothered me much more in the past. It concerns the status of experience as a reason for belief, which is one of the most obvious features of the Mind and World account.

In the first version of my book, I took the following as a key statement of McDowell’s empiricism.

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]

This passage combines two key notions. First, experience has a conceptually articulated content. This is important because of McDowell’s assumption that rational relations connect only conceptualised relata. So if experience is to provide a rational friction on thought by the world it must be the case that experience is conceptually structured. Second, and following from that requirement, experience is, when all goes well, a form of direct openness to the world. This in turns leads to German Idealism because if experience is conceptually structured and is also, at best, a form of openness to the world, then the world, too, is conceptually structured. But I’m not worried about that bit today. Rather, it’s what I didn’t notice before because I focussed on the idea that experience couldn’t play this role unless it were conceptually structured. What I didn’t think about is how it could play a rational role even if it were so structured.

By contrast with later work, on the Mind and World picture, experiences contain the very same kind of propositional content as is contained in judgements and, further, in the specific judgements they can, when all goes well, rationalise.

A judgement of experience does not introduce a new kind of content, but simply endorses the conceptual content, or some of it, that is already possessed by the experience on which it is grounded. [McDowell 1994: 48-49]
Note that grounding need not depend on an inferential step from one content to another. The judgement that things are thus and so can be grounded on a perceptual appearance that things are thus and so. [McDowell 1994: 49 footnote6]

The link from experience to belief is not an inference. Elsewhere McDowell says:

In the conceptual activity I am mainly concerned with, that of making observational judgments, what matters is the rationality exemplified in judging whether things are thus and so in the light of whether things are (observably) thus and so. The content of the item in the light of which a judgement of this kind has its rational standing is the same as the content of the judgement itself. The only inferences corresponding to the rational connection in question would be of the “stuttering” form, “P; so P.” [McDowell 2009: 32]

So the connection between experience and subsequent full blown judgement is not an inference, unless of this vacuous stuttering form. So what is it? Experiences are not themselves perceptual beliefs. They need not be actively endorsed. There is a gap between experiences and active endorsements of them in judgements. So what kind of link is there between experience and judgement? The gap (to be bridged) is stressed in the following passage from Mind and World.

I said (§4) that when we enjoy experience conceptual capacities are drawn on in receptivity, not exercised on some supposedly prior deliverances of receptivity. And it is not that I want to say they are exercised on something else. It sounds off key in this connection to speak of exercising conceptual capacities at all. That would suit an activity, whereas experience is passive. In experience one finds oneself saddled with content. One’s conceptual capacities have already been brought into play, in the content’s being available to one, before one has any choice in the matter. The content is not something one has put together oneself, as when one decides what to say about something. In fact it is precisely because experience is passive, a case of receptivity in operation, that the conception of experience I am recommending can satisfy the craving for a limit to freedom that underlies the Myth of the Given. [McDowell 1994: 10]

If one goes no further than reporting one’s experience as containing the claim that things are thus and so, one still has to determine whether to endorse that claim oneself. If one endorses it, one claims to see that things are thus and so (if the experience is a visual experience). If not, one restricts oneself to saying it looks to one as If things are thus and so. In a “looks” statement, that is, one withholds one’s endorsement of the claim one reports one’s experience as containing. [McDowell 2009: 228]

Elsewhere he sets out Sellar’s account on which his own is closely based (in these regards, at least).

The conceptual episodes Sellars is concerned with, when he speaks of visual experiences as claims, are not as such cases of judging. Even if one does judge that things are as they look, having them look that way to one is not the same as judging that they are that way. In some cases, perhaps, one does judge that things are a certain way when look that way-acquiring the belief that they are that way by freely up one's mind that they are that way. But more typically, perceptual belief-acquisition is not a matter of judging, of actively exercising control over one's cognitive life, at all. Unless there are grounds for suspicion, such as odd lighting conditions, having it look to one as if things are a certain way-ostensibly seeing things to be that way becomes accepting that things are that way by a sort of default, involving no exercise of the freedom that figures in a Kantian conception of judgment. So there is a disconnection between perceptual experience and judging. [McDowell 2009: 11]

As in the key statement from Mind and World I quoted above, this passage suggests that experiences have a content, contain a claim (or rather many claims), that can be endorsed in a judgement. They share the same content, the sort of thing that could be put forward as a claim. That is what the idea of experience as conceptually structured buys for McDowell. But how does an experience provide a positive reason for a judgement? The following passage, which starts with an example that emphasises the distinction between experience and belief, also contains a suggestive metaphor.

Consider a person who thinks her visual experience does not put her in a position to say how things are in some respect. But she later realizes she was wrong about that, and says something on these lines: I thought I was looking at the tie under one of those lights that make it impossible to tell what color things are, so I thought it merely looked green to me, but I now realize that I was seeing it to be green… Our subject accepted the less committal proposition, but having an impression is not to be identified with accepting such propositions, any more than it is to be identified with accepting the more committal proposition that constitutes the impression’s content. An impression is something like an invitation—a petition, as Robert Brandom puts it in his contribution to this volume—to accept a proposition about the objective world. Our subject refused the invitation, but responded to it to the extent of accepting a proposition about how things looked to her. But one need not respond, even to that extent, to the invitation to belief that an impression is. [McDowell 2002: 278]

I mis-remembered Mind and World as also using the idea of experience as invitation to believe but I do not think it does. It’s here in the later collection Reading McDowell [Smith 2002]. McDowell’s response here is to a challenge Barry Stroud issues.

McDowell nonetheless puts his problem of how experience can give rational support to empirical judgments as that of accounting for “the way appearances can constitute reasons for judgements about objective reality” (p.62). His answer appeals to “rational relations” between experiences and the judgments about the world that we make on the basis of them (p.52), and he appears to think of those relations as holding between the contents of the experiences and the beliefs (p.166). “Because it looks square,” he says, is “easily recognized” as giving a reason to believe “It is square” (p.165); it is the person’s reason for believing that the object is square. But is it recognized as a reason because we discern a certain “rational linkage” between the content of the experience and the content of the belief? I think the content of an experience alone cannot give a person reason, or be a person’s reason, to believe something. The content of an experience is typically expressed in a proposition, and propositions are not reasons, nor do they make other propositions reasonable. Propositions are true or false, not reasonable or unreasonable, justified or unjustified. Even if one proposition implies another, it does not justify, support, warrant, or make reasonable that other proposition. What is justified or reasonable or supported or warranted is a person’s accepting a certain proposition, or rejecting it, or taking some other attitude toward its truth. [Smith 2002: 89]

McDowell’s response to this worry includes the following thought:

Stroud writes: “‘Believe’ is perhaps not the best word to capture the attitude of acceptance or endorsement involved in perception, especially if it suggests actively making up one’s mind.” But my problem with the suggestion is not met by insisting, correctly enough, that belief-acquisition can be involuntary. My problem is that I think we need an idea of perception as something in which there is no attitude of acceptance or endorsement at all, but only, as I put it, an invitation to adopt such an attitude, which, in the best cases, consists in a fact’s making itself manifest to one. [McDowell 2002: 279]

I don’t know why this didn’t seem baffling to me before. Before repeating the metaphor of invitation, McDowell here stresses: “I think we need an idea of perception as something in which there is no attitude of acceptance or endorsement at all”. He needs that because experience is supposed to be what provides the grounds for perceptual beliefs and thus cannot simply be – cf Davidson's experience-free picture of justification – a full blown perceptual belief itself. But now, if it is anything less than accepting a claim – which is what is supposed to follow from the experience, not be the experience – what less than that would have any rational sway on subsequent belief at all? An invitation would have to be one which had a good chance of being accepted, not just one of a set of contradictory invitations found on the doormat of a popular socialite. It must be more than just some sort of hypothetical content, such as the antecedent to a conditional. It must be more than just the claim that could be made using a sentence. As Charles Travis puts it:

An English sentence is not in any way committed to things being some one way rather than another. It does not pretend, or purport, that that is how things are. If one understands the English sentence ‘Pigs swim’ one thereby has it on no authority at all that that is how things are. It would be a gross misunderstanding to see English as thus saddled with such a preposterous collection of contradictory commitments. [Travis 2004: 61]

I’ve always focused on the account of how experience might have the right sort of shape to carry a claim that could be endorsed in a subsequent judgement: its having a conceptual articulation modelled on Sellars’ Myth of Jones (according to which we just should not be worried about states containing claims modelled on explicit judgements). But I’ve insufficiently worried about how it was ever supposed to provide reason for that judgement. Of course, this is the focus of that Travis article: to say that there’s no logical space for a notion of representation that does what McDowell needed it to do. But it had not occurred to me until now how little McDowell ever offered by way of an account of the evidential or rationally compelling status of the content supposedly contained in an experience on subsequent judgement. Unless the experience is in some partial sense always already endorsed, what weight can it carry for subsequent judgement?

The decisive moment in the conjuring trick looks to be stressing how the same content can be both contained in an experience and also endorsed in a judgement, not saying why the experience provides any reason at all to do that.

McDowell, J. (1994) Mind and World. Cambridge, MA: Harvard University Press.
McDowell, J. (2002) ‘Responses’ In Reading McDowell, N. Smith (ed.), 269–305. London: Routledge.
McDowell, J. (2009) Having the World in View. Cambridge, MA: Harvard University Press
Smith, N. (ed.) (2002) Reading McDowell. London: Routledge
Travis, C. (2004) ‘The Silence of the Senses’ Mind, 113: 59–94.

Spandrels as counter-examples to evolutionary-theoretic accounts of mental disorder

Because of the debate in one of the modules of the Philosophy and Mental Health Programme we teach, Gloria and I fell into discussion of spandrels as part of a critique of evolutionary theoretic approaches to the concept of mental illness, disease or disorder.

One example of implicit reference to this is in a discussion of Boorse by Elselijn Kingma in Analysis. She comments:

A final interpretation of design as Nature’s intent is closely related to ‘natural’. This should capture the idea that Nature intended there to be men and women, but it did not intend blind people. The latter are an accident, perhaps a ‘freak of nature’. Since I, and I suspect Boorse, reject an appeal to intelligent creation, the most obvious place to justify an appeal to design or Nature’s intent is evolutionary biology. This is not an attractive position for Boorse, however, who explicitly rejects the idea that evolution is relevant to physiological function and health (1976: 85). To evaluate this solution in detail goes beyond the scope of this paper, but if, as I suspect it must, this solution appeals to a difference between polymorphisms that are maintained by natural selection, such as eye-colour and sex- differences, and polymorphisms that are not maintained by natural selection, such as heart-defects, then it must at the very least dispose of the following problem. It must give a non-question begging account that explains why certain traits that are maintained by natural selection, such as sickle cell-anaemia, are nevertheless diseases. Since natural selection can enter into the explanation of both diseased and healthy traits (Sober 1980), this seems neither easy nor obvious... [Kingma 2007 italics added]

One of our students expressed the following eminently reasonable worry (in fact three good concerns) about the appeal to sickle-cell anaemia as a potential counter-example.

The reference to sickle-cell anemia isn’t entirely convincing to me. For one, this seems to be a fairly unique example, which is often the sole reference (at least that I’ve heard) for this type of argument about nature selecting disease. While, yes, one example is enough to disprove a general theory, are there any other examples of this conflict? I have a hard time thinking of conditions exactly like sickle-cell in this way, though there are certainly no shortage of traits originally selected by evolution which have become maladaptive in our present environment (insatiable hunger, metabolic problems, our capacity for salt-retention and resulting hypertension). The other argument I can see is that it’s actually sickle-cell trait (heterozygous allele) which has been selected by evolution; sickle-cell disease (homozygous allele) may be understood as an unfortunate consequence of that selection.

The problem for an evolutionary-selective account that Kingma flags stems from the thought that some things are maintained by natural selection but are nevertheless diseases. And hence the norm of maintenance by natural selection cannot be the norm whose failure is being tracked by, and hence sheds light on, intuitive judgements of illness, disease and disorder.

It seems to me, however, that this is rather the point of spandrels in thinking about natural selection. Spandrels are features maintained by natural selection. In other words they are selected. But they are not selected-for: the spandrel does not possess a function that would be appealed to in giving a natural selective explanation of fitness. This is implicit in our student’s comment that it is the ‘sickle-cell trait (heterozygous allele) which has been selected by evolution; sickle-cell disease (homozygous allele) may be understood as an unfortunate consequence of that selection’. It seems to me that this isn’t quite right. It is the sickle-cell trait (heterozygous allele) which has been selected-for by evolution. The sickle-cell disease (homozygous allele) is the spandrel: a feature selected but not selected-for. It occurs and is maintained because of the former and some biological laws and laws of probability, I imagine. Maintaining is thus disjunctive: occurring as either what is selected-for or what is selected but not selected-for.

This suggests that the misstep was to think of the relevant norm for assessing disease as being maintenance, instead of function or selection-for. But it leaves open whether, nevertheless, a spandrel such as sickle-cell anaemia serves as a counter-example to a general evolutionary-theoretic approach to disorder. It would, if there is no way to answer the challenge Kingma raises: It must give a non-question begging account that explains why certain traits that are maintained by natural selection, such as sickle cell-anaemia, are nevertheless diseases.

But it seems to me to be plausible that there are resources available to evolutionary theorists if they alter their gaze. Sickle-cell anaemia (homozygous allele) counts as a disease because it produces dysfunctions in the cardiovascular system. Short lived, too large red blood cells cannot perform the functions that explain, in natural-selective terms, the existence of the cardiovascular system. It is because of its effect on the performance of this that sickle-cell anaemia counts as a disease. Hence there are two natural selective characterisations in play: the disease is maintained as a spandrel because it rides piggy back on the heterozygous allele, which confers selective advantage in, let’s call it, the malaria-protecting system but itself, in the form of homozygous allele, is biologically dysfunctional in the cardiovascular system. One explains its prevalence; the other its disease status.

If so then it seems that spandrels can be accommodated without counting as counterexamples. The norm of disease might still be natural selective dysfunction as far spandrels are concerned. It is another question, however, especially in the case of mental illness whether there is a principled and non-question-begging method to pick out functions, spandrels and dysfunctions without merely relying on antecedent assumptions about what is and is not an illness, disease or disorder.

Kingma, E. (2007). What is it to be healthy? Analysis, 67, 128–133

The subject matter of the new Centre for the Study of Compassion

Today I went to the launch at UCLan for the Centre for the Study of Compassion including a memorial lecture by the new professor, Patrick Pietroni (pictured) on ‘What does a compassionate university look like?’ And then a talk by John Ballatt on the Darwin International Institute for the Study of Compassion (DIISC) scholarship programme.

The Centre’s key research areas include:

• the role of compassion in health and wellbeing 
• compassion in education and organisations 
• mentoring and compassionate leadership 
• mediation and compassionate approaches to justice 
• the role of compassion and cooperation in establishing sustainable communities

The mood or tone of both of today's talks was on the multidisciplinary basis for the proper study of compassion (and hence, too, an emerging DIISC network). Patrick Pietroni pointed out that compassion might be proximal, in the response to the needs of someone present (raising a question of the psychology why some such appeals command compassion and some do not) or distal. His talk stressed the latter, giving a number of examples of projects which helped people. In one, processes to aid the resettlement of refugees cut the time they spent in cramped B&B hotels in London from 24 to 6 months. Another subtly linked (through representations of where everyone lived shown in a communal room) isolated elderly in high rise accommodation with similarly housed single parents such that they came to support each other. The stress was on practical general strategies or systems to produce good effects. It did not matter whether anyone had had any personal I-thou feelings to those who partook of the systems. One simply had to think through, accurately, their needs.

Both he and John Ballatt also stressed the multitude of disciplines on which any study of compassion should draw, in the former’s case connecting theology’s focus on the golden rule, anthropology on pro social behaviour, social science and the spirit level, psychology on imprinting and empathy, the biology of altruism and its genetic explanation via completion, neurology’s interest in mirror neurones etc. Various disciplines could feed their perspectives into a spectrum of foci from the personal, to the social, to the environmental which in turn would feed into interventions in quite distinct areas (eg mentoring in the NHS, compassionate universities etc).

I couldn’t help wondering, though, what kind of placeholder ‘compassion’ was. For example, would it matter whether a system with sufficiently virtuous ends was ruthlessly efficiently run by soulless bureaucrats? And how would that relate, say, to the Biblical widow generously but practically uselessly donating her mite? Once compassion can take as its focus the mindless environment, is it clear that this is the same virtue as that involved in fellow-feeling? If it can be elicited from listening to the fourth movement of Mahler’s Fifth Symphony (singled out by Pietroni), how does that compare with practical effectiveness, as the systems approach emphasised?

By the end, I half wondered whether ‘compassion’ played the same role as ‘quality’ does in Zen and the Art of Motorcycle Maintenance. Some thing, or property, or virtue that always lies on both sides all the many distinctions mentioned today. If so, does that matter providing some tacit grasp of the good is shared and communicated by examples rather than flowing from some more explicitly univocal concept?

Univie Summer School on Philosophy and Psychiatry

Call For Application (Deadline: February 15, 2019)

PHILOSOPHY AND PSYCHIATRY

Univie Summer School – Scientific World Conceptions (USS-SWC) July 1–12, 2019

The Univie Summer School – Scientific World Conceptions (USS-SWC) – until 2014 under the label "Vienna International Summer University" – will be held from July 1 to 12, 2019. The topic of the two-week course is „Philosophy and Psychiatry“ The main lecturers are Rachel Cooper (Lancaster University), Dominic Murphy (The University of Sydney) and Tim Thornton (University of Central Lancashire).

As an international interdisciplinary program, USS SWC brings graduate students in close contact with world-renowned scholars. The program is directed primarily to graduate students and junior researchers in fields related to the annual topic, but the organizers also encourage applications from gifted undergraduates and from people in all stages of their career who wish to broaden their horizon through crossdisciplinary studies of methodological and foundational issues in science.

The topic of the two-week course is „ Philosophy and Psychiatry “:

By its very nature, psychiatry – the medical specialism devoted to mental healthcare – raises as many conceptual as empirical questions. The philosophy of psychiatry is a rapidly emerging field which draws broadly on philosophical traditions – centrally analytic philosophy and phenomenology – to address a range of questions as broad as the demands made on psychiatry to address problems of human suffering, distress and disorder. It is also an area where philosophical methods, accounts and theories can be applied to and thus tested against psychiatric and psychopathological phenomena. But at its heart lies the question of whether, since psychiatry sees itself as part of medicine, the medical conceptualisation of illness and disease can be articulated in such a way that it properly applies to the distinct ‘problems of living’ that psychiatry addresses in response to the crisis of legitimacy often raised. This summer school will address a number key questions which impact on mental health care.

Application form and further information: http://www.univie.ac.at/ivc/SWC/

The Main Lecturers:

Rachel Cooper (Lancaster University) http://www.lancaster.ac.uk/people-profiles/Rachel-Cooper

Dominic Murphy (The University of Sydney) https://sydney.edu.au/science/people/dominic.murphy.php

Tim Thornton (University of Central Lancashire) https://www.uclan.ac.uk/staff_profiles/prof-tim-thornton.php

Guest lecturer:

Raffaella Campaner (Università di Bologna) https://www.unibo.it/sitoweb/raffaella.campaner/en

USS-SWC operates under the academic supervision of an International Program Committee of distinguished philosophers, historians, and scientists. Its members represent the scientific fields in the scope of USS-SWC, make contact to their home universities and will also support acknowledgement of courses taken by the students. USS-SWC is organised every year by the Institute Vienna Circle of the University of Vienna. http://ivc.univie.ac.at/ http://www.univie.ac.at/ivc/ http://wienerkreis.univie.ac.at/

Opening

Venue: Kapelle, Institut für Ethik und Recht in der Medizin, Campus der Universität Wien, Entrance 2.8

Time: Monday, July 1, 2019, 9 a.m.

Further Information www.univie.ac.at/ivc/SWC

Since 2010 USS-SWC is a part of the curriculum of the doctoral programme "The Sciences in Historical, Philosophical and Cultural Contexts" http://dkplus-sciences-contexts.univie.ac.at/

There is an exchange programme with Duke University (North Carolina): http://international.univie.ac.at/outgoing-students/non-eu-student-exchange-program/kom-2-bewerbungsunterlagen/

For further inquiries, please send email to martin.kusch@univie.ac.at or consult the IVC's Web site

Inquiries:

Organisation:
Robert Kaller
Institute Vienna Circle
Spitalgasse 2-4, Hof 1, 1090 Wien ivc@univie.ac.at
Tel. +43-1-4277-46504

Scientific director:
Prof. Martin Kusch
Department of Philosophy
University of Vienna martin.kusch@univie.ac.at

Idiographic Approach to Health

Idiographic Approach to Health

Edited by:
Raffaele De Luca Picione, University of Naples Federico II
Jensine Nedergaard, Aalborg University
Maria Francesca Freda, University of Naples Federico II
Sergio Salvatore, University of Salento
A volume in the series: Yearbook of Idiographic Science. Editor(s): Sergio Salvatore, University of Salento. Jaan Valsiner, Niels Bohr Professor of Cultural Psychology, Aalborg University.
In Press 2018
The concept of health is a challenge of great complexity in terms of theoretical, methodological and intervention within the idiographic frame.

Health cannot be considered an abstract condition, but a means, a resource aimed at achieving objectives that relate to the ability of people to lead their lives in a productive way - individually, socially, and economically. Health is a process that is not based on the definition of standards and categories on the basis of which typifying the states of health. Rather, it has to be considered a process, on a large scale and on many entangled levels, aimed at generating a culture of the health as a resource for individuals and communities and to promote skills needed to transform these resources into developmental goals.

The notion of health, indeed, defined and interpreted in terms of "state" and not of process, meets the immediate paradox of being an indicator of normativity by reason of which we risk a proliferation of new and potentially infinite forms of "deviation". The approach of the idiographic sciences (see previous volumes of the Yearbook Idiographic Science Series, by same publisher IAP) considers that every psychological process (but in general every process, from organic to the social and cultural ones) is characterized by a contextual, situated and contingent dynamics. That dynamics is always characterized by a never-ending opening of its cycles and great variability. Conditions of stagnation and hypostatization are characteristic of all forms of disease (physical, mental and social) that sclerotize relational links between people and their environments. Health is therefore a process that presents oscillation in the same way of any developmental process that has moments of crisis and rupture in order to re-organize new forms of relationship with the social and cultural environment.

This book represent a fruitful way to deep many cogent issues and to dialogue with an idiographic perspective in order to discuss the concept of health, to define its cultural meanings and possible polysemy (e.g., wellness, care, hygiene, quality of life, resilience, prevention, healing, deviation/normality, subjective potentiality for development, etc.), its areas of pertinence and intervention (somatic, psychological, social) trying to offer possible alternatives to the "normalization" of health and creating new incentives for the reflection.

CONTENTS
Series Editor’s Preface: Health: The General in the Unique, Jaan Valsiner. Health: A Current Challenge for the Idiographic Sciences, Maria Francesca Freda, Raffaele De Luca Picione, Jensine. Nedergaard, and Sergio Salvatore. SECTION 1: THE DYNAMIC CONSTRUCTION OF BORDERS BETWEEN HEALTH AND ILLNESS SECTION 1.1: CRITICAL ANALYSIS OF THE HEALTH NOTION. AN IDIOGRAPHIC LENS ON THE TOPIC. DIFFERENT PATHS BETWEEN GENERALIZATION AND IDIOGRAPHY. Five Inconsistencies in Scientific Discourse, Sven Hroar Klempe.The Enigmatic Soul of Health: From Balance to Inscape, Robert E. Innis. Values and the Singular Aims of Idiographic Inquiry, Tim Thornton. Psychopathology: Mental Illness and Relationship Between Idiography and Health: The Case of Transsexuals’ Experience, Roberto Vitelli. SECTION 1.2: HEALTHCARE RELATIONSHIP AND POSSIBLE FUNCTIONS OF IDIOGRAPHIC APPROACHES.Crisis of Medical Institution: An Idiographic Approach, Annalisa Venezia and Chiara Marangio. From Medicalizing Discourse to Situated Practices. From Reification to Semiotization of Processes of Sensemaking: The Function of Psychological Scaffolding in the Experience of the Disease Within the Healthcare Relationship, Raffaele De Luca Picione, Francesca Dicé, and Maria Francesca Freda. Communicative Partnership Between More Than Two: When a Child Becomes a Patient, Jensine Ingerslev Nedergaard and Elise Snitker Jensen.SECTION 1.3: THE CARE OF SOCIAL CONTEXT. THE EXTENSION OF IDIOGRAPHY TO WIDER FRAMES. Growing up in the Suburbs: Stories of Adolescents at Risk and of Their “Maestri di Strada”, Santa Parrello. The Generational Shift in the Family Business: Defining the Condition to Plan the Intervention, Barbara Cordella and Assunta Capasso. SECTION 2: NARRATIONS OF HEALTH AND ILLNESS SECTION 2.1: THE NARRATION OF THE UNSPEAKABLE. HEALTH AND ILLNESS IN ONE’S OWN EXPERIENCE. Disquieting Experiences, Borders, and Healthcare Processes, Lívia Mathias Simão and Giuseppina Marsico. “I Get Along Without You...”: On Billie Holiday, Clichés and Psychological Truth, Yair Neuman.Lessons of Pathosophy—And Implications for Medical Care, Elin Håkonsen Martinsen. SECTION 2.2: THE MODELLING OF NARRATIVES PROCESSES IN THE CLINICAL CONTEXT. Narrative Functions to Support the Meaning-Making Process During Cancer Traumatic Experience in Pediatric Oncology, Maria Luisa Martino and Maria Francesca Freda. The Power of Self-Narratives in Health, João Tiago Oliveira, Miguel M. Gonçalves, João Batista, and Adrián Montesano.Commentary: The Enchantment of Stories, Luca Tateo. SECTION 2.3: THE IDIOGRAPHIC CHALLENGE OF NARRATIONS IN THE RESEARCH PROCESSES. The Idiographic Science Perspective Applied to the Treatment of Younger Women with BRCA Mutation, Emanuela Saita, Sara Molgora, and Chiara Acquati. Risk and Prevention: Women’s Experiences of Barriers to Cancer Screening, Daniela Lemmo and Adele Nunziante Cesàro. The Role of Narrative in Promoting Changes in Illness Transitions of the Life-Span: An Idiographic Approach, Andrea Smorti and Chiara Fioretti. Author Biosketches.

Dialogues in Philosophy, Mental and Neuro Sciences – Volume 11, Issue 1 (June 2018)

“Dear Colleague,

I'm pleased to inform you that the new issue of the international online journal Dialogues in Philosophy, Mental and Neuro Sciences has been published, it is freely readable at:

www.crossingdialogues.com/current_issue.htm

Volume 11, Issue 1, June 2018

ORIGINAL ARTICLES

M. Aragona
The influence of Georg Simmel on Karl Jaspers' empathic understanding (Verstehen)

M. Aragona et al.
Translation and cultural adaptation of the Arabic version of the List of Migration Experiences (LiMEs)

A. M. Petta et al.
Cultural adaptation of the Lifespan Memory Interview in the Asylum Seekers (LMI-AS)

NEGATIVE EXPERIMENTAL RESULTS

V. Pettinicchio et al.
Unaccompanied foreign minors victims of violence: a comparison between new and old arrivals in Rome

HISTORY OF MENTAL CONCEPTS

M. Aragona

Causal understanding: Max Weber and the interpretation of human actions

DIALOGUES

R. Henman
A Response to Maung's Commentary on Moreira-Almeida and Araujo

Dialogues in Philosophy, Mental and Neuro Sciences proposes and includes Original Papers, Negative Experimental Results, History of Mental Concepts, New Ideas and Dialogues, as described in the guidelines for the authors.

Would you like to write a Dialogue? It is a short article (up to 600 words) freely published and without any deadline commenting another article already published on the previous issues of our Journal.
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Simplicity in writing and thinking

I’ve been having a short email discussion of writing with a correspondent from East Molesey. I had suggested that, when reading fiction, I do not positively enjoy good style. Rather, I merely dislike bad style, which sticks out and is obtrusive.

(Cf: Again, our eye passes over printed lines differently from the way it passes over arbitrary pothooks and squiggles. (But I am not speaking here of what can be found out by observing the movement of the eyes of a reader.) The glance slides, one would like to say, entirely unimpeded, without becoming snagged, and yet it doesn’t skid. [Wittgenstein 1953 §168])

Good prose, I suggested, is invisible. And hence, one mistake I had made in one co-authored philosophy piece was picking a co-author who had substantial style aims. I, I suggested (obviously naively), had had none except to render myself invisible.

East Molesey replied “Odd that you think you don’t / should not show in your writing. Perhaps you view what you are doing as letting the ideas and arguments do the work and not your words and your thinking - curious if so!”

Putting this response aside I then stumbled across an article from a week ago in the Guardian on ‘How to write a great sentence?’.

The article raises, and flags some complications in, the issue of why one might aim for a simple writing style.

One very natural way to think of all this is as writing or language as a code for prior thought. One thinks the thought and then finds the right and simplest words with which to express it. Wittgenstein comments about a French politician who thought that French was unique as the only language in which the word order is the same as the order of concepts in thought.

This case is similar to the one in which someone imagines that one could not think a sentence with the curious word order of German or Latin just as it stands. One first has to think it, and then one arranges the words in that strange order. (A French politician once wrote that it was a peculiarity of the French language that in it words occur in the order in which one thinks them.) [Wittgenstein 1953 §336]

Wittgenstein suggests some exercises of saying a sentence while thinking the thought, saying one without thinking the other and thinking the other without saying the first. His suggestion seems to be that the thought is in the words not prior to them. He also draws an analogy with the interdependence of notes and their expression in music.

But if so, what of the strange sentence discussed in the Guardian article attributed to Kate Moss: "Nothing tastes as good as skinny feels"? Suppose one thinks that the way those words are used is odd. The article provides a reason to think so. It says:

Skinny, usually an adjective, is here turned into an abstract noun, paired with another abstract noun, nothing. And yet skinny is also quasi-concrete, because where it lies in the sentence suggests that it can actually be felt, just as food has a taste. But feels also retains its non-sensuous sense of intuiting or experiencing something: skinny feels good. As the sentence ends with the snap of a stressed syllable, our perspective has been altered in a way that feels true, even if we don’t share the sentiment. Reality has shifted a little and then clicked back into place.

If the words are used in some strained (by contrast with normal), novel and non-standard context, then what thought was expressed - oddly - by those words in this non-standard way? What would be the underlying thought stripped of the odd way of putting it? (If that sentence is not weird enough, one can always ask it of one that more obviously is.)

Following the line of thought in John McDowell's account of Davidsonian truth theories, I think the only way to state the thought expressed with words oddly used is with the very same words used in the same odd way. The sentence "Nothing tastes as good as skinny feels" states that / means / is true iff nothing tastes as good as skinny feels.

One has to have ears to hear the second part of that long sentence in the right way. Truths about meaning require the right audience. So I'd say, in response to the question my correspondent asked: the ideas and arguments should/do indeed do the work as expressed in the words and thoughts. Preferences about style are preferences about thinking and thoughts.

The Guardian article goes on to note the way that linking words are much less used to carry implications from one sentence to the next now compared to the past.

Sentences have become less shackled to each other. Those written a few hundred years ago typically began with a whereof or a howsobeit, to resume an unfinished thought. And they used lots of conjunctive adverbs, those connecting words like moreover, namely and indeed. Such adverbs are in historical retreat. The use of indeed peaked in print in the 18th century and has been declining ever since. The number of howevers and moreovers has been falling since the 1840s.

That raises a nice related example. Imagine we had a two sentences or thoughts:

• Nothing tastes as good as skinny feels.

and

• Don't eat that Yorkshire pudding! 

(It doesn't matter that this is an injunction. One might say: no one should eat the Yorkshire pudding. But an injunction makes the normative nature of the inference more explicit.)

In the past (if the history in the article is correct), we might have written or said, with a suitable connection:

• Nothing tastes as good as skinny feels. So, don't eat that Yorkshire pudding!

Despite the word 'so', the reader still needs to see the force of the connection from the previous sentence to the new next one (So, don't eat that Yorkshire pudding!). We might worry about this and decide to flag the connection. "So, don't eat that Yorkshire pudding!" follows from the previous sentence. The whole thought involves a movement from the first sentence through to the end of the second.). What better to flag this than the word 'so'?! Hence:

• Nothing tastes as good as skinny feels. So, so don't eat that Yorkshire pudding!

But now the following thought should come just as naturally. Despite the word 'so' appearing at the start of the second sentence, the reader still needs to see the force of the connection from the previous sentence to the new next one. What better to flag this than the word 'so'?!

etc.

Just as we might need eyes to see or ears to hear the words used as they are in Kate Moss' sentence, so we need eyes to see or ears to hear how one sentence is a reason for the next, to grasp the whole thought expressed. The style and the thought say, and need to say, the same.

Launch of wikiVBP: the Values-based Practice Reference Library

"Launch of wikiVBP: the Values-based Practice Reference Library

We are delighted to announce the launch of this new resource for values-based practice

Our thanks to everyone who has contributed to the library thus far and in particular to the VBP Librarian Michael Loughlin for all his hard work on the project

The library is a wikiVBP library because we depend on your contributions to make it work

For further details including How to Use the library and How to Contribute to the Library please CLICK HERE

The Collaborating Centre for Values-based Practice in Health and Social Care
St Catherine's College
Manor Road Oxford,
Oxford
OX1 3UJ
United Kingdom"

Postscript on the bare presence of artistic intention

Wandering round the Boulder Museum of Contemporary Art today there were some large bold abstract images by Roberto Juarez. The curatorial blurb, however, revealed that the abstract images were partly based on found objects and images. Further, the larger painted works were based on smaller designs which themselves had super-imposed grid lines to enable the construction of the larger works. These smaller designs, which were also on display, comprised collages including - it seemed - images from magazines and objects.

Putting this through the Scruton machinery, the existence of a feature in the larger painting was determined by a corresponding element in the smaller ‘scrap book’ as then carefully and apparently faithfully rendered in paint. Its being there was a combination of direct authorial intention in the application of brush strokes - though even here I’m sure such subsidiary elements were merely left to sub-personal motor-intentional capacities - and what had happened to present itself in magazine pages that morning (let’s assume). If on Scruton’s account, the only art in photography is the theatrical arrangement of elements, then in Juarez’ case, most of the art is in good scrap-booking.

I found that I preferred to forget all about this origin story and pretend that the finished works had fallen fully formed from Juarez’s imagination.

Holiday thoughts of life-style upgrades

I’ve never understood why but, while on holiday, I’m often drawn to thinking about how it would be possible to make the rest of my life rather better: to achieve a ‘life-style upgrade’. This is such a trope of holiday thinking that it’s hard to unpack it, to think about its conditions of possibility. But I think I can see one element this time.

There has never been much point in life-style upgrade thinking while, say, backpacking. Then, I just want to stop having to carry the rucksack or to sleep on the ground. Or, while in particularly stifling 40C temperatures in Thailand, I told Lois, crossly, that, if I ever said I had enjoyed that trip, she should remind me of how, exactly, I’d felt in *this* moment. Life-style upgrade as mere return to ordinary comfort.

So the trope attaches to a particular kind of holiday. And today it seems obvious. I holiday as an attempt to realise the Platonic ideal of an enjoyable life, which is merely poorly approached in the rest of my life. That’s the reason why a holiday might be thought - perhaps mistakenly - to speak to ordinary dwelling. It’s the reason why the holiday experience might seem so much as relevant to anything more general but also why it might have a kind of jurisdiction over the everyday, as opposed to being an irrelevant excursion from Kansas.

So here I am in Boulder, Colorado, to maximise: hiking up mountains, morning jogs along the creek, off-road running, the charms of a university city, good coffee, a ridiculous concentration of micro breweries. And in this milieu, it seems reasonable to ask: what of this should I take back to Blighty?

This thought, though, helps to clarify something about how such a thought even makes sense. I’m comparing the holiday lifestyle with the domestic. One might say that my home town Kendal is a partial and poor exemplification of the Platonic ideal that is - or is not so much beyond - Boulder. The norm of lifestyle assessment is the same: here and there. Both are towns just outside the mountains. Both have growing coffee, beer, artsy culture. It’s just that Boulder is rather better at it at the moment. But this helps rationalise something closer to home.

Kendal’s biggest recent political dispute has been the removal of long-standing informal free parking on a scruffy bit of land by the river and its replacement with an extra bit of green grass and the joining up of a cycle lane. Those supporting the retention of the carpark forced a ballot and, fearing that they would be organised and others would not be, I emailed local friends to tell them about it, simply assuming everyone would share my views on losing the ugly carpark and establishing the cycle path. Fortunately for me, the ballot proposers lost badly. But one of my friends expressed thanks afterwards for the reminder saying that had she been around at the time she would have loved to vote because it had been such a useful carpark. I replied with some practical alternatives but I realised that I could not guarantee that she would never suffer occasionally having to pay to park in Kendal.

I realised, however, that this bit of rational friction gave me an insight I’d failed to have. I wasn’t voting on practicalities at all. Rather, I was voting as a piece of groundless aspiration. I don’t know how inconvenient even for me the loss of a car park will be, nor how helpful a bit of extra cycle path might be, especially given that truly local Kendalians, as opposed to offcomers, have not really taken to cycling. The existing cycle paths are embarrassingly empty. But my correspondent was making a judgement that would seem right for any other North Western post-industrial town. One might dispute the value of carparks over parks and vote practically for a ‘really useful’ carpark. Whereas, whatever the practical utility, I want my adopted hometown to approach a Platonic ideal of a good place to live. I want it to be a Boulder while my correspondent assumes (not falsely) that it’s more of a Burnley.

The bare presence of artistic intention

The chance juxtaposition of two art galleries next door in Denver: the remarkably fine Clifford Still gallery and the modern art gallery showing an exhibition of landscape photography, forced me again to rethink photography.

So the Clifford Still gallery is a testament to the artist’s confidence in his own importance and, strangely, I came away thinking he was probably right. The confidence lay in his reluctance to sell his own work and his resistance to being included in exhibitions merely as one among many. His view was that only in single artist exhibitions was there a way to understand the art, the unifying vision etc. And hence in a strange description of his working practice on one of the gallery walls was, as a final step, that the work was rolled up for storage. Not packed off to a gallery or a private buyer. But hence there was an enormous body of work ready to be presented to any city willing to establish a gallery devoted solely to him (hence Denver).

More substantially, however, was the gallery’s case for his key role in the establishment of a distinctive form of American Abstract Expressionism. Helpful placing showed the gradual removal of realism while retaining increasingly abstract elements originally derived from, say, the human form or the sun or moon. For my point here, the key leitmotif was that everything was deliberate. Clifford Still knew what he was doing.

After a beer and now in the landscape photography exhibition of the adjacent gallery and I was baffled as to what game was being played. In one series of pictures, landscape photographs had been developed onto material (lace and burlap) and then buried in then ground for some months to decay and the results displayed. In another, radioactive soil from Fukuyama had been placed on photographic paper. In a third, ancient photographic paper had been dipped in developer in such a way as to give an impression of hills. None of this began to engage me but what seemed more embarrassing was that I seized on a large photograph of a breaking wave, frozen in time, as having something worth staying for. How mortifying to be entranced by something apparently simple in conception even if hugely difficult to achieve: photographic realism.

Roger Scruton (not a philosopher I ever otherwise cite) argues that photography isn’t art because it is not true that the reason for the presence of elements in a photograph is primarily dictated by the photographer’s intention. Elements in the picture are there primarily because they were there in the scene photographed. Hence the only art, according to Scruton, is the art of theatre in arranging or selecting the tableau to be pictured. My qualm about the experimental use of photographic material and methods seemed to be not that this freed the artists from Scruton’s criticism by injecting non-realist intention. Rather, it threw away the guidance of any vision in the process. The ethos seemed instead to be a random experiment to see what happened when, for example, photographs were buried in the ground. But who cares? The result seems to render pointless any attempt to think through the pictures akin to how I’d react if I knew the poem on a lecturer’s board simply replicated Stanley Fish’s famous aesthetic experiment.

It turns out that I cannot escape the lure of a kind of Myth of Presence, in this case, of the artist’s intention. It seems I am reassured to know that there’s something going on for a reason. I feel somewhat ashamed of this but there it is. How very pre-post-modern.

Some speculation about Piaget on schemata and Wittgenstein

One of the better aspects of academia is getting interesting emails asking questions. An ex student, John, asked me this the other day.

“Hi Tim,

I understand that Wittgenstein maintains the correct use of a word will always presuppose our ability to use it. i.e. there is no separation between concept and ability to apply it. This made me think about Jean Piaget’s ‘schema theory’ involved in child development. As infants learn to interact with their environments, they develop mental schemata which assimilate objects from the environment. A schema might be learning to grasp and, by assimilating a toy into this schema, the child is able to pick it up. Piaget was confident that the child repeats and practices schemata before their successful use in assimilation. Schemata which fail to assimilate in the intended way are subsequently revised. He also maintains that this way of learning is maintained throughout development and into maturity.

On Piaget’s account, language would classify as symbolic schemata, where a given word will have its schema as anticipatory knowledge of the external environment. Initially, this makes me think that Piaget advocates a method of empirical judgement that easily falls foul of [Wittgenstein’s] regression [of interpretations].

Trying to find compatibility between Wittgenstein and Piaget, I’d be tempted to suggest that a word-schema lacks meaning for the child (even though he/she may know the sound of it etc.) until it is correctly applied and accurately assimilates the intended aspect of experience. At this point, the correct use of the word will be simultaneous with its application, pace Wittgenstein.

Would Wittgenstein buy into this theory of learning, do you think? What status would he give to undeveloped word-schemata - perhaps as having the same standing as objective definitions i.e. without meaning until applied?

John”

Sadly Piaget isn’t one of my authors so I spent an evening looking at ‘The Origins of Intelligence in Children’ to try the following quick, but possibly wholly misguided reply.

Schemata for Piaget start with examples such as grasping and develop into more concept-like instances. It is the latter that looks the better link to Wittgenstein but the former may shed light on our options. Let’s take the idea of grasping or ‘prehension’ (a word I seldom use, to be truth). Grasping seems to be something that floats free or successful and unsuccessful cases. That is, one might equally say of an action that it was an unsuccessful attempt at grasping or a successful grasping. Both have something in common. At some philosophical risk, we might use the same word (‘grasping’) for both. If so – and to put the point needlessly paradoxically! – grasping doesn’t reach as far as the world. I mean, there’s no necessary world-involvingness of any instance of ‘grasping’ (on this way of speaking). Grasping can be characterised in terms independent of the world as a free-standing action or event.

In fact, this seems wrong to me. Grasping is a teleological action and hence I think that the root concept is world-involving. If someone were grasping, then they were grasping something and we can ask what. They might try to grasp and fail, in which case we cannot ask what they were grasping with any guarantee of an answer (they may merely might succeed in grasping the wrong thing). What is world-independent and free-standing is the muscle and finger movements that coincide with successful and unsuccessful grasping alike. That inheres in the body and stops at the outer boundary of the skin. But for the moment, let’s loosely talk of ‘grasping’ to mean this and hence in accord with the earlier suggestion that the same word can be used for successful and unsuccessful cases.

Suppose, then, that we imagine a more concept-like schema on the basis of grasping. It too will be world-independent and will be applicable to orientations towards the world of a subject (necessarily an older child) where things go well and badly, where instances fit and where they fail to fit such a concept-schema. It now makes sense to ask how well the schema fits the experiences or the bits of the world experienced by a subject. Just as a grasping action that fits a mug may not work so well with stemmed wine glass, so perhaps a concept-schema for dog fits some instances of dogs better than others. Since it seems right to say that there will be some instances that cause even an experienced language user pause, this picture seems plausible at first.

But what is the analogue of the world-independent grasping action – or the muscle and finger movements that coincide with successful and unsuccessful grasping alike – for a concept-schema? Think of any free-standing mental (or neurological) state and call that the schema, if you like. Because it is free-standing it can exist however it stands to the world so it can cope with good fit, poor fit and lack of fit.

The problem now becomes: what gives such a free-standing state any kind of fit with the world? One possibility: an interpretation. But now, what encodes the interpretation: another free-standing concept-schema?

The diagnosis is that starting with a free-standing state is fatal for an account of thought’s directedness. Hence if Piaget’s account of schemata assume that they are world-independent and brought in better and worse contact with the world then they might fit some basic actions (especially when described in non-teleogical terms) but they won’t fit concepts. It will be a bad account of the conceptual. By contrast, a concept, on a Wittgensteinian view, is all in the reach to the world. It’s not in the mind. Or: it’s no more in the mind than the relation of being on the mat is in the cat.

Phenomenology and Mental Health Network (PMH)

Phenomenology and Mental Health Network (PMH)

Understanding the diverse character of lived experience

Network Leads

• Lead: Marcin Moskalewicz, philosopher, Poznan University of Medical Sciences (Poland) & The Oxford Research Centre in the Humanities (TORCH)
• Co-Lead: Richard Gipps, philosopher and psychotherapist, Faculty of Philosophy, University of Oxford
• Co-Lead: Giovanni Stanghellini, psychiatrist and psychotherapist, Università degli Studi G. d'Annunzio Chieti e Pescara (Italy)

Background and aims

Phenomenology is a rigorous philosophical method of studying the structures of consciousness and how these structures underlie and affect human experience. By undergoing a clinical turn, 20th century phenomenology became more pragmatic in seeking to understand the variety of lived experiences of patients suffering from mental disorders, often undermining a sense of a strict boundary between the normal and the pathological. Basic phenomenological themes, such as temporality, embodiment, intentionality, understanding, and intersubjectivity, thereby gained a new diagnostic and therapeutic significance. The tradition of phenomenological psychopathology became an important actor on the scene of 20th century psychiatry. The PMH network strives to promote the best of this tradition. It was launched at a workshop “Phenomenology and psychoanalysis: a dialogue” at St Catherine’s College in June 2018. The network connects philosophers, medical anthropologists, and social scientists with health care professionals – psychiatrists, psychotherapists, and caregivers, in order to bring together phenomenological expertise with actual life-world experience of the realities of mental health and illness.

Objectives The PMH network has the following objectives:

• To provide a forum for the exchange of ideas between those working in mental health care and academic researchers in phenomenology
• To explore the rich tradition of phenomenological psychopathology, its concepts, values, and critical potential
• To investigate the ways in which phenomenology informs diagnosis and treatment, and to explore how its potential could be utilized and further expanded in order to improve the care for the mentally ill persons
• To examine new (phenomenologically inspired) perspectives on mental illness in the context of diversity and plurality of human being
• To undertake research programs in applied phenomenology and facilitate collaboration between members as well as to seek collaboration with ongoing initiatives elsewhere
• To build a bridge between Central-European traditions of phenomenology and Anglo-Saxon scholarship

Members 
The network is open to all working at the intersection of phenomenological philosophy (as well as related fields of philosophy of mind and philosophical hermeneutics) and mental health. Membership is free of charge. To join please send a request to Marcin Moskalewicz at moskalewicz@gmail.com.

Meetings 
To advance our objectives, meetings and workshops will be organized regularly, some of them with an open call for papers in the conference format. The network will also support local initiatives.

Forthcoming events 
24th of October 2018, Diversity and Mental Illness (one-day workshop) at St. Catherine’s College. The workshop is a part of TORCH’s annual headline series Humanities & Identities and is co-sponsored by The Oxford Research Centre in the Humanities.

Mindfulness-inspired existential nihilism

I’ve been using the Headspace webpage to practice mindfulness meditation for the last 18 months or so. So far it has been with mixed success with respect to the reliability of any transformation of how I’m feeling but the ‘vocabulary’ of processes has become familiar: the sequence of forms of attention and its opposite.

I’ve pinched the picture from here. Which suggests that ‘Mindfulness to put it simply is being fully present in the moment. It means to be aware of our surroundings and to pay attention to what we are doing’.

Cycling up a lengthy hill in Cumbria a week ago, I realised that I wasn’t enjoying the experience very much. Or rather, I was finding it actively unpleasant. And so I tried some mindfulness techniques to identify the components of the experience. On reflection, it seemed that the bodily feeling of exertion, well short of pain, wasn’t in itself unpleasant: simply a feeling of bodily effort.

What made the general experience unpleasant was an overlying atmosphere of anxiety: not that that had a specific recognisable propositional content. It was not, for example, an anxiety of not being able to reach the top of the hill (what would it matter?). But there was a feeling ‘in the vicinity’ of anxiety that could nevertheless be neutralised just by focusing instead on what was in the bodily experience in the moment. What remained had no negative valence.

That seemed a quick victory for even my feeble skills in mindfulness meditation. But then it occurred to me that whilst that got rid of what is unpleasant about cycling consistently uphill, it also threatened to remove all the pleasure too. The pleasure, it seems to me, lies not in what is immediately bodily present but rather in the anticipation of the downhills to come, a memory of previous downhills but also uphills and the realisation that one is able to continue like this in ‘steady state’ over time. Further, it’s contributed to by a realisation that the activity on any one day will tend to sustain similar activity in the future. Hence also, the bodily tiredness and soreness to come is itself positive because of its history, what it means. The same bodily experiences imposed by drugs would not ‘in themselves’ be at all pleasant. But the knowledge that they result from a day in the saddle gives them a kind of satisfied pleasure.

But now what puzzles me about the virtues of this approach to bodily sensations – focusing on what is there ‘in the moment’ – is that subsequent retreat now seems impotent to re-establish previous pleasure. If the move that does the work of removing displeasure and pleasure is removal of a kind of temporal conceptual structure, a structure of habit, for example, simply adding back in past and future moments, also, presumably, stripped of positive (or negative) valence doesn’t seem able to re-establish the pre-meditative state.

It seems to me that mindfulness meditation, as I have no doubt misunderstood it, is a kind of equivalent of a form of philosophical scepticism, in this case promoting a kind of existential nihilism.

Psychiatry’s inchoate wish for a paradigm shift and the bio-psych-social model of mental illness

Overview

In recent years, there have been repeated calls for a ‘paradigm shift’ in psychiatry. In this chapter, I take this idea seriously and explore its consequences. Having illustrated calls for a paradigm shift, I sketch the Kuhnian account of science from which the idea is taken and highlight the connection to incommensurability. I then outline a distinction drawn from Winch between putative sciences where the self-understanding of subjects plays no role and those where it is fundamental and I argue that psychiatry falls into the latter kind. This suggests that the wish for a paradigm shift in psychiatry is either incoherent or a wish for a radical but unforeseeable overhaul of a significant aspect of our self-understanding as subjects and agents. The bio-psych-social model of mental illness is thus a helpful reminder of the cost of a paradigm shift in psychiatry.

Introduction: the inchoate desire for a psychiatric paradigm shift

During preliminary discussions of the development of DSM-5 (then referred to as ‘DSM-V’), there was a widespread assumption expressed that psychiatry needed a ‘paradigm shift’. For example, in the introduction to A Research Agenda for DSM-V the [Kupfer et al 2002], the editors, including the DSM-5 Task Force Chair Dr. David Kupfer claimed that:

limitations in the current diagnostic paradigm suggest that research exclusively focused on refining the DSM-defined syndromes may never be successful in uncovering their underlying etiologies. For that to happen, an as yet unknown paradigm shift may need to occur. Therefore, another important goal of this volume is to transcend the limitations of the current DSM paradigm. [Kupfer et al 2002: ix bold added]

In a paper published 8 years later (but before DSM-5) called ‘Paradigm Shifts and the Development of the Diagnostic and Statistical Manual of Mental Disorders: Past Experiences and Future Aspirations’, one of those editors, Michael First, expressed pessimism about such a possible radical change.

Work is currently under way on the preparation of DSM-5, which is due in May 2013. From the outset of the DSM-5 revision process in 1999, its developers were hopeful that the changes would be so significant so as to constitute a paradigm shift in psychiatric diagnosis. [First 2010: 691 bold added]

Despite hopes that DSM-5 may be able to move beyond its current descriptive categorical paradigm as a result of the fruits of the past 16 years of scientific research, based on A Research Agenda for DSM-V, the DSM-5 research planning conference presentations, and the initial drafts of the DSM-5 proposals, it seems evident that DSM-5 will continue to follow the DSM-IV paradigm, namely, a descriptive categorical system augmented by dimensions. Any future paradigm shift will have to await significant advances in our understanding of the etiology and pathophysiology of mental disorders. [ibid: 698 bold added]

Allan Frances, the Task Force Chair of the previous DSM-IV later described the initial optimism about the possibility of such a change as ‘absurdly premature’.

The DSM-V goal to effect a “paradigm shift” in psychiatric diagnosis is absurdly premature. Simply stated, descriptive psychiatric diagnosis does not now need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even 1 biological test is ready for inclusion in the criteria sets for DSM-V. [Frances 2009a: 2 bold added]

Elsewhere, in ‘Whither DSM-V?’ he wrote:

Not surprisingly, the disappointing conclusion of all this effort was that there are no biological markers even remotely ready for inclusion in DSM–V. The good news is that the remarkable revolutions in neuroscience, molecular biology, and genetics of the past three decades have given us great insights into the functioning of the normal brain. The bad news is that our understanding of psychopathology is fairly primitive and may remain so for some time… Thus, it is obvious that our field lacks the fundamental understanding of pathogenesis that will be required before we can take the next meaningful step forward towards a paradigm-shifting aetiological model of diagnosis. [Frances 2009b: 391 bold added]

Such passages imply that the nature of the radical shift envisaged was a turn towards a biological disease model for psychiatry and that this was undermined by the lack of biological markers for psychiatric diagnostic categories. But even those who rejected a disease model still appealed for a ‘paradigm shift’. In a position paper written in the same year as DSM-5 was published, the British Psychological Society wrote:

The DCP [Division of Clinical Psychology] is of the view that it is timely and appropriate to affirm publicly that the current classification system as outlined in DSM and ICD, in respect of the functional psychiatric diagnoses, has significant conceptual and empirical limitations. Consequently, there is a need for a paradigm shift in relation to the experiences that these diagnoses refer to, towards a conceptual system which is no longer based on a ‘disease’ model. [British Psychological Society 2013: 1 bold added]

Since the publication of DSM-5, hope for a biological disease model for psychiatry has been placed, instead, on the NIMH’s Research Domain Criteria (RDoC). It is not a rival taxonomy but rather a research framework to underpin new approaches to investigating mental disorders.

RDoC itself does not propose an alternative nosology, but rather seeks to unfetter research from clinical definitions and provide an initial framework and set of constructs for reconceptualizing psychiatric research directions in line with basic neuroscience concepts… The RDoC framework seeks to reorient conceptions of psychopathology by encouraging infusion of neuroscientific thinking and data into such conceptions. [Hettema 2016: 349]

NIMH gave emphasis to RDoC as a paradigm with the hypothesis that research based on already defined behavioral constructs with known neural circuits will accelerate the development of fundamental knowledge applicable to psychopathology while reducing problems associated with heterogeneous clinical syndromes. [Carpenter 2016: 562 bold added]

In ‘Research domain criteria: a final paradigm for psychiatry?’, the philosopher of psychiatry Walter Glannon sums up an assessment with the claim that:

Despite its limitations, RDoC offers the most conceptually coherent and scientifically sound paradigm for explaining psychiatric disorders. [Glannon 2015: 3]

As I will explain (briefly) below, the fact that RDoC is not a rival taxonomy to DSM-5 but a framework and set of constructs for research provides some rationale for the use of the label ‘paradigm’. But aside from that specific feature of RDoC, the mere fact of the broader assumption that psychiatry is generally thought to need a paradigm-shift is worthy of note. It suggests the question: for what does one hope if one hopes for such a thing? ‘Paradigm’ is the great term of art of the historian of science Thomas Kuhn, author of The Structure of Scientific Revolutions [Kuhn [1962] 1996]. In the next section, I will draw out some of the consequences of this on a broadly Kuhnian picture of science. Central to this picture is the connection between paradigms and the meaning of theoretical terms and hence the connection between changing paradigms and the consequent incommensurability of the meanings of terms across time. It is this that helps to support Kuhn’s theoretical scepticism about whether sciences can be said to progress. And this in turn calls into question whether it can be rational to wish for a paradigm shift.

In the third section, I address a related but more substantial point. Whilst the wish for a paradigm shift typically reflects optimism about the developments of neuroscience, psychiatry aims to use its technical innovations to relieve human distress. An improved psychiatry should thus be better able to address those issues. But if so its understanding of mental illness and distress - which guides diagnosis, treatment, management and shared plans for recovery - had better remain closely wedded to the self-understanding of those it is supposed to help. And if so, any plans for a paradigm shift threatens either to disconnect medical psychiatry from the understanding of human agents which should guide it or to revise in unforeseeable ways much of every day human self-understanding. But in order to prepare the way to that conclusion, I will briefly outline the role of paradigms and paradigm shifts in Kuhn’s account of science.

Paradigms, paradigm shifts and incommensurability

The widespread and sometimes indiscriminate use of the word ‘paradigm’ in the description of scientific change is the result of the popularity of Thomas Kuhn’s Structure of Scientific Revolutions in which it is a key term [Kuhn 1996]. Margaret Masterman (a pupil of Wittgenstein and founder of the Cambridge Language Research Laboratory) identified 21 different ways in which Kuhn used the word but suggested that there were three main ideas [Masterman 1970: 61]. These are paradigm as metaphysical world-view, a sociologically describable body of activity and a particular concrete instance such as a textbook. To shed light on these it will be helpful to offer a thumbnail sketch of his account of scientific practice.

Kuhn argues that scientific activity falls into two sorts. In the main, scientists are engaged in ‘normal science’. This comprises the articulation and application of stable dominant theories and meta-theoretical assumptions to new areas. Kuhn refers to both background worldview and the agreed forms of activities with the word ‘paradigm’ (the first and second of Masterman’s uses). The paradigm offers a way of seeing the world and one such tool is a paradigmatic worked example, or classic solution (Masterman’s third sense). The business of normal science is puzzle solving: using familiar methods to arrive at solutions to problems against a background assumption that the paradigm provides the resources for such solutions.

As I advertised above, these characteristics suggest a rationale for calling RDoc a ‘paradigm’ as it is broader than just a taxonomy to rival DSM-5 but rather encourages a particular approach to explaining mental illness emphasising biological and neurological causes. It offers a way of seeing mental illness as a biological disease.

During periods of normal science, no serious attempt is made to refute or even defend the theoretical background and shared practices, which are instead simply presupposed. But these stable periods of normal science are punctuated by brief periods of revolutionary theory change. Sparked both by the accumulation of anomalous results – such as ‘puzzles’ that resist solution – and by the development of rival theories or even rival meta-theoretical assumptions, the dominant orthodoxy is cast aside and a new theory or set of theories put in its place. Only during these revolutionary periods is the truth of what will become the new scientific background called into question.

Thus, while during periods of normal science, some measure of progress can be based on an increasing ability to solve recognised puzzles against the background of a stable paradigm, that measure does not apply over periods of revolutionary change.

In the first place, the proponents of competing paradigms will often disagree about the list of problems that any candidate for paradigm must resolve. Their standards or their definitions of science are not the same. [Kuhn 1996: 148]

This reason for a lack of a common measure – the claim that standards of assessment are internal, and hence relative, to a paradigm is called ‘the incommensurability of standards’. But it is not the only reason to think that different paradigms are incommensurable.

More is involved, however, than the incommensurability of standards. Since new paradigms are born from old ones, they ordinarily incorporate much of the vocabulary and apparatus, both conceptual and manipulative, that the traditional paradigm had previously employed. But they seldom employ these borrowed elements in quite the traditional way. Within the new paradigm, old terms, concepts, and experiments fall into new relationships one with the other. The inevitable result is what we must call, though the term is not quite right, a misunderstanding between the two competing schools. [ibid: 149]

This source of incommensurability follows from his, at the time, influential view of the meaning of theoretical terms. Like other philosophers and historians of science, Kuhn reacted against an influential view of the meaning of theoretical terms taken from the Logical Empiricists of the 1930s [Feigl 1970]. On that older view, theories could be judged against the standard of theoretically neutral observations and that separation was supposedly maintained by the independence of observation from theoretical language. Although theoretical terms were grounded in the observational predictions they collectively inferentially warranted, observational terms were thought to be definable antecedently.

A group of arguments towards the end of the twentieth century undermined that distinction between theory and observation (establishing instead the ‘theory dependence of observation’) [eg. Churchland 1979, Hanson 1958, Kuhn 1996]. Kuhn concludes that the holism that had been thought to apply to theoretical terms – albeit a holism constrained from the outside by their implications for observation claims – must apply to theoretical and observational terms collectively. But without a stable set of neutral observation claims against which to judge them, the new holism seems to imply that a change of overall theory would change the context and hence the meaning of all now hybrid theory-observation terms. This seems to suggest that there is no standard by which to compare overall theories across a paradigm change since different paradigms defined different scientific languages leaving no resources for an objective translation manual. Translation depends instead on difficult judgements about the best way to render one description into another. And thus, paradigm change is incommensurable undermining the very idea that science progresses.

Kuhn himself notoriously suggests that, after such a shift, scientists inhabit a different world.

These examples point to the third and most fundamental aspect of the incommensurability of competing paradigms. In a sense that I am unable to explicate further, the proponents of competing paradigms practice their trades in different worlds. [Kuhn 1996: 150]

This is not the only way to view the meaning of theoretical terms and thus not the only view of the impact on the possibility of comparing theories of potential meaning change. One possible alternative, motivated by referential approaches to meaning influenced by Putnam, puts weight on the role of actual samples in fixing the extension of scientific terms [Putnam 1975]. But part of the force of the idea of a paradigm shift is that the change of worldview is radical and Kuhn’s view of meaning incommensurability is part of the reason for that. Any less radical account of the consequences of theory change would undermine the point of deploying the suggestive phrase ‘paradigm shift’.

This, however, suggests that, at the very least, there is something strange about psychiatry’s frequently expressed wish to usher in a new paradigm. Without a standard by which to judge progress across such a change, what rational motive is there to wish in advance for such a change? By what pre-shift standard can a replacement be said to be rationally preferable? Afterwards, there might equally be no grounds for rational regret and perhaps even a parochial preference for the newly familiar, but that does not provide a rational argument to favour the change.

That, however, is not my main purpose in recalling the close connection between paradigms, meaning and incommensurability. The main issue concerns the application of these ideas to psychiatry in particular. In the next section I will suggest that a paradigm shift would come at a high price for psychiatry and that the apparent willingness to pay that price suggests a radical scepticism about solving psychiatry’s current conceptual problems.

Scientific and lay understanding of mental illness

In order to develop my main concern, I will return to (and re-quote) the passage from Frances I quoted at the start. The most obvious reason for thinking that psychiatry is awaiting a paradigm shift are developments at the hard science end of psychiatry. Even Frances mentions ‘incredible recent advances in neuroscience, molecular biology, and brain imaging’ when discussing others’ confidence in the possibility of a new paradigm. Frances himself argues that ‘descriptive psychiatric diagnosis does not now need and cannot support a paradigm shift’ but he goes on to say that there ‘can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders’ and that the absence of biological tests in diagnostic criteria suggests that this has not been reached. But that comment does not distance himself from what might seem a plausible aspiration for a bio-medical psychiatry. What is needed, on this assumption, is greater biological understanding of ‘what causes mental disorders’ and a sufficiently ‘fundamental leap’ in that might give us the hoped-for paradigm shift.

I think there are two fundamental complexities that this view – a view from which Frances does not sufficiently distance himself – ignores. The first is that, within psychiatry, the focus of neuroscientific, biological and brain imaging technology is, nevertheless, mental pathology. Progress has been recently made in these areas and more progress is needed but, additionally, progress is also needed in determining not just what causes mental disorders but what they comprise. What is it, in other words, for something to be a mental disorder? There is no reason to think that an answer to this question can be provided by neuroscience, molecular biology, and brain imaging since, insofar as these can help shed light on psychopathology, one needs first to have decided the extension of that concept then to study its neurological and biological underpinnings. Given the conceptual complexity of the very idea of mental disorder, and that what is so classed is so contested, any leap forward in knowledge of brain mechanisms needs to go hand in hand with answers to that question.

The second complexity follows from the first. Suppose that innovations in neuroscience, molecular biology, and brain imaging were used to articulate a form of psychopathology on the basis of its neurological similarity to currently identified forms but which had no connection to any mental distress or suffering. That would not, I suggest, mark a triumph of neuroscientific psychiatry. Rather, it would amount to psychiatry losing its way by losing its connection to its particular distinct subject matter.

This point suggests a more general moral that derives from the Wittgensteinian philosopher Peter Winch’s arguments in The Idea of a Social Science and its Relation to Philosophy [Winch 1958]. Winch argues that there can be no such thing as a social science. The argument for this conclusion starts from the assumption that a central element of understanding meaningful behaviour is an understanding of the nature of rules. For this he draws on Wittgenstein’s lengthy discussion of rules, rule following and understanding in the Philosophical Investigations [Wittgenstein 1953]. Winch makes three claims:

1. Rules are central to so-called social science because actions are constituted as the actions that they are by the rules that govern them. Thus, to give one of his examples, putting a cross on a piece of paper is an act of voting given the right context of rules. Sound patterns, similarly, are constituted as meaningful assertions only given the rules of spoken language.

2. Explaining an action by citing a rule presupposes a grasp of the rule not just by the putative social scientist but also (to a first approximation) by the agent whose behaviour is being explained.

3. Rule following is grounded in implicit practical knowledge of what actions count as going on in the same way. Rule following cannot rest entirely on explicit linguistically codified knowledge because that explicit knowledge would require further implicit knowledge of how the written prescription is to be understood.

Rules also have a further implicit but important feature. They are normative: they prescribe correct and incorrect moves. In the example mentioned above, they prescribe the difference between a successful vote and a spoiled ballet paper. Only certain actions count as casting a vote. Thus, if understanding an event involves relating it to a rule, this form of understanding involves a notion of correctness. It involves understanding what makes it correct or appropriate as a piece of voting behaviour. This is not the same as saying that most votes are cast at a particular time of day or night or by a particular socio-economic proportion of the electorate. That may be discovered by empirical study. But the normative rules that characterize an event as an act of voting are not provided by any such statistical generalizations. With these claims in place, Winch goes on to argue that so-called social science is fundamentally dissimilar to natural science.

[W]hereas in the case of the natural scientist we have to deal with only one set of rules, namely those governing the scientist’s investigation itself, here what the sociologist is studying, as well as his study of it, is a human activity and is therefore carried on according to rules. And it is these rules, rather than those which govern the sociologist’s investigation, which specify what is to count as ‘doing the same kind of thing’ in relation to that kind of activity. [Winch 1990: 87]

In understanding social phenomena, the understanding possessed by the objects of study (human subjects, people) of their own behaviour plays a key role and this is not reflected in say the physics of billiard ball motion. The putative social scientist has to understand social behaviour by understanding it, at least in part, through the understanding that the agents he or she studies have. That is not to say that the analysis of social phenomena can go no further than agents’ self-understanding. But it is rooted in it.

I do not wish to maintain that we must stop at the unreflective kind of understanding of which I gave as an instance the engineer’s understanding of the activities of his colleagues. But I do want to say that any more reflective understanding must necessarily presuppose, if it is to count as genuine understanding at all, the participant’s unreflective understanding. [Winch 1990: 89]

Winch himself uses these points to argue, contentiously, that there can thus be no such thing as social science and, even more contentiously, that the proper study of social phenomena is continuous with philosophical analysis. Neither of these conclusions is necessary, however, for the more modest point that there is an important distinction between cases where the understanding of phenomena by those who are – or what is –being studied is important and those where it plays no role.

Psychiatry, unlike a more disinterested study of the brain, has an essential connection to human distress and suffering and to norms governing social dysfunction, emotional dysregulation etc. Thus, it has an essential connection to the concepts with which we, as subjects and agents, make sense of ourselves. The implication from Winch’s analysis is that norms, deviation from which constitute mental illnesses, have to be understood, at least initially, via agents’ self-understanding of them. This suggests a distinction between psychiatry and some at least of the natural sciences. While there seems to be no constraint imposed by the subject matter of much of natural science on the limits of conceptual innovation (as long as the concepts arrived at can still be understood by at least some scientists), the concepts of psychiatry need to retain some connection to those concepts in terms of which we ordinarily make sense of ourselves. Only so, can human experiences play at least some guiding role for psychiatric diagnosis, theorising and care.

Implications for psychiatric paradigm shifts and bio-psycho-social model

If the Winch-inspired argument above is correct, the psychiatry, unlike, for example, quantum physics, has to keep one foot on the ground via a lay understanding of the norms governing mental illness, disorder, dysfunction and distress. That in turn has implications for paradigm shifts in psychiatry, given their connection to incommensurability. If, on the one hand, a future psychiatry maintains its links to the ordinary understanding of mental illness that currently sets the agenda for mental healthcare, then that ordinary understanding provides a bridge head for scientific understanding, undermining the very idea of there being a paradigm shift. If the Winchean argument is right, whilst psychiatry can go beyond ordinary agents’ understanding of the norms deviations from which amount to illness, it must still be rooted in it. If, on the other hand, a radical change in psychiatry severs those links, that might amount to a genuine paradigm shift for medical psychiatry - because that would imply a lack of the commensurability – then it would lose its identify as a response to mental illness and distress. It would no longer be psychiatry.

Consistent with this basic framework, there is one other possibility. The call for a paradigm shift may be intended not just to cover scientific psychiatric theorising about the causes of mental illnesses and distress – for example, a turn to more biological models and biomarkers – but also everyday conceptualisations of them. That is, it might be a kind of counsel of despair. On the assumption that everyday thinking about mental illness is essentially confused and raises insoluble conceptual questions of the sort expressed in the dilemma, ‘mad or bad?’, it might be thought that the rational response is a kind of conceptual radical overhaul. But given the consequences of a Kuhnian paradigm shift, such a move risks putting into an ungraspable future not merely elements of medical science but also a significant element of our self-understanding as agents, the basic norms governing actions, emotions, responsibility and free will.

If this working through of the combination of Kuhn and Winch is correct, then the wish for a paradigm shift in psychiatry seems doubly misplaced. First, the connection to incommensurability undermines the rationality of the wish even when limited to an area of medical science. Second, a change which did not sever the connection to the concepts we use to make sense of ourselves would not be a paradigm shift since the innovation would be merely partial leaving in place standards for rational assessment of the technical innovations. But a paradigm shift localised to psychiatry which rendered the pre- and the post-shift worldviews incommensurable would have to sever the connection to those grounding concepts and that could only be because psychiatry had lost its way. Finally, a paradigm shift of not only medical psychiatry but also of the everyday norms against which folk conceptions of illness, distress and suffering are measured is such a radical view that there is no way now to conceptualise what it is for which one would be wishing.

Against this long-standing inchoate wish for a paradigm shift in psychiatry, the bio-psycho-social model of psychiatry is a helpful reminder of its potential costs [Engel 1977]. Our understanding of mental illness is not merely rooted in biological natural science. It is much more broadly rooted in psychological and sociological basic norms and rules governing activity, thought and feeling. Genuine fundamental change in that whole conceptual package is not something to be lightly entertained.

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