The echo of the Tractarian saying versus showing distinction in the later rule following considerations
2.172 A picture cannot, however, depict its pictorial form: it displays it.
4.121 Propositions cannot represent logical form: it is mirrored in them. What finds its reflection in language, language cannot represent. What expresses itself in language, we cannot express by means of language. Propositions show the logical form of reality. They display it.
The paradigmatic role of the saying-showing distinction in the Tractatus concerns the representational powers of pictures and propositions. The account of representation apparently articulated cannot, somewhat paradoxically, be put into words but can be shown. On ‘resolute’ interpretations, however, the distinction itself is part of what has to be jettisoned when the insight offered in the book is finally understood, an aspect of the ‘ladder’ to be thrown down. On a traditional reading, the distinction is what permits something substantial still to be conveyed even when the ladder is thrown down. On McGinn’s elucidatory reading, the distinction survives as an aspect of the continuity between the earlier and later Wittgenstein though McGinn offers an example of that continuity discussion of epistemic matters from On Certainty which is only of indirect connection to representation itself.
In this chapter, I discuss an analogy between the saying-showing distinction as it seems to apply in the Tractatus – whether or not it survives as genuine insight – and the rule following considerations in the Philosophical Investigations. But even in this latter context, difficulties remain.
On one approach, the rule following considerations highlight the gap between what can be set out in any explanation of a rule and what – philosophically – one took to be conveyed. Examples of deviant responses serve as the equivalent of ringers in arguments for epistemological scepticism. And hence so much the worse for ‘saying’.
One response is a radical form of scepticism – Kripke’s meaning scepticism - in which there is less to rule following than was previously thought. Another (eg Brandom) is to fill the gap between what is said and what is understood by a tacit background. Neither approach, however, fits what Wittgenstein himself says.
A third response is to deny that there is any necessary gap between an explanation and what is understood but that, nevertheless, there is a requirement for the distinction between saying and showing at the heart of representation. The content of a rule, such as one governing application of a word, grounds out in particular judgements. For example, there is no further explanation of the fact that 'blue' applies to light and dark blue but not to green than that this is our natural practice. It depends, in Stanley Cavell's fine phrase, on our whirl of organism. The content of our concepts is thus given by our practice. This is the aspect of the ‘logic’ of representation that has to be shown in the later Wittgenstein.
Wednesday, 22 April 2020
The implications of the loss of self-respect for the recovery model in mental healthcare
Recovery as the goal of mental healthcare.
Over the last two decades, recovery has come to be promoted as a novel and desirable target for mental healthcare. It has become a proud boast that mental healthcare is recovery orientated. Nevertheless, whilst there is agreement that in this context, it does not mean merely getting better or returning to a previous state of health, there remains disagreement as to what exactly recovery is.
There is an increasing global commitment to recovery as the expectation for people with mental illness. There remains, however, little consensus on what recovery means in relation to mental illness. [Davidson and Roe 2007: 450]
The term ‘recovery’ appears to have a simple and self-evident meaning, but within the recovery literature it has been variously used to mean an approach, a model, a philosophy, a paradigm, a movement, a vision and, sceptically, a myth. [Roberts and Wolfson 2004: 38]
In this section, I outline a view of recovery I have developed previously [refs removed].
In the UK, a policy paper published by the Sainsbury Centre for Mental Health, titled ‘Making recovery a reality’, begins by summarising some key points of emphasis which, it is suggested, characterise any broadly conceived recovery-based approach. These points include:
Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems. Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness. Hope is central to recovery and can be enhanced by each person seeing how they can have more active control over their lives (‘agency’) and by seeing how others have found a way forward. Self-management is encouraged and facilitated. The processes of self-management are similar, but what works may be very different for each individual. No ‘one size fits all’. The helping relationship between clinicians and patients moves away from being expert / patient to being ‘coaches’ or ‘partners’ on a journey of discovery. Clinicians are there to be “on tap, not on top”. People do not recover in isolation. Recovery is closely associated with social inclusion and being able to take on meaningful and satisfying social roles within local communities, rather than in segregated services. Recovery is about discovering – or re-discovering – a sense of personal identity, separate from illness or disability. [Shepherd, Boardman and Slade 2008: 0]
The Scottish Recovery Network summarises its views of recovery in similar terms:
Recovery is about living a satisfying and fulfilling life. Recovery is about more than the absence of the symptoms of illness. Some people describe themselves as being in recovery whilst still experiencing symptoms. There can be lots of ups and downs during the recovery process – some people describe it as a journey. For this reason people often talk about being in recovery rather than recovered. Some people consider recovery as being ‘back to the way things were’ or back to ‘normal’ but for others recovery is more about discovering a new life or a new way of being. [Brown and Kandirikirira 2007: 3]
These lists provide a starting point for setting out a theoretical model of recovery. But there is a further structural constraint. To articulate a recovery model that is distinct from, or contrasts with, for example, a bio-medical model of mental healthcare, it is not enough to say that recovery (construed in some broad way) is a desirable aim of mental health care. One could hold that whilst holding a broadly bio-medical view of health and illness: for example, as pertaining to biological function versus dysfunction. To count as a distinct model of healthcare, it must offer more than just a broad aim but, rather, a theoretical conception of what illness, or health, or something like health is. (In the UK, the rise of the recovery movement coincided with both greater optimism within biological psychiatry of the efficacy of medicines but also the kind of theoretical articulation of a novel view of recovery with which I am here concerned. Both elements played a role, complicating the historical story.)
The characterisations of recovery in the quotations above suggest the importance of two distinctions. First, there is a distinction of focus between pathology and whatever is its relevant contrast, perhaps health or wellbeing. Second, there is the distinction between what is evaluative or normative and what is merely plainly factual. Together these can be used to sketch a distinct although abstract conception of recovery which genuinely contrasts with a medical model. It is to locate it on the health-focused rather than pathology-focused side of the first distinction and on the values-laden or normative side of the second. The recovery model combines: a) a focus on a conception of wellbeing and b) in normative or evaluative terms.
The latter element, however, merely hints at something of great importance to the recovery model. The normative and evaluative elements enter the picture in a conception of a life worth living as conceived by the patient or service user him- or herself. Healthcare resources are thus deployed in the service of choices and values of the patient whose views are thus central. This contrasts with a value-free conception of healthcare as aimed at returning patients to statistically normal or biologically functional states.
The recovery model is also opposed to paternalistic models of health service provision which are guided by the choices of clinicians on behalf of patients. An essential feature of recovery is thus the authorship of an agenda by patients themselves. One indication of this is the proliferation of ‘recovery stories’ as part of the promotion of the recovery approach. These explore:
the personal and existential dimensions of recovery, taking the form of subjective and self-evaluated accounts of how an individual has learned to accommodate to an illness. These accounts have become the founding stories of the recovery movement [e.g. Chamberlin, 1978; Lovejoy, 1984; Deegan, 1988, 1996; Leete, 1989; Unzicker, 1989; Clay, 1994; Coleman, 1999; Ridgeway, 2000], and anthologies of these personal stories have been used by governments and professions as a means of combating stigma and reasserting a focus on personal perspectives [Leibrich, 1999; Lapsley et al, 2002; Ramsay et al, 2002]. [Roberts and Wolfson 2004: 38-9]
Given this anti-paternalist stance, however, much weight has to be placed on the capacities of authorship and agency of those with mental illnesses. Thus Larry Davidson, a foremost proponent of the recovery approach to mental healthcare asserts:
There can be no recovery without self-determination… Mental illness may pose an obstacle to the person’s achievement of the kind of life he or she wishes to have, may make it more difficult to live that life, and, at its most extreme, may even deprive the person of life altogether. In none of these cases, though, does mental illness fundamentally alter the basic nature of human beings, which is that of being self-determined agents, free to choose and pursue the kind of life they as individuals value. Mental illness does not rob people of their agency, nor does it deprive them of their fundamental civil rights. [Davidson et al 2009: 40-1 italics added]
By contrast, Kim Hopper warns that the choices made people with mental illnesses may lack authenticity. Their choices may be affected or distorted as a consequence of illness itself or their treatment as a result of that illness.
Deprivation and disgrace can so corrode one’s self worth that aspiration can be distorted, initiative undercut and preferences deformed. Sensitive work will be needed to recover that suppressed sense of injustice and reclaim lost possibility. [Hopper 2007: 877]
In the rest of this paper I will shed light on the threat to authorship and agency raised by mental illness in virtue of its effects on self-respect and shame and thus suggest a tension at the heart of the recovery model.
Respect, self-respect, self-esteem, shame and action
While the concepts of respect, self-respect, self-esteem, shame, and agency are obviously interrelated, the precise nature of the connections is contested, with self-esteem more widely used in psychology and self-respect in philosophy especially moral philosophy [Roland and Foxx 2003]. In this section I will draw on the literature to set out some of their connections. If the connections are neither completely tight nor uncontentious, that will not undermine the key claim needed here: that loss of self-respect and feelings of shame can undermine free agency. Given, however, that some philosophers equate self-respect and self-esteem while others argue for their difference and given that there is disagreement concerning the absence of which is more closely connected to shame, it will be helpful to spell out a broad frame which can shed light on these differences. The best route to that is, I think, via Stephen Darwall’s distinction between two kinds of respect [Darwall 1995]
Darwall takes it for granted that respect for persons plays an important role in moral philosophy. But, he argues, moral philosophical accounts of it have in general failed to draw a key distinction between two kinds of attitude, which he labels ‘recognition respect’ and ‘appraisal respect’.
Of the former he says:
There is a kind of respect which can have any of a number of different sorts of things as its object and which consists, most generally, in a disposition to weigh appropriately in one’s deliberations some feature of the thing in question and to act accordingly. The law, someone’s feelings, and social institutions with their positions and roles are examples of things which can be the object of this sort of respect. Since this kind of respect consists in giving appropriate consideration or recognition to some feature of its object in deliberating about what to do, I shall call it recognition respect. [ibid: 183]
This form of respect applies more broadly than just to persons, though it also applies to persons. Holding the attitude – respecting, in this sense – simply consists in weighing some fact, such as that someone is a person, with their rights and roles, appropriately in deliberation and judgement. The object of this attitude is thus a fact. But given how potentially widely the idea of weighing facts in deliberation could range, to count as respect it must be restricted to weighing appropriately the moral propriety of acting in particular ways with respect to some fact.
The second attitude is appraisal respect. Darwall introduces it as follows:
There is another attitude which differs importantly from recognition respect but which we likewise refer to by the term “respect.” Unlike recognition respect, its exclusive objects are persons or features which are held to manifest their excellence as persons or as engaged in some specific pursuit. For example, one may have such respect for someone’s integrity, for someone’s good qualities on the whole, or for someone as a musician. Such respect, then, consists in an attitude of positive appraisal of that person either as a person or as engaged in some particular pursuit. [ibid: 183-4]
This attitude consists in the having of positive regard. It may in turn rationalise and motivate particular actions but whereas recognition respect is a disposition to an intellectual act – the weighing of something in deliberation – appraisal respect can be independent of any particular conception of how to act. A second distinction is that appraisal respect much more readily admits of degree. People merit appraisal respect in virtue of them meeting particular expectations. They can do this to greater and lesser degrees. By contrast, recognition respect turns on the status of someone simply as a person. And hence the distinction between the two attitudes explains the different aspects of respect for persons.
The distinction between appraisal respect and recognition respect for persons enables us to see that there is no puzzle at all in thinking both that all persons are entitled to respect just by virtue of their being persons and that persons are deserving of more or less respect by virtue of their personal characteristics. [ibid: 192]
It might be assumed that with the distinction in play, the ‘personal characteristics’ in virtue of which appraisal respect is earned might range over anything another subject might value. In fact, however, Darwall argues that genuine (appraisal) respect is more narrowly bounded. It must relate, in part at least, to excellence of character. Taking the example of a tennis player, he suggests that to be respected as a tennis player, one must demonstrate excellence in tennis playing. But that is not sufficient to merit respect as a person, even as a tennis player.
To begin with, somebody may be an excellent tennis player without being a highly respected one. He may be widely acclaimed as one of the best players in the world and not be widely respected by his fellows— though they may (in the extended recognition sense) respect his return of serve, his vicious backhand, and so on. Human pursuits within which a person may earn respect seem to involve some set of standards for appropriate and inappropriate behavior within that pursuit. In some professions this may be expressly articulated in a ‘code of ethics.’ In others it will be a more or less informal understanding, such as that of ‘honor among thieves.’ To earn more respect within such a pursuit it is not enough to exercise the skills which define the pursuit. One must also demonstrate some commitment to the (evolving) standards of the profession or pursuit. [ibid: 187]
In other words, while the personal characteristics necessary to perform a role skilfully may modify the excellences of character that merit respect, they do not replace them. They augment them.
The two distinct attitudes that comprise respect for persons also comprise forms of self-respect, since both are attitudes which one can bear to oneself. Thus:
It is recognition self-respect to which we appeal in such phrases as “have you no self-respect?” hoping thereby to guide behavior. This is not a matter of self-appraisal but a call to recognize the rights and responsibilities of being a person. [ibid: 193]
Similarly, like appraisal respect, appraisal self-respect is based on the excellences of persons that constitute good character. It is thus, according to Darwall, narrower or more specific than other forms of positive self-appraisal.
One such attitude is that which we normally refer to as self-esteem. Those features of a person which form the basis for his self-esteem or lack of it are by no means limited to character traits, but include any feature such that one is pleased or downcast by a belief that one has or lacks it. One’s self-esteem may suffer from a low of opinion of, for example, one’s appearance, temperament, wit, physical capacities, and so forth. [ibid: 194]
In other words, while both self-respect and self-esteem are forms of positive self-appraisal, the self-appraisal which constitutes self-respect is of oneself as a person, a being with a will who acts for reasons. I will return to this distinction shortly.
John Rawls offers the following influential account of the connection between self-respect or self-respect (between which he did not distinguish) and what he calls ‘moral shame’ which fits well with Darwall’s account of self-respect.
[S]omeone is liable to moral shame when he prizes as excellences of his person those virtues that his plan of life requires and is framed to encourage. He regards the virtues, or some of them anyway, as properties that his associates want in him and that he wants in himself. To possess these excellences and to express them in his actions are among his regulative aims and are felt to be a condition of his being valued and esteemed by those with whom he cares to associate. Actions and traits that manifest or betray the absence of these attributes in his person are likely then to occasion shame, and so is the awareness or recollection of these defects. [Rawls 1995: 129]
This conceptual articulation of shame has been criticised. John Deigh points out that shame is commonly felt over trivial things that do not seem connected to ‘excellences of character’. He gives the example of a young French girl who felt shame on her first day of school because her name ‘Mlle Péterat’ carried a connotation ‘which might be rendered in English by calling her Miss Fartwell’ [Deigh 1995: 141] As Deigh points out: ‘The morphemes of one’s surname do not make one better or worse suited for pursuing the aims and ideals around which one has organized one’s life’ [ibid: 141]. Further, shame is ascribed to small children.
Shaming is a familiar practice in their upbringing; “Shame on you” and “You ought to be ashamed of yourself” are familiar admonishments. And, setting aside the question of the advisability of such responses to a child’s misdemeanors, we do not think them nonsensical or incongruous in view of the child’s emotional capacities. Furthermore, close observers of small children do not hesitate to ascribe shame to them. [ibid: 142]
In such cases, it seems ridiculous to ascribe an explicit self-conception of ambition to excellences of character up to which the child, for example, has failed to live. Shame, Deigh argues, need not presuppose the rational reconstruction Rawls offers. In sum, it may apply more broadly than cases of the failure of an explicit failure of the form Rawls sets out.
That said, one way to reconcile this difference is to think that the archetype of shame is the one that Rawls describes and thus to think that the one ascribed in the case of young children, or to more trivial aspects of one’s person but not one’s character, is an extension of the archetypal or paradigmatic case. There are other species of the genus shame, though connected neither directly to a subject’s explicit conception of broader virtues (excellences of character) nor more narrowly to moral properties but rather more broadly to some conception of what is personally important. As Gabriele Taylor asserts:
Shame can be seen as a moral emotion, then, not because sometimes or even often it is felt when the person believes himself to have done something morally wrong, but rather because the capacity for feeling shame is so closely related to the possession of self-respect and thereby to the agent’s values. [Taylor 1995: 163]
With that broad outline of the nature of self-respect – and its connection to respect and self-esteem – and a standard Rawlsian account of its link to shame in place, I can now look to a further connection reflected in the literature. Failure of self-respect and shame undermine agency of the sort that underpins the recovery approach in mental health. In other words, failures of self-respect – and possibly self-esteem – are not just symptoms of mental illness but threaten the very idea of the current central aim in mental healthcare.
The link is explored by Paul Benson using, first, the example of the 1944 film Gaslight in which Ingrid Bergman plays a character married to an man who plans to reduce her to a state of confusion and disorientation such that she will not be able to block his plans to steal a jewel she has inherited. He does this by keeping her isolated, persuading her that she is losing her memory and generally confusing her by a variety of means which include turning down the titular gaslight (hence the phrase ‘gaslighting’). The net effect is not to undermine those abilities that are taken in ‘proceduralist’ accounts to underpin agency and autonomy such as Harry Frankfurt nested hierarchy of first order desires and second order endorsements of those desires [Frankfurt 1971]. As Benson says:
It is possible that Bergman [ie her character] has retained whatever procedurally definable abilities have been held to suffice for freedom. She can act intentionally. She is not frozen in space, nor are her bodily movements ‘mere behavior.’ Her will may not be afflicted with unconscious, compulsive, or otherwise ungovernable motives. And the privileged region of her will which, on any given theory, is allegiance or engagement as a free agent in her will, may be intact and functional, properly coupled to her behavior… Despite the possibility that Bergman can reflectively regulate or authorize her conduct, she is nevertheless not a free agent. She is quite disengaged from her actions. [Benson 1994: 655]
This case suggests a way in which a person’s autonomy can be undermined by undermining their self-respect, not that Benson puts it quite this way. The victim of gaslighting doubts her competence to make reasonable evaluations because of her, in fact fictitious, mental instability and thus doubts her capacity as an agent. She thus lacks recognitional self-respect by falsely thinking she is incapable of full autonomous agency.
Benson mentions a second relevant case. Shame, too, can undermine agency even when it does not directly undermine the features of a ‘proceduralist’ account of agency and autonomy (though it can do that too).
But shame can also diminish freedom when it involves a collapse of the person’s sense of worthiness to act. Like the gaslighted woman, the ashamed person can become dissociated from his reflective or evaluative capacities because his apparent dishonor or disgrace undercuts his view of himself as a competent agent. As before, this sort of disorientation need not impede the person’s capacities to authorize his will as his own... [Similarly] Slaves who internalized the debased public images of themselves as nonpersons felt barred from entering into relations or practices fit only for persons. [ibid: 658]
Having now sketched a distinction between two sorts of respect, and hence of self-respect and the potential connection between a lack of self-respect and the undermining of free action, I can now return to the challenge of the recovery model of mental healthcare.
Self-respect and mental illness
Earlier I quoted Larry Davidson’s assertion that mental illness does not ‘fundamentally alter the basic nature of human beings, which is that of being self-determined agents, free to choose and pursue the kind of life they as individuals value. Mental illness does not rob people of their agency’ [Davidson et al 2009: 40-1]. I contrasted this with Hopper’s claim that ‘Deprivation and disgrace can so corrode one’s self worth that aspiration can be distorted, initiative undercut and preferences deformed’ [Hopper 2007: 877]. The detour via the recent philosophy of self-respect helps to shed light on the nature of the conflict here. If mental illness can corrode recognition self-respect then that alone can undermine autonomy and free-agency. But can it?
In this final section I will sketch two routes from mental illness to a loss of recognition self-respect and then draw some conclusions for recovery.
The first route is a directly from the pathology itself. Some mental illnesses directly impact on emotions. As Matthew Ratcliffe describes in his book length description of the phenomenology of depression, depression often involves an experience of guilt.
Depression experiences often involve feelings of all-enveloping, irrevocable guilt. These cause considerable suffering and are sometimes singled out as the most troubling symptom. Rowe (1978) quotes several interviewees with depression diagnoses who complain of profound guilt. One states that the depression itself is ‘a sign that I’m not what I should be’ (p.39). Another describes the experience as follows: ‘I feel I am suffering more than a murderer is suffering. In the end a murderer forgets and it all goes away from him. […] I know I’m not the only one that suffers from depression, but it’s my guilt—it’s worse than the depression’ (p.173). Talk of ‘guilt’ usually features alongside a host of related themes, including ‘inadequacy’, ‘shame’, and ‘damnation’. ‘Self-hatred’ is very common (e.g. Rowe, 1978, p.215), as is worthlessness (e.g. Styron, 2001, p.3). Several DQ [depression questionnaire] respondents similarly describe a feeling of being guilty, of a kind that does not attach to anything specific and permeates one’s relationship with the world as a whole: #16. When I am depressed everything seems so bad. It seems as if there is nothing good in the world and that all the bad is because of me somehow. #179 [When depressed] I hate myself. The reason my life is so awful at these times is because I am a terrible, wicked, failure of a person. I’m not a proper human being, I am a failed human being. Everything that goes wrong in my life is directly my fault; I caused it by not doing things I should have done, or doing things I shouldn’t have done. I am a waste of a human life. No-one knows just what a horrible useless nothing of a person I really am, because I hide it from people—if they ever found out the truth, they will all hate me and I will never have a single friend in the world ever again. [Ratcliffe 2015: 135]
Such experiences play a role akin to the case of gaslighting described above in that they undermine a proper self-appraisal of the subject as a competent agent. The illness of depression itself undermines the subject’s self-respect. Such a connection most obviously applies in the case of mental illnesses that involve emotional dysregulation such as major depression, PTSD and C-PTSD, Borderline Personality Disorder, and substance abuse. But it might also apply in cases of delusions of value. Bill Fulford describes the case of Mr H who having failed to give his children pocket money thought this a deeply wicked omission, a sign of his own worthless and that his family would be better off were he dead [Fulford 1989: 206].
A second route goes from having a mental illness to a loss of self-respect via the internalisation of social stigma towards such illness. In their paper ‘The paradox of self-stigma and mental illness’, Patrick Corrigan and Amy Watson argue that ‘[P]ersons with mental illness, living in a culture steeped in stigmatizing images, may accept these notions and suffer diminished self-esteem and self-efficacy as a result’ [Corrigan and Watson 2002: 35]. They quote a first person testimony.
I perceived myself, quite accurately unfortunately, as having a serious mental illness and therefore as having been relegated to what I called “the social garbage heap.” … I tortured myself with the persistent and repetitive thought that people I would encounter, even total strangers, did not like me and wished that mentally ill people like me did not exist. Thus, I would do things such as standing away from others at bus stops and hiding and cringing in the far corners of subway cars. Thinking of myself as garbage, I would even leave the sidewalk in what I thought of as exhibiting the proper deference to those above me in social class. The latter group, of course, included all other human beings. [Gallo 1994: 407–408].
Since social stigma attaches widely across different forms of mental illness, this connection to a loss of self-respect and hence diminishment of free agency is not limited to illnesses of emotional dysregulation.
What then of the prospects for a recovery model of mental healthcare? As I stressed in the first section, such a model is designed to counter historic psychiatric paternalism and to place the perspectives and values of those with mental illnesses at the heart of healthcare. But it does this by making the goal of healthcare the support of a flourishing life, whether or not accompanied by ongoing mental illness symptoms, identified by the subject him- or herself. It thus presupposes the agency and capacity for authorship of a conception of flourishing by the subject. The problem, however, is that mental illness can undermine self-respect and hence agency and the capacity for authorship in the way flagged in this and the previous section.
As I have described, Larry Davidson, a proponent of the recovery model, denies this. He claims that mental illness never robs people of their agency. But such a claim seems mere wishful thinking in the light of the connections explored here. If so, as Kim Hopper suggests, ‘sensitive work’ is required to compensate in order to preserve the anti-paternalist aims of the recovery model. ‘Sensitive’ because the imposition by a clinician of what are deemed to be the best interests of the patient would run counter to the ethos of the model. But it is surely better to acknowledge this tension at the heart of the current orthodox approach to mental healthcare than to deny some of the more damaging but all too frequent consequences of mental illness.
Bibliography
Benson, P. (1994) ‘Free Agency and Self-Worth’ The Journal of Philosophy 91: 650-668
Brown, W. and Kandirikirira, N (2007). Recovering mental health in Scotland. Report on narrative investigation of mental health recovery. Glasgow, Scottish Recovery Network
Chamberlin, J. (1978) On Our Own: Patient Controlled Alternatives to the Mental Health System, New York: McGraw-Hill
Clay, S. (1994) The wounded prophet. In Recovery: The New Force in Mental Health, Columbus, OH: Ohio Department of Mental Health
Coleman, R. (1999) Recovery: An Alien Concept, Gloucester: Hansell Publishing
Corrigan, P.W. and Watson, A.C. (2002) ‘The Paradox of Self-Stigma and Mental Illness’ Clinical Psychology: Science and Practice 9: 35–53
Darwall, S. (1995) ‘Two kinds of respect’ in Dillon, R.S. (ed.) Dignity, Character and Self-Respect, London: Routledge 181-97
Davidson, L. and Roe, D. (2007) ‘Recovery from recovery in serious mental illness: one strategy for lessening confusion plaguing recovery’ Journal of Mental Health 16: 459-470.
Deegan, P. E. (1988) ‘Recovery: the lived experience of rehabilitation’ Psychosocial Rehabilitation Journal, 11: 11-19
Deegan, P. (1996) ‘Recovery as a journey of the heart’ Psychiatric Rehabilitation Journal 19: 91-97
Deigh, J. (1995) ‘Shame and self-esteem: a critique’ in Dillon, R.S. (ed.) Dignity, Character and Self-Respect, London: Routledge 133-56
Frankfurt, H. (1971) ‘Freedom of the Will and the Concept of the Person’ Journal of Philosophy 68:5-20
Fulford, K.W.M. (1989) Moral Theory and Medical Practice, Cambridge: Cambridge University Press
Gallo, K. M. (1994) ‘First person account: Self-stigmatization’ Schizophrenia Bulletin 20: 407–410
Hopper, K. (2007) Rethinking social recovery in schizophrenia: what a capabilities approach might offer. Social Science & Medicine 65: 868-879
Lapsley, H., Waimarie, L. N. & Black, R. (2002) Kia Mauri Tau! Narratives of Recovery from Disabling Mental Health Problems, Wellington: Mental Health Commission
Leete, E. (1989) ‘How I perceive and manage my illness’ Schizophrenia Bulletin, 8: 605-609
Leibrich, J. (1999) A Gift of Stories: Discovering How to Deal with Mental Illness, Dunedin: University of Otago Press
Lovejoy, M. (1984) ‘Recovery from schizophrenia: a personal Odyssey’ Hospital and Community Psychiatry, 35: 809-812
Ramsay, R., Page, A., Goodman, T., et al (2002) Changing Minds: Our Lives and Mental Illness, London: Gaskell
Ratcliffe, M.R. (2015) Experiences of Depression: a study in phenomenology, Oxford: Oxford University Press
Rawls, J. (1995) ‘Self-respect, excellences, and shame’ in Dillon, R.S. (ed.) Dignity, Character and Self-Respect, London: Routledge: 125-32
Ridgeway, P. A. (2000) ‘Re-storying psychiatric disability: learning from first person narrative accounts of recovery’ Psychiatric Rehabilitation Journal 24: 335-343
Roberts, G. (1999) ‘The rehabilitation of rehabilitation: a narrative approach to psychosis’ In Healing Stories: Narrative in Psychiatry and Psychotherapy (eds G .Roberts & J. Holmes), pp. 152-180. Oxford: Oxford University Press.
Roberts, G. (2000) ‘Narrative and severe mental illness: what place do stories have in an evidence-based world?’ Advances in Psychiatric Treatment 6: 432-441
Roberts, G. and Wolfson, P. (2004) ‘The rediscovery of recovery: open to all’ Advances in Psychiatric Treatment 10: 37-49
Shepherd, G., Boardman, J. & Slade, M. (2008) Making Recovery a Reality London: Sainsbury Centre for Mental Health
Taylor, G. (1995) ‘Shame, integrity and self-respect’ in Dillon, R.S. (ed.) Dignity, Character and Self-Respect, London: Routledge: 157-80
Unzicker, R. (1989) ‘On my own: a personal journey through madness and re-emergence’ Psychosocial Rehabilitation Journal 13: 70-77
Over the last two decades, recovery has come to be promoted as a novel and desirable target for mental healthcare. It has become a proud boast that mental healthcare is recovery orientated. Nevertheless, whilst there is agreement that in this context, it does not mean merely getting better or returning to a previous state of health, there remains disagreement as to what exactly recovery is.
There is an increasing global commitment to recovery as the expectation for people with mental illness. There remains, however, little consensus on what recovery means in relation to mental illness. [Davidson and Roe 2007: 450]
The term ‘recovery’ appears to have a simple and self-evident meaning, but within the recovery literature it has been variously used to mean an approach, a model, a philosophy, a paradigm, a movement, a vision and, sceptically, a myth. [Roberts and Wolfson 2004: 38]
In this section, I outline a view of recovery I have developed previously [refs removed].
In the UK, a policy paper published by the Sainsbury Centre for Mental Health, titled ‘Making recovery a reality’, begins by summarising some key points of emphasis which, it is suggested, characterise any broadly conceived recovery-based approach. These points include:
Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems. Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness. Hope is central to recovery and can be enhanced by each person seeing how they can have more active control over their lives (‘agency’) and by seeing how others have found a way forward. Self-management is encouraged and facilitated. The processes of self-management are similar, but what works may be very different for each individual. No ‘one size fits all’. The helping relationship between clinicians and patients moves away from being expert / patient to being ‘coaches’ or ‘partners’ on a journey of discovery. Clinicians are there to be “on tap, not on top”. People do not recover in isolation. Recovery is closely associated with social inclusion and being able to take on meaningful and satisfying social roles within local communities, rather than in segregated services. Recovery is about discovering – or re-discovering – a sense of personal identity, separate from illness or disability. [Shepherd, Boardman and Slade 2008: 0]
The Scottish Recovery Network summarises its views of recovery in similar terms:
Recovery is about living a satisfying and fulfilling life. Recovery is about more than the absence of the symptoms of illness. Some people describe themselves as being in recovery whilst still experiencing symptoms. There can be lots of ups and downs during the recovery process – some people describe it as a journey. For this reason people often talk about being in recovery rather than recovered. Some people consider recovery as being ‘back to the way things were’ or back to ‘normal’ but for others recovery is more about discovering a new life or a new way of being. [Brown and Kandirikirira 2007: 3]
These lists provide a starting point for setting out a theoretical model of recovery. But there is a further structural constraint. To articulate a recovery model that is distinct from, or contrasts with, for example, a bio-medical model of mental healthcare, it is not enough to say that recovery (construed in some broad way) is a desirable aim of mental health care. One could hold that whilst holding a broadly bio-medical view of health and illness: for example, as pertaining to biological function versus dysfunction. To count as a distinct model of healthcare, it must offer more than just a broad aim but, rather, a theoretical conception of what illness, or health, or something like health is. (In the UK, the rise of the recovery movement coincided with both greater optimism within biological psychiatry of the efficacy of medicines but also the kind of theoretical articulation of a novel view of recovery with which I am here concerned. Both elements played a role, complicating the historical story.)
The characterisations of recovery in the quotations above suggest the importance of two distinctions. First, there is a distinction of focus between pathology and whatever is its relevant contrast, perhaps health or wellbeing. Second, there is the distinction between what is evaluative or normative and what is merely plainly factual. Together these can be used to sketch a distinct although abstract conception of recovery which genuinely contrasts with a medical model. It is to locate it on the health-focused rather than pathology-focused side of the first distinction and on the values-laden or normative side of the second. The recovery model combines: a) a focus on a conception of wellbeing and b) in normative or evaluative terms.
The latter element, however, merely hints at something of great importance to the recovery model. The normative and evaluative elements enter the picture in a conception of a life worth living as conceived by the patient or service user him- or herself. Healthcare resources are thus deployed in the service of choices and values of the patient whose views are thus central. This contrasts with a value-free conception of healthcare as aimed at returning patients to statistically normal or biologically functional states.
The recovery model is also opposed to paternalistic models of health service provision which are guided by the choices of clinicians on behalf of patients. An essential feature of recovery is thus the authorship of an agenda by patients themselves. One indication of this is the proliferation of ‘recovery stories’ as part of the promotion of the recovery approach. These explore:
the personal and existential dimensions of recovery, taking the form of subjective and self-evaluated accounts of how an individual has learned to accommodate to an illness. These accounts have become the founding stories of the recovery movement [e.g. Chamberlin, 1978; Lovejoy, 1984; Deegan, 1988, 1996; Leete, 1989; Unzicker, 1989; Clay, 1994; Coleman, 1999; Ridgeway, 2000], and anthologies of these personal stories have been used by governments and professions as a means of combating stigma and reasserting a focus on personal perspectives [Leibrich, 1999; Lapsley et al, 2002; Ramsay et al, 2002]. [Roberts and Wolfson 2004: 38-9]
Given this anti-paternalist stance, however, much weight has to be placed on the capacities of authorship and agency of those with mental illnesses. Thus Larry Davidson, a foremost proponent of the recovery approach to mental healthcare asserts:
There can be no recovery without self-determination… Mental illness may pose an obstacle to the person’s achievement of the kind of life he or she wishes to have, may make it more difficult to live that life, and, at its most extreme, may even deprive the person of life altogether. In none of these cases, though, does mental illness fundamentally alter the basic nature of human beings, which is that of being self-determined agents, free to choose and pursue the kind of life they as individuals value. Mental illness does not rob people of their agency, nor does it deprive them of their fundamental civil rights. [Davidson et al 2009: 40-1 italics added]
By contrast, Kim Hopper warns that the choices made people with mental illnesses may lack authenticity. Their choices may be affected or distorted as a consequence of illness itself or their treatment as a result of that illness.
Deprivation and disgrace can so corrode one’s self worth that aspiration can be distorted, initiative undercut and preferences deformed. Sensitive work will be needed to recover that suppressed sense of injustice and reclaim lost possibility. [Hopper 2007: 877]
In the rest of this paper I will shed light on the threat to authorship and agency raised by mental illness in virtue of its effects on self-respect and shame and thus suggest a tension at the heart of the recovery model.
Respect, self-respect, self-esteem, shame and action
While the concepts of respect, self-respect, self-esteem, shame, and agency are obviously interrelated, the precise nature of the connections is contested, with self-esteem more widely used in psychology and self-respect in philosophy especially moral philosophy [Roland and Foxx 2003]. In this section I will draw on the literature to set out some of their connections. If the connections are neither completely tight nor uncontentious, that will not undermine the key claim needed here: that loss of self-respect and feelings of shame can undermine free agency. Given, however, that some philosophers equate self-respect and self-esteem while others argue for their difference and given that there is disagreement concerning the absence of which is more closely connected to shame, it will be helpful to spell out a broad frame which can shed light on these differences. The best route to that is, I think, via Stephen Darwall’s distinction between two kinds of respect [Darwall 1995]
Darwall takes it for granted that respect for persons plays an important role in moral philosophy. But, he argues, moral philosophical accounts of it have in general failed to draw a key distinction between two kinds of attitude, which he labels ‘recognition respect’ and ‘appraisal respect’.
Of the former he says:
There is a kind of respect which can have any of a number of different sorts of things as its object and which consists, most generally, in a disposition to weigh appropriately in one’s deliberations some feature of the thing in question and to act accordingly. The law, someone’s feelings, and social institutions with their positions and roles are examples of things which can be the object of this sort of respect. Since this kind of respect consists in giving appropriate consideration or recognition to some feature of its object in deliberating about what to do, I shall call it recognition respect. [ibid: 183]
This form of respect applies more broadly than just to persons, though it also applies to persons. Holding the attitude – respecting, in this sense – simply consists in weighing some fact, such as that someone is a person, with their rights and roles, appropriately in deliberation and judgement. The object of this attitude is thus a fact. But given how potentially widely the idea of weighing facts in deliberation could range, to count as respect it must be restricted to weighing appropriately the moral propriety of acting in particular ways with respect to some fact.
The second attitude is appraisal respect. Darwall introduces it as follows:
There is another attitude which differs importantly from recognition respect but which we likewise refer to by the term “respect.” Unlike recognition respect, its exclusive objects are persons or features which are held to manifest their excellence as persons or as engaged in some specific pursuit. For example, one may have such respect for someone’s integrity, for someone’s good qualities on the whole, or for someone as a musician. Such respect, then, consists in an attitude of positive appraisal of that person either as a person or as engaged in some particular pursuit. [ibid: 183-4]
This attitude consists in the having of positive regard. It may in turn rationalise and motivate particular actions but whereas recognition respect is a disposition to an intellectual act – the weighing of something in deliberation – appraisal respect can be independent of any particular conception of how to act. A second distinction is that appraisal respect much more readily admits of degree. People merit appraisal respect in virtue of them meeting particular expectations. They can do this to greater and lesser degrees. By contrast, recognition respect turns on the status of someone simply as a person. And hence the distinction between the two attitudes explains the different aspects of respect for persons.
The distinction between appraisal respect and recognition respect for persons enables us to see that there is no puzzle at all in thinking both that all persons are entitled to respect just by virtue of their being persons and that persons are deserving of more or less respect by virtue of their personal characteristics. [ibid: 192]
It might be assumed that with the distinction in play, the ‘personal characteristics’ in virtue of which appraisal respect is earned might range over anything another subject might value. In fact, however, Darwall argues that genuine (appraisal) respect is more narrowly bounded. It must relate, in part at least, to excellence of character. Taking the example of a tennis player, he suggests that to be respected as a tennis player, one must demonstrate excellence in tennis playing. But that is not sufficient to merit respect as a person, even as a tennis player.
To begin with, somebody may be an excellent tennis player without being a highly respected one. He may be widely acclaimed as one of the best players in the world and not be widely respected by his fellows— though they may (in the extended recognition sense) respect his return of serve, his vicious backhand, and so on. Human pursuits within which a person may earn respect seem to involve some set of standards for appropriate and inappropriate behavior within that pursuit. In some professions this may be expressly articulated in a ‘code of ethics.’ In others it will be a more or less informal understanding, such as that of ‘honor among thieves.’ To earn more respect within such a pursuit it is not enough to exercise the skills which define the pursuit. One must also demonstrate some commitment to the (evolving) standards of the profession or pursuit. [ibid: 187]
In other words, while the personal characteristics necessary to perform a role skilfully may modify the excellences of character that merit respect, they do not replace them. They augment them.
The two distinct attitudes that comprise respect for persons also comprise forms of self-respect, since both are attitudes which one can bear to oneself. Thus:
It is recognition self-respect to which we appeal in such phrases as “have you no self-respect?” hoping thereby to guide behavior. This is not a matter of self-appraisal but a call to recognize the rights and responsibilities of being a person. [ibid: 193]
Similarly, like appraisal respect, appraisal self-respect is based on the excellences of persons that constitute good character. It is thus, according to Darwall, narrower or more specific than other forms of positive self-appraisal.
One such attitude is that which we normally refer to as self-esteem. Those features of a person which form the basis for his self-esteem or lack of it are by no means limited to character traits, but include any feature such that one is pleased or downcast by a belief that one has or lacks it. One’s self-esteem may suffer from a low of opinion of, for example, one’s appearance, temperament, wit, physical capacities, and so forth. [ibid: 194]
In other words, while both self-respect and self-esteem are forms of positive self-appraisal, the self-appraisal which constitutes self-respect is of oneself as a person, a being with a will who acts for reasons. I will return to this distinction shortly.
John Rawls offers the following influential account of the connection between self-respect or self-respect (between which he did not distinguish) and what he calls ‘moral shame’ which fits well with Darwall’s account of self-respect.
[S]omeone is liable to moral shame when he prizes as excellences of his person those virtues that his plan of life requires and is framed to encourage. He regards the virtues, or some of them anyway, as properties that his associates want in him and that he wants in himself. To possess these excellences and to express them in his actions are among his regulative aims and are felt to be a condition of his being valued and esteemed by those with whom he cares to associate. Actions and traits that manifest or betray the absence of these attributes in his person are likely then to occasion shame, and so is the awareness or recollection of these defects. [Rawls 1995: 129]
This conceptual articulation of shame has been criticised. John Deigh points out that shame is commonly felt over trivial things that do not seem connected to ‘excellences of character’. He gives the example of a young French girl who felt shame on her first day of school because her name ‘Mlle Péterat’ carried a connotation ‘which might be rendered in English by calling her Miss Fartwell’ [Deigh 1995: 141] As Deigh points out: ‘The morphemes of one’s surname do not make one better or worse suited for pursuing the aims and ideals around which one has organized one’s life’ [ibid: 141]. Further, shame is ascribed to small children.
Shaming is a familiar practice in their upbringing; “Shame on you” and “You ought to be ashamed of yourself” are familiar admonishments. And, setting aside the question of the advisability of such responses to a child’s misdemeanors, we do not think them nonsensical or incongruous in view of the child’s emotional capacities. Furthermore, close observers of small children do not hesitate to ascribe shame to them. [ibid: 142]
In such cases, it seems ridiculous to ascribe an explicit self-conception of ambition to excellences of character up to which the child, for example, has failed to live. Shame, Deigh argues, need not presuppose the rational reconstruction Rawls offers. In sum, it may apply more broadly than cases of the failure of an explicit failure of the form Rawls sets out.
That said, one way to reconcile this difference is to think that the archetype of shame is the one that Rawls describes and thus to think that the one ascribed in the case of young children, or to more trivial aspects of one’s person but not one’s character, is an extension of the archetypal or paradigmatic case. There are other species of the genus shame, though connected neither directly to a subject’s explicit conception of broader virtues (excellences of character) nor more narrowly to moral properties but rather more broadly to some conception of what is personally important. As Gabriele Taylor asserts:
Shame can be seen as a moral emotion, then, not because sometimes or even often it is felt when the person believes himself to have done something morally wrong, but rather because the capacity for feeling shame is so closely related to the possession of self-respect and thereby to the agent’s values. [Taylor 1995: 163]
With that broad outline of the nature of self-respect – and its connection to respect and self-esteem – and a standard Rawlsian account of its link to shame in place, I can now look to a further connection reflected in the literature. Failure of self-respect and shame undermine agency of the sort that underpins the recovery approach in mental health. In other words, failures of self-respect – and possibly self-esteem – are not just symptoms of mental illness but threaten the very idea of the current central aim in mental healthcare.
The link is explored by Paul Benson using, first, the example of the 1944 film Gaslight in which Ingrid Bergman plays a character married to an man who plans to reduce her to a state of confusion and disorientation such that she will not be able to block his plans to steal a jewel she has inherited. He does this by keeping her isolated, persuading her that she is losing her memory and generally confusing her by a variety of means which include turning down the titular gaslight (hence the phrase ‘gaslighting’). The net effect is not to undermine those abilities that are taken in ‘proceduralist’ accounts to underpin agency and autonomy such as Harry Frankfurt nested hierarchy of first order desires and second order endorsements of those desires [Frankfurt 1971]. As Benson says:
It is possible that Bergman [ie her character] has retained whatever procedurally definable abilities have been held to suffice for freedom. She can act intentionally. She is not frozen in space, nor are her bodily movements ‘mere behavior.’ Her will may not be afflicted with unconscious, compulsive, or otherwise ungovernable motives. And the privileged region of her will which, on any given theory, is allegiance or engagement as a free agent in her will, may be intact and functional, properly coupled to her behavior… Despite the possibility that Bergman can reflectively regulate or authorize her conduct, she is nevertheless not a free agent. She is quite disengaged from her actions. [Benson 1994: 655]
This case suggests a way in which a person’s autonomy can be undermined by undermining their self-respect, not that Benson puts it quite this way. The victim of gaslighting doubts her competence to make reasonable evaluations because of her, in fact fictitious, mental instability and thus doubts her capacity as an agent. She thus lacks recognitional self-respect by falsely thinking she is incapable of full autonomous agency.
Benson mentions a second relevant case. Shame, too, can undermine agency even when it does not directly undermine the features of a ‘proceduralist’ account of agency and autonomy (though it can do that too).
But shame can also diminish freedom when it involves a collapse of the person’s sense of worthiness to act. Like the gaslighted woman, the ashamed person can become dissociated from his reflective or evaluative capacities because his apparent dishonor or disgrace undercuts his view of himself as a competent agent. As before, this sort of disorientation need not impede the person’s capacities to authorize his will as his own... [Similarly] Slaves who internalized the debased public images of themselves as nonpersons felt barred from entering into relations or practices fit only for persons. [ibid: 658]
Having now sketched a distinction between two sorts of respect, and hence of self-respect and the potential connection between a lack of self-respect and the undermining of free action, I can now return to the challenge of the recovery model of mental healthcare.
Self-respect and mental illness
Earlier I quoted Larry Davidson’s assertion that mental illness does not ‘fundamentally alter the basic nature of human beings, which is that of being self-determined agents, free to choose and pursue the kind of life they as individuals value. Mental illness does not rob people of their agency’ [Davidson et al 2009: 40-1]. I contrasted this with Hopper’s claim that ‘Deprivation and disgrace can so corrode one’s self worth that aspiration can be distorted, initiative undercut and preferences deformed’ [Hopper 2007: 877]. The detour via the recent philosophy of self-respect helps to shed light on the nature of the conflict here. If mental illness can corrode recognition self-respect then that alone can undermine autonomy and free-agency. But can it?
In this final section I will sketch two routes from mental illness to a loss of recognition self-respect and then draw some conclusions for recovery.
The first route is a directly from the pathology itself. Some mental illnesses directly impact on emotions. As Matthew Ratcliffe describes in his book length description of the phenomenology of depression, depression often involves an experience of guilt.
Depression experiences often involve feelings of all-enveloping, irrevocable guilt. These cause considerable suffering and are sometimes singled out as the most troubling symptom. Rowe (1978) quotes several interviewees with depression diagnoses who complain of profound guilt. One states that the depression itself is ‘a sign that I’m not what I should be’ (p.39). Another describes the experience as follows: ‘I feel I am suffering more than a murderer is suffering. In the end a murderer forgets and it all goes away from him. […] I know I’m not the only one that suffers from depression, but it’s my guilt—it’s worse than the depression’ (p.173). Talk of ‘guilt’ usually features alongside a host of related themes, including ‘inadequacy’, ‘shame’, and ‘damnation’. ‘Self-hatred’ is very common (e.g. Rowe, 1978, p.215), as is worthlessness (e.g. Styron, 2001, p.3). Several DQ [depression questionnaire] respondents similarly describe a feeling of being guilty, of a kind that does not attach to anything specific and permeates one’s relationship with the world as a whole: #16. When I am depressed everything seems so bad. It seems as if there is nothing good in the world and that all the bad is because of me somehow. #179 [When depressed] I hate myself. The reason my life is so awful at these times is because I am a terrible, wicked, failure of a person. I’m not a proper human being, I am a failed human being. Everything that goes wrong in my life is directly my fault; I caused it by not doing things I should have done, or doing things I shouldn’t have done. I am a waste of a human life. No-one knows just what a horrible useless nothing of a person I really am, because I hide it from people—if they ever found out the truth, they will all hate me and I will never have a single friend in the world ever again. [Ratcliffe 2015: 135]
Such experiences play a role akin to the case of gaslighting described above in that they undermine a proper self-appraisal of the subject as a competent agent. The illness of depression itself undermines the subject’s self-respect. Such a connection most obviously applies in the case of mental illnesses that involve emotional dysregulation such as major depression, PTSD and C-PTSD, Borderline Personality Disorder, and substance abuse. But it might also apply in cases of delusions of value. Bill Fulford describes the case of Mr H who having failed to give his children pocket money thought this a deeply wicked omission, a sign of his own worthless and that his family would be better off were he dead [Fulford 1989: 206].
A second route goes from having a mental illness to a loss of self-respect via the internalisation of social stigma towards such illness. In their paper ‘The paradox of self-stigma and mental illness’, Patrick Corrigan and Amy Watson argue that ‘[P]ersons with mental illness, living in a culture steeped in stigmatizing images, may accept these notions and suffer diminished self-esteem and self-efficacy as a result’ [Corrigan and Watson 2002: 35]. They quote a first person testimony.
I perceived myself, quite accurately unfortunately, as having a serious mental illness and therefore as having been relegated to what I called “the social garbage heap.” … I tortured myself with the persistent and repetitive thought that people I would encounter, even total strangers, did not like me and wished that mentally ill people like me did not exist. Thus, I would do things such as standing away from others at bus stops and hiding and cringing in the far corners of subway cars. Thinking of myself as garbage, I would even leave the sidewalk in what I thought of as exhibiting the proper deference to those above me in social class. The latter group, of course, included all other human beings. [Gallo 1994: 407–408].
Since social stigma attaches widely across different forms of mental illness, this connection to a loss of self-respect and hence diminishment of free agency is not limited to illnesses of emotional dysregulation.
What then of the prospects for a recovery model of mental healthcare? As I stressed in the first section, such a model is designed to counter historic psychiatric paternalism and to place the perspectives and values of those with mental illnesses at the heart of healthcare. But it does this by making the goal of healthcare the support of a flourishing life, whether or not accompanied by ongoing mental illness symptoms, identified by the subject him- or herself. It thus presupposes the agency and capacity for authorship of a conception of flourishing by the subject. The problem, however, is that mental illness can undermine self-respect and hence agency and the capacity for authorship in the way flagged in this and the previous section.
As I have described, Larry Davidson, a proponent of the recovery model, denies this. He claims that mental illness never robs people of their agency. But such a claim seems mere wishful thinking in the light of the connections explored here. If so, as Kim Hopper suggests, ‘sensitive work’ is required to compensate in order to preserve the anti-paternalist aims of the recovery model. ‘Sensitive’ because the imposition by a clinician of what are deemed to be the best interests of the patient would run counter to the ethos of the model. But it is surely better to acknowledge this tension at the heart of the current orthodox approach to mental healthcare than to deny some of the more damaging but all too frequent consequences of mental illness.
Bibliography
Benson, P. (1994) ‘Free Agency and Self-Worth’ The Journal of Philosophy 91: 650-668
Brown, W. and Kandirikirira, N (2007). Recovering mental health in Scotland. Report on narrative investigation of mental health recovery. Glasgow, Scottish Recovery Network
Chamberlin, J. (1978) On Our Own: Patient Controlled Alternatives to the Mental Health System, New York: McGraw-Hill
Clay, S. (1994) The wounded prophet. In Recovery: The New Force in Mental Health, Columbus, OH: Ohio Department of Mental Health
Coleman, R. (1999) Recovery: An Alien Concept, Gloucester: Hansell Publishing
Corrigan, P.W. and Watson, A.C. (2002) ‘The Paradox of Self-Stigma and Mental Illness’ Clinical Psychology: Science and Practice 9: 35–53
Darwall, S. (1995) ‘Two kinds of respect’ in Dillon, R.S. (ed.) Dignity, Character and Self-Respect, London: Routledge 181-97
Davidson, L. and Roe, D. (2007) ‘Recovery from recovery in serious mental illness: one strategy for lessening confusion plaguing recovery’ Journal of Mental Health 16: 459-470.
Deegan, P. E. (1988) ‘Recovery: the lived experience of rehabilitation’ Psychosocial Rehabilitation Journal, 11: 11-19
Deegan, P. (1996) ‘Recovery as a journey of the heart’ Psychiatric Rehabilitation Journal 19: 91-97
Deigh, J. (1995) ‘Shame and self-esteem: a critique’ in Dillon, R.S. (ed.) Dignity, Character and Self-Respect, London: Routledge 133-56
Frankfurt, H. (1971) ‘Freedom of the Will and the Concept of the Person’ Journal of Philosophy 68:5-20
Fulford, K.W.M. (1989) Moral Theory and Medical Practice, Cambridge: Cambridge University Press
Gallo, K. M. (1994) ‘First person account: Self-stigmatization’ Schizophrenia Bulletin 20: 407–410
Hopper, K. (2007) Rethinking social recovery in schizophrenia: what a capabilities approach might offer. Social Science & Medicine 65: 868-879
Lapsley, H., Waimarie, L. N. & Black, R. (2002) Kia Mauri Tau! Narratives of Recovery from Disabling Mental Health Problems, Wellington: Mental Health Commission
Leete, E. (1989) ‘How I perceive and manage my illness’ Schizophrenia Bulletin, 8: 605-609
Leibrich, J. (1999) A Gift of Stories: Discovering How to Deal with Mental Illness, Dunedin: University of Otago Press
Lovejoy, M. (1984) ‘Recovery from schizophrenia: a personal Odyssey’ Hospital and Community Psychiatry, 35: 809-812
Ramsay, R., Page, A., Goodman, T., et al (2002) Changing Minds: Our Lives and Mental Illness, London: Gaskell
Ratcliffe, M.R. (2015) Experiences of Depression: a study in phenomenology, Oxford: Oxford University Press
Rawls, J. (1995) ‘Self-respect, excellences, and shame’ in Dillon, R.S. (ed.) Dignity, Character and Self-Respect, London: Routledge: 125-32
Ridgeway, P. A. (2000) ‘Re-storying psychiatric disability: learning from first person narrative accounts of recovery’ Psychiatric Rehabilitation Journal 24: 335-343
Roberts, G. (1999) ‘The rehabilitation of rehabilitation: a narrative approach to psychosis’ In Healing Stories: Narrative in Psychiatry and Psychotherapy (eds G .Roberts & J. Holmes), pp. 152-180. Oxford: Oxford University Press.
Roberts, G. (2000) ‘Narrative and severe mental illness: what place do stories have in an evidence-based world?’ Advances in Psychiatric Treatment 6: 432-441
Roberts, G. and Wolfson, P. (2004) ‘The rediscovery of recovery: open to all’ Advances in Psychiatric Treatment 10: 37-49
Shepherd, G., Boardman, J. & Slade, M. (2008) Making Recovery a Reality London: Sainsbury Centre for Mental Health
Taylor, G. (1995) ‘Shame, integrity and self-respect’ in Dillon, R.S. (ed.) Dignity, Character and Self-Respect, London: Routledge: 157-80
Unzicker, R. (1989) ‘On my own: a personal journey through madness and re-emergence’ Psychosocial Rehabilitation Journal 13: 70-77
Tuesday, 14 April 2020
Narrative identity and dementia
Narrative identity and dementia
Co-constructionist claims for narrative identity in dementia
It seems obvious that one of the harms that dementia does, both directly to the person who develops it and indirectly to their kith and kin, is to undermine the person’s identity. One reason for thinking this is that, since John Locke’s discussion of it, personal identity has been associated with continuity of a subjective perspective on the world held together by memory that that memory is severely curtailed in dementia. Hence dementia seems to threaten an individual’s identity as a particular person, gradually undermining it.
But the necessity, or the closeness, of the connection has been criticised by a number of philosophers and healthcare professionals who subscribe to a narrative account of personal identity. Their argument goes as follows. If personal identity is constituted through a personal narrative rather than, for example, a memory connection, then while the capacity to author a self-narrative also seems to be threatened by dementia, that need not undermine personal identity providing that the narrative that constitutes identity can be co-constructed. As dementia takes hold, authorial weight can fall to others.
Clive Baldwin, a professor of narrative studies with a social work background, argues in this way. First, he claims that human subjects have narratively constituted selves and hence, pessimistically, are susceptible to harm via that narrative in, for example, the case of dementia.
[W]e are indeed narrative beings who find our Selves in the stories we tell about ourselves and the stories that others tell about us; that narrativity is essentially an inter-personal activity; that some people find their stories marginalized, themselves as narrators dispossessed; but that it does not have to be that way. The stories we tell… can subvert the status quo and open the door to new ways of telling, and thus new ways of being. I will develop this argument through the lens of the experience of people with dementia, though it has been argued elsewhere that people experiencing severe mental illness may also be narratively dispossessed. [Baldwin 2008: 223]
But, more positively, the threat of such harm can be turned aside through the joint authorship and co-construction of identity-constituting narratives.
[W]e look towards the joint authorship of narratives where the narrative process is shared by people living with dementia and those around them. This may take the form of co-construction of narratives [see Keady & Williams 2005] whereby the final narrative is very deliberately and consciously a negotiated product between those people living with dementia and others or the piecing together and progression of the fragmented narratives of people living with dementia by those who support them. [ibid: 225]
The philosopher of psychiatry Jennifer Radden and psychotherapist Joan Fordyce deploy a similar argumentative strategy. First, they subscribe to a form of narrative identity theory concerning what Marya Schechtman calls ‘characterization identity’: ‘the set of characteristics each person has that make her the person she is’ [Schechtman 1996: 74].
A person’s identity comes in the form of a self-narrative in the work of many who employ these categories... The actions and experiences making up that narrative comprise the personal story of which the subject stands as ‘author’. [Radden and Fordyce 2006: 73]
Such self narratives are always, they suggest, co-constructed, though generally this is tacit. But in the case of dementia, the relative contributions to authorship change and become more noticeable.
The construction and sustaining of the person’s characterization identity have been, until the deficits of dementia make themselves known, collective efforts conducted largely tacitly. Increasingly, as these deficits erode aspects of the person’s memory and self-awareness, the task will come to include the provision of explicit identity recognition—a response that says, in some form, ‘this is who you are and what you are like’… Until now, also, to the extent that others were called on to sustain the identities of those around them, this task will have been largely mutual. Other people will have helped sustain, just as they helped constitute, my identity at the same time as I helped maintain (and constitute) theirs. Now, however, the task of holding and preserving the identity of the person suffering dementia will come to be placed more squarely on the shoulders of others (often, these are the shoulders of second persons, intimates, and the customary societal carers, women)… [Radden and Fordyce 2006: 81]
It might seem that this account is too optimistic. If personal identity is constituted by self-narratives that can be co-authored then providing that caregivers or kith and kin are ready to step up to the breach then dementia is no longer a threat to identity. Radden and Fordyce concede that this is not how it seems, however.
The most noticeable initial problem with this model is perhaps the discomfort and sense of falsity it sometimes brings upon those others left with the burden of sustaining the identity of a loved one through these processes of holding, reinforcing, and reinscribing. Although perhaps a distorted reaction, the response is often angry and disappointed. The loved identity seems to have gone—replaced by an alien changeling, it sometimes seems, or by no one. ‘This is what you were and were like’ we want to say to the dementia sufferer, ‘but no more!’… The heart-breaking aspect of this task of sustaining characterization identity cannot be ignored. Nonetheless, it is an enterprise apparently required by very notion of characterization identity as that identity has been defined and explained here. [Radden and Fordyce 2006: 81-2]
Taking the relevant sense of personal identity to be Schechtman’s characterization identity and taking that to be constituted by a co-constructed personal narrative, it follows, they claim, that there is a normative requirement on carers however angry and disappointed they may feel at the misleading appearance of the loss of their loved one. They do not, however, explain the nature of this obligation.
There is a further problem which can be illustrated by an example from the other end of life: it would allow the sincere ascription of youthful authorship of the ‘round robin’ letters sometimes written in the UK ‘as from’ small babies around Christmas. Such ascription would simply require a generous interpretation of a baby’s still limited behavioural repertoire by doting parents through which the meaning and thus authorial intention would be constructed, rather than revealed. There would be no further issue of whether this accurately tracked antecedent communicative intentions. Whilst in the case of such round robin letters no abuse – except perhaps of good taste – is risked, in the case of dementia the construction of a narrative by only one party in a supposed conversation does carry that risk.
Stephen Sabat, who has done much to promote the idea that even advanced Alzheimer’s sufferers may still be ‘semiotic subjects’ gives one such example:
In many cases, caregivers often do attribute intention to the afflicted person in that caregivers may believe that he or she is acting deliberately to annoy them, when in fact the annoying behaviour is due to cognitive impairment. If the afflicted person’s recall memory is severely affected, he or she may ask the same question repeatedly. This is hardly due to an intention to annoy anyone. It is of utmost import that caregivers identify the circumstances in which intention is present and healthy and not meant to annoy. [Sabat 2001, p. 222].
The idea of co-construction is particularly dangerous in psychiatry because of its history of paternalism. Humane responses to that history have stressed the perspective of individuals, the importance of respect for autonomy and patient values even where these are hard to discern. Suggesting that personal narratives, and hence selves, can be made up by others seems a complete abandonment of the rejection of paternalism by the most insidious of means. So why has the idea of constructing those, supposedly on someone else’s behalf, come to seem a humane response to dementia? I will argue that it follows from misrecognising the fundamental difference between this dangerous, paternalistic invocation of co-construction of personal identity and the innocent role of constructionism in response to an issue that looks superficially similar: asking whether someone is still the same person as they were before dementia but where the word ‘same’ is used in Wittgensteinian secondary sense. What may look merely like a subtle difference makes all the difference.
The structure of this paper is, sadly, quite complex. Starting, here, from Radden and Fordyce’s unfortunately paternalist account of identity and dementia, I will work ‘backwards’ and then ‘forwards’.
Radden and Fordyce’s account is based on Schechtman’s 1996 narrative account of personal identity. Schechtman argues for her narrative account by saying that it is a good answer to what she calls the ‘characterization question’, which she contrasts with the ‘reidentification question’. She rejects the reidentification question because neo-Lockean attempts to answer it fail. In arguing for this, however, she ignores the best neo-Lockean approach: McDowell’s anti-reductionist version. This is a defect in her argument given that it is in part, at least, an argument from elimination.
Working ‘forwards’, Schechtman’s answer to the characterization question is a substantive narrative theory of identity but both that question and her answer is ambiguous between a notion of basic identity and a richer notion of a moral subject. Because she says that she builds her account from two others, which I will characterise – following her citations – as Dennett’s and MacIntyre’s, I use these to assess the two interpretations or aspects of her account. There is, however, independent reason to reject Dennett’s account – and anything like it – leaving MacIntyre as the only plausible model of a narrative account. But his account does not support Radden and Fordyce’s stronger claims about co-construction. Further, since Schechtman’s account is motivated by an argument from elimination that ignores a better option, it is not clear we need a substantive account anyway. Freed from that, a better way of learning lessons from MacIntyre to apply in the case of dementia is available. Narrative can help shed light on very specific identity questions asked in the case of dementia but in a different way to Radden and Fordyce’s paternalism.
Marya Schechtman’s rejection of the reidentification question
Radden and Fordyce’s account of co-construction of identity is based on their modification of Marya Schechtman’s narrative constitution view of personal identity. That in turn is her proposed answer to what she calls the ‘characterization question’ which she contrasts with the more familiar reidentification question in the philosophy of personal identity.
Most simply put, this [characterization] question asks which actions, experiences, beliefs, values, desires, character traits, and so on… are to be attributed to a given person. Reidentification theorists ask [by contrast] what it means to say that a person at t2 is the same person as a person at t1; characterization theorists ask what it means to say that a particular characteristic is that of a given person. [Schechtman 1996: 73].
Schechtman prefers the characterization to the reidentification question and her proposed account of identity is an answer to the former rather than the latter. It might thus seem that, by answering a distinct question, it is incommensurable with answers to the latter question proposed by other philosophers, especially those working in a broadly Lockean framework. But although there is one relevant difference (to which I will return), I think that Schechtman takes her narrative constitution view to be an account of personal identity, however precisely that is to be understood, and hence to be a competitor to neo-Lockean accounts. Before returning to her answer to the characterization question, I will briefly sketch the nature of the reidentification question.
In a more recent book, Schechtman summarises her earlier approach thus:
I thus suggested that we instead think of the problem of personal identity as one of characterization—the question of which actions, experiences, and traits are rightly attributable to a person. The answer to a question of personal identity can then take the form of a relation between persons and psychological elements or actions rather than of a relation between time-slices. [Schechtman 2014: 100 latter italics added]
The contrast with a relation of time slices stems from a view of personal identity that derives from an interpretation of John Locke who said:
To find wherein personal identity consists, we must consider what person stands for; which, I think, is a thinking intelligent being that has reason and reflection and can consider itself as itself, the same thinking thing in different times and places. [Locke 1975: II.xxvii.9]
Person, as I take it, is the name for this self. Where-ever a Man finds, what he calls himself, there I think another may say is the same Person. It is a Forensick Term appropriating Actions and their Merit; and so belongs only to intelligent Agents capable of a Law, and Happiness and Misery. [Locke 1975: II.xxvii.26]
Locke thus suggests that personal identity has, and depends on, a continuity of inner perspective. To illustrate this, he considers a case in which the ‘Soul of a Prince, carrying with it the consciousness of the Prince’s past Life, enter[s] and inform[s] the Body of a Cobbler as soon as deserted by his own Soul’ In such a case, he claims that ‘every one sees, he would be the same Person with the Prince, accountable only for the Prince’s Actions’ [Locke 1975: II.xxvii.15].
This has inspired a philosophical industry concerning the idea that being the very same person, in the forensic sense of the person who should be punished for the earlier self’s crimes, is constituted by a kind of internal consciousness of identity over time. And then, so the thought goes, if that is the case, then it ought to be possible to give an account of this continuous inner awareness in terms which do not presuppose sameness of the person over time because the aim is to define the latter using the former.
There are, then, some familiar questions. Is it really the case that events that someone does not recall cannot be part of their temporally extended existence as a subject? And does not memory presuppose the identity of the self/person because memory is awareness of things that have happened to oneself, not just historical knowledge in an impersonal manner? Various solutions have been outlined.
Schechtman argues, however, that none of the standard answers to the reidentification question in the Lockean tradition are successful. For that reason, she recommends swapping questions and then proposing a narrative answer to her preferred question. Before considering that, it is, however, worth highlighting an option she ignores.
As John McDowell argues, there is no need to assume that a reductionist project must work [McDowell 1994: 325-40]. He suggests instead that we should not take Locke to be trying to reduce personal identity to continuity of inner awareness (and failing at that because Locke says explicitly: ‘can consider itself as itself, the same thinking thing in different times and places’ which presupposes sameness). But, rather, Locke is pointing out non-reductively that it is a feature of persons that they have an inner perspective on their lives which gathers together events as theirs without any criterion or test of identity and without even the exercise of a skill in picking themselves out (contrasting the way that one might keep track of one of the red balls in a game of snooker). One does not have to identify oneself to oneself, one’s memories as one’s own rather than someone else’s. But that is not because one is a special locus of ‘mind-stuff’ as Descartes assumed. No, it is because one is a body, with bodily criteria of identity, but one which happens to have – as a human – an inner perspective too which goes hand in hand, effortlessly, and, in general, agrees with those bodily criteria.
What are those bodily criteria for the identity of persons over time? Here, McDowell rather breezily suggests spatio-temporal continuity under a sortal. One way to make this clear is to imagine an alien with a very different kind of bodily life – perhaps as a cloud of gas – studying plant and animal life on earth down as far as the cellular level. As a rabbit, for example, lives, it eats grass and excretes dung. Thus vegetable matter gets merged with the rabbit and separated. Over time, there are complex chains of connection. But the spatio-temporal continuity of any particular rabbit does not have to take account of the grass and the dung with which it is brutely continuous: but rather the career of the rabbit itself rather than its food or dung. In other words, an appeal to spatio-temporal continuity is not a reductionist explanation of rabbit identity over time. Rather, the relevant mode of spatio-temporal continuity presupposes the sortal rabbit. The same applies to persons though with some complications.
One such complication is raised by the science fiction cases of the sort Locke himself considers: the mind of the prince transported into the body of the cobbler. In such a case, identity goes with the inner dimension rather than the outer body. But that is not to say that, in general, we have an understanding of the inner dimension independently of, or more fundamental than, the normal bodily criteria of identity.
The fact that Schechtman ignores this possibility is one reason to be suspicious of her argument from elimination in favour of the characterisation over the reidentification question. There may simply be no need to articulate a narrative theory of identity in the first place. Putting this point on hold for the moment, I will outline the development of her answer to her favoured question.
Schechtman’s characterization question and narrative constitution answer
In more recent work, Schechtman provides the following overview of her position.
I thus suggested that we instead think of the problem of personal identity as one of characterization—the question of which actions, experiences, and traits are rightly attributable to a person. The answer to a question of personal identity can then take the form of a relation between persons and psychological elements or actions rather than of a relation between time-slices. Such an account, I argued, will be non-reductive but still informative. In particular I urged that rather than thinking of identity-constituting psychological continuity in terms of overlapping chains of psychological connections properly caused, we should instead understand it in narrative terms, a revision made possible by framing the question as one of characterization. We constitute ourselves as persons, on this view, by developing and operating with a (mostly implicit) autobiographical narrative which acts as the lens through which we experience the world. [Schechtman 2014: 100]
The characterization question, and her answer to it, is, however, ambiguous. In asking which actions, experiences, and traits are rightly attributable to a person, it might be asking which are authentic expressions of the person, their moral selves, aspects of their deeper character by contrast with momentary whims or temptations, or the distortions of alcoholic high spirits, for example. Or it might mean simply which of all the actions in human history were those of a particular person. More prosaically, the latter might be asked by a detective of an act of theft: who did it?
Schechtman has conceded this point about her earlier 1996 work.
For many, the switch from the reidentification to the characterization question automatically signals a switch to questions about the moral self. There are some good reasons for thinking so—my first move in introducing the view is to draw a distinction between the “Who am I?” question raised by a confused adolescent (which I link to the characterization question) and the “Who am I?” question asked by an amnesia victim (which I link to the reidentification question). At the same time, however, I meant for the characterization question also to answer questions about attribution at the most fundamental level—not only which beliefs and desires are truly mine in the sense of the moral self, but which are mine in the most basic and literal sense. [Schechtman 2014: 102]
Given this latent ambiguity in the question, how should her earlier 1996 answer – the account which informs Radden and Fordyce’s view – be assessed? Fortunately, in her earlier work, Schechtman suggests a clue. She reports that her narrative constitution view:
draws its inspiration from a number of sources both philosophical and psychological which argue either that persons are self creating… or that the lives of persons are narrative in form. Weaving strands from these discussions together with my own analysis, I develop a view according to which a person creates his identity by forming an autobiographical narrative – a story of his life. [Schechtman 1996]
I suggest that these two distinct strands are responses to distinct interpretations, or aspects, of the characterization questions and I will use two of the philosophers Schechtman cites as sources to examine these two strands: Dennett and MacIntryre.
Schechtman cites Daniel Dennett as a philosopher who defends the idea that persons are self-creating. He claims that a self is a ‘centre of narrative gravity’. To outline his view, he suggests an analogy with the physical notion of a centre of gravity.
A centre of gravity is just an abstractum. It’s just a fictional object. But when I say it’s a fictional object, I do not mean to disparage it; it’s a wonderful fictional object, and it has a perfectly legitimate place within serious, sober, echt physical science. [Dennett 1992: 104]
The idea of a centre of gravity is deployed within a branch of physics to describe and predict the behaviour of physical systems acting under physical forces. What a centre of gravity is depends on this theoretical context and it is one of the useful tools and ideas that go to make that context. The concept is one amongst others interdependent on a theoretical stance.
Selves are given similar treatment. Like centres of gravity or mental states, they are theoretical, even fictional, entities articulated within an interpretative theoretical stance.
A self is also an abstract object, a theorist’s fiction. The theory is not particle physics but what we might call a branch of people-physics; it is more soberly known as a phenomenology or hermeneutics, or soul-science (Geisteswissenschaft). The physicist does an interpretation, if you like, of the chair and its behaviour, and comes up with the theoretical abstraction of a centre of gravity, which is then very useful in characterising the behaviour of the chair in the future, under a wide variety of conditions. The hermeneuticist or phenomenologist--or anthropologist--sees some rather more complicated things moving about in the world--human beings and animals--and is faced with a similar problem of interpretation. It turns out to be theoretically perspicuous to organise the interpretation around a central abstraction: each person has a self (in addition to a centre of gravity). In fact we have to posit selves for ourselves as well. The theoretical problem of self-interpretation is at least as difficult and important as the problem of other-interpretation. [ibid: 104]
What is the motivation for Dennett’s version of a narrative approach? I think that it is useful to consider the perceived alternative to it that Dennett rejects. He gives a clear statement of this in the following passage which starts with a brisk re-iteration of the advantages of his narrative account for describing psychopathology but also mentions the alternative to which it stands opposed.
We sometimes encounter psychological disorders, or surgically created disunities, where the only way to interpret or make sense of them is to posit in effect two centers of gravity, two selves. One isn’t creating or discovering a little bit of ghost stuff in doing that. One is simply creating another abstraction. It is an abstraction one uses as part of a theoretical apparatus to understand, and predict, and make sense of, the behavior of some very complicated things. The fact that these abstract selves seem so robust and real is not surprising. They are much more complicated theoretical entities than a center of gravity. And remember that even a center of gravity has a fairly robust presence, once we start playing around with it. But no one has ever seen or ever will see a center of gravity. As David Hume noted, no one has ever seen a self, either. [ibid: 114]
Dennett here supports his account by reinforcing the apparent robustness and reality of narrative selves on the basis of a comparison with the robustness of centres of gravity. Nevertheless they are ‘created’ abstractions. And this contrasts with the other possibility: ‘creating or discovering a little bit of ghost stuff’. I take it that more important alternative here is ‘discovering a little bit of ghost stuff’ which stands in as a brisk summary of a Cartesian account.
It should come as no surprise that Dennett’s main opponent is a form of Cartesianism, whether of a traditional immaterialist kind or a form of materialism which shares a key feature. That feature, and a key target of his Consciousness Explained, is the idea that ‘somewhere, conveniently hidden in the obscure ‘centre’ of the mind/brain, there is a Cartesian Theatre, a place where ‘it all comes together’ and consciousness happens’ [Dennett 1993: 39]. Even if Descartes’ immaterialism is rejected, this idea can remain implicit in thinking about the brain.
Let’s call the idea of such a locus in the brain Cartesian Materialism, since it’s the view you arrive at when you discard Descartes’s dualism but fail to discard the imagery of a central (but material) Theatre where ‘it all comes together’. The pineal gland would be one candidate for such a Cartesian Theatre… [Dennett 1993: 107].
I take it that an immaterial centre might constitute a self and a material centre could at least underpin one. Dennett rejects any such approach and deploys the narrative account as (part of) his alternative. This also explains his comment (above) that ‘[a]s David Hume noted, no one has ever seen a self’. He continues by quoting with approval Hume’s doomed attempt to spot his own self among his mental states.
For my part, when I enter most intimately into what I call myself, I always stumble on some particular perception or other, of heat or cold, light or shade, love or hatred, pain or pleasure. I never can catch myself at any time without a perception, and never can observe anything but the perception.... If anyone, upon serious and unprejudiced reflection, thinks he has a different notion of himself, I must confess I can reason no longer with him. All I can allow him is, that he may be in the right as well as I, and that we are essentially different in this particular. He may, perhaps, perceive something simple and continued, which he calls himself; though I am certain there is no such principle in me. [Hume 1978: 252]
Hume’s final comment is clearly meant to be ironic. Introspection, Hume suggests, reveals nothing that could stand in the sort of relation to one’s mental states that a self is supposed to do. This leads him to advocate a minimalist ‘bundle theory’ of mind. The self is identified simply with the mental states encountered in instrospection and not with an ego which stands in a relation to them.
Dennett shares Hume’s opposition to a Cartesian ego but he adds a principle of organisation to the mental states gathered together via narrative. The self is not just a bundle of states but states structured in a narrative. Given his related account of mental states there is no tension between primitively real mental states and mere fictional selves. Both mental states and the narrative structure that adds up to a self are theoretical constructs. But it is also important to note that there is no antecedently understood author to the narrative. That idea would correspond to a substantial, pre-narrative self. Dennett’s idea, by contrast, is that the self just is the structured narrative.
Given the choice between Cartesian ‘ghost stuff’ and a narrative account, then the latter is obviously the more attractive. It also seems to receive support as descriptively accurate from both Hume’s introspection and Dennett’s ‘hetero-pheomenological’ method which at least takes account of first person reports (whilst not uncritically according them apodictic certainty). But the choice is, nevertheless, a forced choice.
If Schechtman’s narrative constitution account is viewed through the prism of Dennett’s account, then it can be seen as answering the more austere question of basic identity, rather than to the richer notion of the nature of the moral self. Schechtman seems to take a narrative answer to the characterization question to be a rival to the reductionist version of the neo-Lockean account of basic identity. Sniffy about traditional accounts that argue that the different temporal stages of a person are unified by overlapping chains of memory, she raises a prior question: ‘what unites even at a given temporal stage the experiences that are those of a particular individual?’ answering narrative. Narrative unites at a given time. But it also unites over time because narratives are temporally extended wholes. Further, it suggests a nice distinction. On a narrative account, temporal elements are abstractions from a whole rather than free-standing elements needing uniting together. They are more like the pitch and timbre of a note than like the individual bricks that can be combined to make a wall.
Dennett, too, deploys narrative as a basic principle of organisation to unite actions, experiences, and traits in a single person. But although it is austere, it is nevertheless radical. Fully assessing such a radical claim about the connection between self and narrative lies outside the scope of this paper. But it is worth noting that, influential though it has been, it faces at least three significant difficulties:
First, what is the claim actually being made? Are selves narratives or are they the authors of narratives? They cannot be both. But in many published accounts, these two ideas are not consistently distinguished. Baldwin, for example, blurs both together because, in addition to the claim above that selves are stories, he also says:
If we are narrative beings and the primary narrative of our life is the one we construct for ourselves in relationship with others, then the maintenance of narrative agency takes on major importance. [Baldwin 2005: 1025, italics added]
According to this second passage, we construct, or are authors, of the narrative rather than being the narrative itself. Similarly, in the quotation above, Dennett says ‘In fact we have to posit selves for ourselves as well’ (italics added). But if selves are authors of narratives then what constitutive work is the idea of narrative doing, after all?
Second, if selves are, literally, narratives then how do narratives have meaning? A narrative is made up of a collection of signs (written or spoken). So how can those signs come to carry a meaning? The problem is this. Most plausible account of how linguistic meaning is possible presuppose an embodied agent whose beliefs and actions are appealed to to explain meaning. Gricean theories, for example, explain linguistic meaning by appeal to a speaker’s intentions to communicate his or her beliefs by such and such signs [Grice 1969]. But a narrative account of self inverts that order of priority and thus must, somehow, explain the meaning of a narrative without appealing to agents. And that seems a difficult venture.
Third, if selves are constituted by narratives then the component elements of the narratives must not presuppose any concept of self. But it is difficult to see how a narrative account of self could avoid including elements which correspond to psychological states. A narrative which avoided all mention of mental phenomena would be useless to explain the notion of a self. But if the narrative presupposes psychological states, then that will surely, illicitly, presuppose a concept of self of whom the psychological states are states [Thornton 2003].
I think that the difficulties Dennett’s account faces are endemic in substantive narrative accounts of the metaphysics of the self. If this is a strand in Schechtman’s narrative account, so much the worse for it.
Schechtman also invokes a distinct idea: the lives of persons are narrative in form. One philosopher she invokes in support of this idea is Alasdair MacIntryre. This idea, while still contentious, is much less radical than the idea that selves just are narratives. MacIntryre, for example, is led to it through a consideration of the way action explanation iterates.
It is a conceptual commonplace, both for philosophers and for ordinary agents, that one and the same segment of human behavior may be correctly characterized in a number of different ways. To the question ‘What is he doing?’ the answers may with equal truth and appropriateness be ‘Digging’, ‘Gardening’, ‘Taking exercise’, ‘Preparing for winter’ or ‘Pleasing his wife’. Some of these answers will characterize the agent’s intentions, other unintended consequences of his actions, and of these unintended consequences some may be such that the agent is aware of them and others not. What is important to notice immediately is that any answer to the questions of how we are to understand or to explain a given segment of behavior will presuppose some prior answer to the question of how these different correct answers to the question ‘What is he doing?’ are related to each other. [MacIntryre 1981: 206]
MacIntryre argues that the interconnection between different explanations of actions appealing to narrower or broader contexts has the form of a narrative. Actions are intelligible insofar as they can be fitted into an intelligible narrative and this process iterates. Making sense of one action by citing a broader context of action into which it fits itself presupposes that that broader context makes sense. And hence, MacIntryre concludes, it presupposes a narrative view of the whole of a life, which he connects to the idea of personal identity or selfhood.
What the narrative concept of selfhood requires is thus twofold. On the one hand, I am what I may justifiably be taken by others to be in the course of living out a story that runs from my birth to my death; I am the subject of a history that is my own and no one else’s, that has its own peculiar meaning. I am not only accountable, I am one who can always ask others for an account, who can put others to the question. I am part of their story, as they are part of mine. The narrative of any one life is part of an interlocking set of narratives… To be the subject of a narrative that runs from one’s birth to one’s death is, I remarked earlier, to be accountable for the actions and experiences which compose a narratable life. [MacIntryre 1981: 217]
If Schechtman’s narrative constitution account is viewed through the prism of MacIntryre’s account, then it can be seen as answering to the richer notion of the nature of the moral self rather than to more austere question of basic identity because, as MacIntryre acknowledges, his is a modest and anti-reductionist account of selfhood or personal identity.
I am not arguing that the concepts of narrative or of intelligibility or of accountability are more fundamental than that of personal identity. The concepts of narrative, intelligibility and accountability presuppose the applicability of the concept of personal identity... [MacIntryre 1981: 218]
The account charts a connection between selves as subjects or agents, their actions and the broader narratives into which these fit. It does not provide an independent way to characterise selves, persons or personal identity.
There is reason, too, to believe that this is the sense of identity that Radden and Fordyce have in mind.
New terms and contrasts have been introduced to separate the more political, and more recent, types of identity discourse. Marya Schechtman speaks of identity as concerning characterization (Schechtman 1996) (The identity associated with earlier theorizing in the Lockean tradition she designates reidentification identity, in contrast.)... The notion of characterization identity captures other presuppositions found in less formal discussions of identity as well, particularly those associated with the politics of recognition. [Radden and Fordyce 2006: 73]
But does a narrative account of a richer notion of identity, associated with identity politics and identity crises, and on the model of MacIntryre’s account, support their radical con-constructivist claims?
There is no reason to think it does. MacIntryre’s account is a generalisation from action explanation by reasons concerning which neither constructivism nor co-constructivism seem plausible. The ascription, or avowal, of a reason for action answers to the facts about motivation rather than constructing them. First person reports can be sincere or insincere because of that. While first person privilege attaches to reports of motivation, as it does for other aspects of mental life, this is not where the element of truth in constructionism applies to action explanation specifically. That element consists in the fact that actions are constituted – created, perhaps – by agents. Decisions are made – constructed, perhaps – by subjects and, if they are practical, executed. But subsequent explanations of actions answer to those facts. Co-construction may thus apply to decisions for action jointly arrived at but that provides no grounds for thinking co-constructivism is true of action explanations. And hence there is no reason to think it anything other than a distortion of a narrative conception of the whole of a life, and hence a self, on MacIntyre’s view. Co-constructivism is not only dangerously paternalistic in the case of dementia but it is also implausible as any account of personal identity.
A positive use of narrative in dementia?
Despite this sceptical view of narrative as a means of co-constructing identity in the face of dementia, it may, nevertheless have some role. Consider the case of the offspring who asks of their elderly and confused father: ‘Is he still my dad? Is he still him?’ Such a question is not a question about what Schechtman calls basic identity, which might be asked by a long-lost offspring in order to find which unrecognised person in a nursing home, for example, is their father. Rather, if the question is asked of a particular person, whether he is still their father, it carries a different sense.
I suggest that it is a question about whether there is still sufficient continuity of character to count as the same person in a richer but quite specific sense (see below). This is not simply the characterization question as reconstructed using MacIntrye’s narrative concept of selfhood (and certainly not as asking about the basic sense of identity in the style of Dennett’s account of narrative centres of gravity). It is asked in a context in which, despite the person concerned being the same person – in the basic sense – who used to be a loving father or fugitive Nazi, or, strangely, both, the ravages of memory loss call into question one sense of (Lockean) forensic identity. In the case where the father is a fugitive Nazi, there may be no reason to punish a confused old man who has no understanding of that for which he is being punished. But neither the clear answer: ‘Yes: he is the same person in the basic sense of identity’ nor the answer ‘No: he should not be held forensically responsible for past actions because he has lost his memory of them’ is appropriate for this question. And yet it is a question that can seem pressing.
That questions asked with the same words may call for quite different answers is nicely illustrated in a discussion of Wittgenstein’s critique of Frazer’s Golden Bough.
Someone bereaved might exclaim, ‘Why did she die?’ Such a question, uttered in a particular tone and under particular circumstances, would only be taken by the most obtuse as requests for an explanation – as being satisfied by the sort of response appropriate to the question in the context, say, of a coronial enquiry. [Redding 1987: 264.]
In such a case, what looks like a question may not be one at all but an expression of loss clothed in interrogative form. By contrast, in the case I have in mind, I do think that the apparent question “Is he still my dad?” is a genuine question meaning something like: “Is he still the same person that I remember” but in such a way that the notion of sameness is not captured by either the basic or the forensic senses set out above.
I suggest that the asking of this question in this context stands to those senses in the way that Wittgenstein describes as ‘secondary sense’ [Wittgenstein 2009 [1953] ptII sec xi]. The first instance he gives is the attitude most of us have towards words. We feel that a word carries its meaning somehow immediately with it. It can lose this kind of meaning if repeated. Wittgenstein describes this kind of immediate perception of the meaning of a word in isolation as a form of understanding meaning. Since Wittgenstein’s official recommendation is to think of understanding as grasp of a practice, the use of the words ‘understanding’ and ‘meaning’ in the case at hand is not straightforward. It is not a metaphor, however, because nothing can be said to explain why we want to use these words for this kind of experience. But whilst this is not a metaphorical use it is nevertheless a secondary use: one which we find natural given the primary use, but which is discontinuous with, and could not be used to teach, the primary use.
Another example Wittgenstein gives is the use of ‘fat’ in the claim that Wednesday is fat.
Given the two concepts ‘fat’ and ‘lean’, would you be inclined to say that Wednesday was fat and Tuesday lean, or the other way round? (I am strongly inclined towards the former.) Now have “fat” and “lean” some different meaning here from their usual one? – They have a different use. – So ought I really to have used different words? Certainly not. – I want to use these words (with their familiar meanings) here… Asked “What do you really mean here by ‘fat’ and ‘lean’?”, I could only explain the meanings in the usual way. I could not point them out by using Tuesday and Wednesday as examples… The secondary meaning is not a ‘metaphorical’ meaning. If I say, “For me the vowel e is yellow”, I do not mean: ‘yellow’ in a metaphorical meaning a for I could not express what I want to say in any other way than by means of the concept of yellow. [Wittgenstein 2009 pt II §§274-278]
Secondary sense as introduced is neither a metaphor nor a simile because there is no way to begin to justify the use by articulating the similarity with the literal sense. It is spontaneous extension of the paradigmatic meaning of a word but reliant on that meaning.
Whilst experiencing the meaning of a word or ascribing a width to days of the week may seem to be of limited interest, the Wittgensteinian philosopher Oswald Hanfling argues that the secondary use of words is widespread (Hanfling, 1991). In aesthetics, he argues, words such as ‘sad’ applied to music are used in secondary sense. (The music need not make a hearer sad, does not sound like a sad person etc.). In the description of feelings, phrases such as ‘pins and needles’, ‘butterflies in the stomach’ and ‘stabbing pains’ are all used in this way. Wittgenstein’s own description of ‘feelings of unreality’ in which ‘everything seems somehow not real’ is also secondary.
Wittgenstein himself gives an example of an aesthetic description of a piece of music which seems to be a case of secondary sense:
If I say for example: Here it’s as if a conclusion were being drawn, here as if something were confirmed, this is like an answer to what went before—then my understanding presupposes a familiarity with inferences, with confirmations, with answers [Wittgenstein 1967 §175]
The application to music of language whose primary use concerns the description of arguments lacks a justification through an appeal to objective similarities. Someone who was mystified by this deployment of language need have made no mistake. But that is not to say that for those for whom this extension comes naturally there are no aesthetic justifications for hearing a particular phrase as a conclusion of a previous passage of music or as answering a previous phrase. Such justifications might consist in playing the music with a particular emphasis or stripped of some of its detail. So while there is no justification for the whole extension of a language of argument to music, for those who do find it natural there can be justifications or points of disagreement for specific applications. Nevertheless, even in this case, the justifications can come to an end without agreement and again implying no cognitive shortcoming. One may simply disagree with hearing a theme as the conclusion.
Aesthetic discussions [are] like discussions in a court of law, where you try to “clear up the circumstances” of the action which is being tried, hoping that in the end what you say will “appeal to the judge”... if by giving reasons of this sort you make another person “see what you see” but it still “does not appeal to him” that is “an end” of the discussion. [Moore 1955: 19]
This combination of (unjustified) spontaneous extension but piecemeal partial justification captures the case at hand. The offspring who asks whether their father is still their father, still the same person, still their ‘dad’, even though already having answers to the basic question and the forensic question is pressing the notion of sameness in a novel way. ‘Same’ in this case is used in secondary sense.
In this context, narrative can provide the material for a response which does not simply answer to the facts. Imagine a case in which the elderly person in question cannot recall who his children are but, despite that, he reacts to them with affective warmth. Perhaps hearing a once familiar tune prompts jovial attempts to whistle the refrain. Perhaps he is visibly calmer in the presence of his offspring, instinctively reaching out a hand. In such a case, a narrative account may weave together these affective responses in a such a way to trump cognitive failings. Perhaps the offspring sees in a single gesture, or hears in a single characteristic utterance, sufficient sign of the presence of the remembered father to be reassured and to answer the question in the affirmative.
In such case, the mark of the success of the narrative in conveying an answer to the question – whether happily positive or sadly negative – is not simply answering to neutral facts. Rather, it is the response, to the proffered narrative answer, of the person who asks the question, akin to Wittgenstein’s account of aesthetic justification. The success of the narrative answer lies in part at least in the affective response of the person who asks the question. What constitutes the success of the narrative in affirming or denying that the person still is the father is not its objectively successfully marshalling the facts but rather its being accepted as significant by the questioner.
That is, I suggest, the very limited truth in a constructionist approach to a narrative form of identity in dementia, one which carries no risk of insidious paternalism.
References
Baldwin, C. (2005) ‘Narrative, ethics and people with severe mental illness’ Australian and New Zealand Journal of Psychiatry 39: 1022-1029
Baldwin, C. (2008) ‘Narrative(,) citizenship and dementia: The personal and the political’ Journal of Aging Studies, 22: 222–228
Dennett, D. (1992) ‘The Self as a Center of Narrative Gravity’ in Kessel, F. and Cole, P. and Johnson, D., Eds. Self and Consciousness: Multiple Perspectives. Hillsdale, NJ: Erlbaum reprinted at cogprints.ecs.soton.ac.uk/archive/00000266/
Grice, H.P. (1969) ‘Utterer’s meaning and intentions’ Philosophical Review 78: 147-77
Hanfling, O. (1991). I heard a plaintive melody. In A. Philips Griffiths, (Ed.), Wittgenstein centenary essays. Cambridge: Cambridge University Press
Hume, D. (1978) A Treatise of Human Nature, Oxford: Oxford University Press
Keady, J., & Williams, S. (2005) ‘Co-constructed inquiry: A new approach to the generation of shared knowledge in chronic illness’ Paper presented at RCN International Research Conference. Belfast.
Locke, J. (1975) An Essay Concerning Human Hnderstanding, Oxford: Oxford University Press
MacIntyre, A. (1981) After Virtue, Notre Dame, Indiana: University of Notre Dame Press
McDowell, J. (1998) Mind value and reality, Cambridge, Mass.: Harvard University Press
Moore, G.E. (1955) ‘Wittgenstein’s Lectures in 1930-33’ Mind 64: 1-27
Radden, J. and Fordyce, J. (2005) ‘Discursive psychology, social constructionism and dementia’ in J. Hughes, S. Louw and S. Sabat (eds) Dementia: Mind, Meaning and the Person Oxford: Oxford University Press
Redding, P. (1987) ‘Anthropology and ritual: Wittgenstein’s reading of Frazer’s The Golden Bough’, Metaphilosophy 18: 264.
Schechtman, M. (1996) The Constitution of Selves, New York: Cornell University Press
Schechtman, M. (2014) Staying Alive: Personal Identity, Practical Concerns,and the Unity of a Life, Oxford: Oxford University Press
Thornton, T. (2003) ‘Psychopathology and two varieties of narrative account of the self’ Philosophy Psychiatry and Psychology 10: 361-367
Wittgenstein, L. (1967) Zettel, Oxford: Blackwell
Wittgenstein, L. (2009 [1953]) Philosophical Investigations, Oxford: Blackwell
Co-constructionist claims for narrative identity in dementia
It seems obvious that one of the harms that dementia does, both directly to the person who develops it and indirectly to their kith and kin, is to undermine the person’s identity. One reason for thinking this is that, since John Locke’s discussion of it, personal identity has been associated with continuity of a subjective perspective on the world held together by memory that that memory is severely curtailed in dementia. Hence dementia seems to threaten an individual’s identity as a particular person, gradually undermining it.
But the necessity, or the closeness, of the connection has been criticised by a number of philosophers and healthcare professionals who subscribe to a narrative account of personal identity. Their argument goes as follows. If personal identity is constituted through a personal narrative rather than, for example, a memory connection, then while the capacity to author a self-narrative also seems to be threatened by dementia, that need not undermine personal identity providing that the narrative that constitutes identity can be co-constructed. As dementia takes hold, authorial weight can fall to others.
Clive Baldwin, a professor of narrative studies with a social work background, argues in this way. First, he claims that human subjects have narratively constituted selves and hence, pessimistically, are susceptible to harm via that narrative in, for example, the case of dementia.
[W]e are indeed narrative beings who find our Selves in the stories we tell about ourselves and the stories that others tell about us; that narrativity is essentially an inter-personal activity; that some people find their stories marginalized, themselves as narrators dispossessed; but that it does not have to be that way. The stories we tell… can subvert the status quo and open the door to new ways of telling, and thus new ways of being. I will develop this argument through the lens of the experience of people with dementia, though it has been argued elsewhere that people experiencing severe mental illness may also be narratively dispossessed. [Baldwin 2008: 223]
But, more positively, the threat of such harm can be turned aside through the joint authorship and co-construction of identity-constituting narratives.
[W]e look towards the joint authorship of narratives where the narrative process is shared by people living with dementia and those around them. This may take the form of co-construction of narratives [see Keady & Williams 2005] whereby the final narrative is very deliberately and consciously a negotiated product between those people living with dementia and others or the piecing together and progression of the fragmented narratives of people living with dementia by those who support them. [ibid: 225]
The philosopher of psychiatry Jennifer Radden and psychotherapist Joan Fordyce deploy a similar argumentative strategy. First, they subscribe to a form of narrative identity theory concerning what Marya Schechtman calls ‘characterization identity’: ‘the set of characteristics each person has that make her the person she is’ [Schechtman 1996: 74].
A person’s identity comes in the form of a self-narrative in the work of many who employ these categories... The actions and experiences making up that narrative comprise the personal story of which the subject stands as ‘author’. [Radden and Fordyce 2006: 73]
Such self narratives are always, they suggest, co-constructed, though generally this is tacit. But in the case of dementia, the relative contributions to authorship change and become more noticeable.
The construction and sustaining of the person’s characterization identity have been, until the deficits of dementia make themselves known, collective efforts conducted largely tacitly. Increasingly, as these deficits erode aspects of the person’s memory and self-awareness, the task will come to include the provision of explicit identity recognition—a response that says, in some form, ‘this is who you are and what you are like’… Until now, also, to the extent that others were called on to sustain the identities of those around them, this task will have been largely mutual. Other people will have helped sustain, just as they helped constitute, my identity at the same time as I helped maintain (and constitute) theirs. Now, however, the task of holding and preserving the identity of the person suffering dementia will come to be placed more squarely on the shoulders of others (often, these are the shoulders of second persons, intimates, and the customary societal carers, women)… [Radden and Fordyce 2006: 81]
It might seem that this account is too optimistic. If personal identity is constituted by self-narratives that can be co-authored then providing that caregivers or kith and kin are ready to step up to the breach then dementia is no longer a threat to identity. Radden and Fordyce concede that this is not how it seems, however.
The most noticeable initial problem with this model is perhaps the discomfort and sense of falsity it sometimes brings upon those others left with the burden of sustaining the identity of a loved one through these processes of holding, reinforcing, and reinscribing. Although perhaps a distorted reaction, the response is often angry and disappointed. The loved identity seems to have gone—replaced by an alien changeling, it sometimes seems, or by no one. ‘This is what you were and were like’ we want to say to the dementia sufferer, ‘but no more!’… The heart-breaking aspect of this task of sustaining characterization identity cannot be ignored. Nonetheless, it is an enterprise apparently required by very notion of characterization identity as that identity has been defined and explained here. [Radden and Fordyce 2006: 81-2]
Taking the relevant sense of personal identity to be Schechtman’s characterization identity and taking that to be constituted by a co-constructed personal narrative, it follows, they claim, that there is a normative requirement on carers however angry and disappointed they may feel at the misleading appearance of the loss of their loved one. They do not, however, explain the nature of this obligation.
There is a further problem which can be illustrated by an example from the other end of life: it would allow the sincere ascription of youthful authorship of the ‘round robin’ letters sometimes written in the UK ‘as from’ small babies around Christmas. Such ascription would simply require a generous interpretation of a baby’s still limited behavioural repertoire by doting parents through which the meaning and thus authorial intention would be constructed, rather than revealed. There would be no further issue of whether this accurately tracked antecedent communicative intentions. Whilst in the case of such round robin letters no abuse – except perhaps of good taste – is risked, in the case of dementia the construction of a narrative by only one party in a supposed conversation does carry that risk.
Stephen Sabat, who has done much to promote the idea that even advanced Alzheimer’s sufferers may still be ‘semiotic subjects’ gives one such example:
In many cases, caregivers often do attribute intention to the afflicted person in that caregivers may believe that he or she is acting deliberately to annoy them, when in fact the annoying behaviour is due to cognitive impairment. If the afflicted person’s recall memory is severely affected, he or she may ask the same question repeatedly. This is hardly due to an intention to annoy anyone. It is of utmost import that caregivers identify the circumstances in which intention is present and healthy and not meant to annoy. [Sabat 2001, p. 222].
The idea of co-construction is particularly dangerous in psychiatry because of its history of paternalism. Humane responses to that history have stressed the perspective of individuals, the importance of respect for autonomy and patient values even where these are hard to discern. Suggesting that personal narratives, and hence selves, can be made up by others seems a complete abandonment of the rejection of paternalism by the most insidious of means. So why has the idea of constructing those, supposedly on someone else’s behalf, come to seem a humane response to dementia? I will argue that it follows from misrecognising the fundamental difference between this dangerous, paternalistic invocation of co-construction of personal identity and the innocent role of constructionism in response to an issue that looks superficially similar: asking whether someone is still the same person as they were before dementia but where the word ‘same’ is used in Wittgensteinian secondary sense. What may look merely like a subtle difference makes all the difference.
The structure of this paper is, sadly, quite complex. Starting, here, from Radden and Fordyce’s unfortunately paternalist account of identity and dementia, I will work ‘backwards’ and then ‘forwards’.
Radden and Fordyce’s account is based on Schechtman’s 1996 narrative account of personal identity. Schechtman argues for her narrative account by saying that it is a good answer to what she calls the ‘characterization question’, which she contrasts with the ‘reidentification question’. She rejects the reidentification question because neo-Lockean attempts to answer it fail. In arguing for this, however, she ignores the best neo-Lockean approach: McDowell’s anti-reductionist version. This is a defect in her argument given that it is in part, at least, an argument from elimination.
Working ‘forwards’, Schechtman’s answer to the characterization question is a substantive narrative theory of identity but both that question and her answer is ambiguous between a notion of basic identity and a richer notion of a moral subject. Because she says that she builds her account from two others, which I will characterise – following her citations – as Dennett’s and MacIntyre’s, I use these to assess the two interpretations or aspects of her account. There is, however, independent reason to reject Dennett’s account – and anything like it – leaving MacIntyre as the only plausible model of a narrative account. But his account does not support Radden and Fordyce’s stronger claims about co-construction. Further, since Schechtman’s account is motivated by an argument from elimination that ignores a better option, it is not clear we need a substantive account anyway. Freed from that, a better way of learning lessons from MacIntyre to apply in the case of dementia is available. Narrative can help shed light on very specific identity questions asked in the case of dementia but in a different way to Radden and Fordyce’s paternalism.
Marya Schechtman’s rejection of the reidentification question
Radden and Fordyce’s account of co-construction of identity is based on their modification of Marya Schechtman’s narrative constitution view of personal identity. That in turn is her proposed answer to what she calls the ‘characterization question’ which she contrasts with the more familiar reidentification question in the philosophy of personal identity.
Most simply put, this [characterization] question asks which actions, experiences, beliefs, values, desires, character traits, and so on… are to be attributed to a given person. Reidentification theorists ask [by contrast] what it means to say that a person at t2 is the same person as a person at t1; characterization theorists ask what it means to say that a particular characteristic is that of a given person. [Schechtman 1996: 73].
Schechtman prefers the characterization to the reidentification question and her proposed account of identity is an answer to the former rather than the latter. It might thus seem that, by answering a distinct question, it is incommensurable with answers to the latter question proposed by other philosophers, especially those working in a broadly Lockean framework. But although there is one relevant difference (to which I will return), I think that Schechtman takes her narrative constitution view to be an account of personal identity, however precisely that is to be understood, and hence to be a competitor to neo-Lockean accounts. Before returning to her answer to the characterization question, I will briefly sketch the nature of the reidentification question.
In a more recent book, Schechtman summarises her earlier approach thus:
I thus suggested that we instead think of the problem of personal identity as one of characterization—the question of which actions, experiences, and traits are rightly attributable to a person. The answer to a question of personal identity can then take the form of a relation between persons and psychological elements or actions rather than of a relation between time-slices. [Schechtman 2014: 100 latter italics added]
The contrast with a relation of time slices stems from a view of personal identity that derives from an interpretation of John Locke who said:
To find wherein personal identity consists, we must consider what person stands for; which, I think, is a thinking intelligent being that has reason and reflection and can consider itself as itself, the same thinking thing in different times and places. [Locke 1975: II.xxvii.9]
Person, as I take it, is the name for this self. Where-ever a Man finds, what he calls himself, there I think another may say is the same Person. It is a Forensick Term appropriating Actions and their Merit; and so belongs only to intelligent Agents capable of a Law, and Happiness and Misery. [Locke 1975: II.xxvii.26]
Locke thus suggests that personal identity has, and depends on, a continuity of inner perspective. To illustrate this, he considers a case in which the ‘Soul of a Prince, carrying with it the consciousness of the Prince’s past Life, enter[s] and inform[s] the Body of a Cobbler as soon as deserted by his own Soul’ In such a case, he claims that ‘every one sees, he would be the same Person with the Prince, accountable only for the Prince’s Actions’ [Locke 1975: II.xxvii.15].
This has inspired a philosophical industry concerning the idea that being the very same person, in the forensic sense of the person who should be punished for the earlier self’s crimes, is constituted by a kind of internal consciousness of identity over time. And then, so the thought goes, if that is the case, then it ought to be possible to give an account of this continuous inner awareness in terms which do not presuppose sameness of the person over time because the aim is to define the latter using the former.
There are, then, some familiar questions. Is it really the case that events that someone does not recall cannot be part of their temporally extended existence as a subject? And does not memory presuppose the identity of the self/person because memory is awareness of things that have happened to oneself, not just historical knowledge in an impersonal manner? Various solutions have been outlined.
Schechtman argues, however, that none of the standard answers to the reidentification question in the Lockean tradition are successful. For that reason, she recommends swapping questions and then proposing a narrative answer to her preferred question. Before considering that, it is, however, worth highlighting an option she ignores.
As John McDowell argues, there is no need to assume that a reductionist project must work [McDowell 1994: 325-40]. He suggests instead that we should not take Locke to be trying to reduce personal identity to continuity of inner awareness (and failing at that because Locke says explicitly: ‘can consider itself as itself, the same thinking thing in different times and places’ which presupposes sameness). But, rather, Locke is pointing out non-reductively that it is a feature of persons that they have an inner perspective on their lives which gathers together events as theirs without any criterion or test of identity and without even the exercise of a skill in picking themselves out (contrasting the way that one might keep track of one of the red balls in a game of snooker). One does not have to identify oneself to oneself, one’s memories as one’s own rather than someone else’s. But that is not because one is a special locus of ‘mind-stuff’ as Descartes assumed. No, it is because one is a body, with bodily criteria of identity, but one which happens to have – as a human – an inner perspective too which goes hand in hand, effortlessly, and, in general, agrees with those bodily criteria.
What are those bodily criteria for the identity of persons over time? Here, McDowell rather breezily suggests spatio-temporal continuity under a sortal. One way to make this clear is to imagine an alien with a very different kind of bodily life – perhaps as a cloud of gas – studying plant and animal life on earth down as far as the cellular level. As a rabbit, for example, lives, it eats grass and excretes dung. Thus vegetable matter gets merged with the rabbit and separated. Over time, there are complex chains of connection. But the spatio-temporal continuity of any particular rabbit does not have to take account of the grass and the dung with which it is brutely continuous: but rather the career of the rabbit itself rather than its food or dung. In other words, an appeal to spatio-temporal continuity is not a reductionist explanation of rabbit identity over time. Rather, the relevant mode of spatio-temporal continuity presupposes the sortal rabbit. The same applies to persons though with some complications.
One such complication is raised by the science fiction cases of the sort Locke himself considers: the mind of the prince transported into the body of the cobbler. In such a case, identity goes with the inner dimension rather than the outer body. But that is not to say that, in general, we have an understanding of the inner dimension independently of, or more fundamental than, the normal bodily criteria of identity.
The fact that Schechtman ignores this possibility is one reason to be suspicious of her argument from elimination in favour of the characterisation over the reidentification question. There may simply be no need to articulate a narrative theory of identity in the first place. Putting this point on hold for the moment, I will outline the development of her answer to her favoured question.
Schechtman’s characterization question and narrative constitution answer
In more recent work, Schechtman provides the following overview of her position.
I thus suggested that we instead think of the problem of personal identity as one of characterization—the question of which actions, experiences, and traits are rightly attributable to a person. The answer to a question of personal identity can then take the form of a relation between persons and psychological elements or actions rather than of a relation between time-slices. Such an account, I argued, will be non-reductive but still informative. In particular I urged that rather than thinking of identity-constituting psychological continuity in terms of overlapping chains of psychological connections properly caused, we should instead understand it in narrative terms, a revision made possible by framing the question as one of characterization. We constitute ourselves as persons, on this view, by developing and operating with a (mostly implicit) autobiographical narrative which acts as the lens through which we experience the world. [Schechtman 2014: 100]
The characterization question, and her answer to it, is, however, ambiguous. In asking which actions, experiences, and traits are rightly attributable to a person, it might be asking which are authentic expressions of the person, their moral selves, aspects of their deeper character by contrast with momentary whims or temptations, or the distortions of alcoholic high spirits, for example. Or it might mean simply which of all the actions in human history were those of a particular person. More prosaically, the latter might be asked by a detective of an act of theft: who did it?
Schechtman has conceded this point about her earlier 1996 work.
For many, the switch from the reidentification to the characterization question automatically signals a switch to questions about the moral self. There are some good reasons for thinking so—my first move in introducing the view is to draw a distinction between the “Who am I?” question raised by a confused adolescent (which I link to the characterization question) and the “Who am I?” question asked by an amnesia victim (which I link to the reidentification question). At the same time, however, I meant for the characterization question also to answer questions about attribution at the most fundamental level—not only which beliefs and desires are truly mine in the sense of the moral self, but which are mine in the most basic and literal sense. [Schechtman 2014: 102]
Given this latent ambiguity in the question, how should her earlier 1996 answer – the account which informs Radden and Fordyce’s view – be assessed? Fortunately, in her earlier work, Schechtman suggests a clue. She reports that her narrative constitution view:
draws its inspiration from a number of sources both philosophical and psychological which argue either that persons are self creating… or that the lives of persons are narrative in form. Weaving strands from these discussions together with my own analysis, I develop a view according to which a person creates his identity by forming an autobiographical narrative – a story of his life. [Schechtman 1996]
I suggest that these two distinct strands are responses to distinct interpretations, or aspects, of the characterization questions and I will use two of the philosophers Schechtman cites as sources to examine these two strands: Dennett and MacIntryre.
- Persons are self-creating
Schechtman cites Daniel Dennett as a philosopher who defends the idea that persons are self-creating. He claims that a self is a ‘centre of narrative gravity’. To outline his view, he suggests an analogy with the physical notion of a centre of gravity.
A centre of gravity is just an abstractum. It’s just a fictional object. But when I say it’s a fictional object, I do not mean to disparage it; it’s a wonderful fictional object, and it has a perfectly legitimate place within serious, sober, echt physical science. [Dennett 1992: 104]
The idea of a centre of gravity is deployed within a branch of physics to describe and predict the behaviour of physical systems acting under physical forces. What a centre of gravity is depends on this theoretical context and it is one of the useful tools and ideas that go to make that context. The concept is one amongst others interdependent on a theoretical stance.
Selves are given similar treatment. Like centres of gravity or mental states, they are theoretical, even fictional, entities articulated within an interpretative theoretical stance.
A self is also an abstract object, a theorist’s fiction. The theory is not particle physics but what we might call a branch of people-physics; it is more soberly known as a phenomenology or hermeneutics, or soul-science (Geisteswissenschaft). The physicist does an interpretation, if you like, of the chair and its behaviour, and comes up with the theoretical abstraction of a centre of gravity, which is then very useful in characterising the behaviour of the chair in the future, under a wide variety of conditions. The hermeneuticist or phenomenologist--or anthropologist--sees some rather more complicated things moving about in the world--human beings and animals--and is faced with a similar problem of interpretation. It turns out to be theoretically perspicuous to organise the interpretation around a central abstraction: each person has a self (in addition to a centre of gravity). In fact we have to posit selves for ourselves as well. The theoretical problem of self-interpretation is at least as difficult and important as the problem of other-interpretation. [ibid: 104]
What is the motivation for Dennett’s version of a narrative approach? I think that it is useful to consider the perceived alternative to it that Dennett rejects. He gives a clear statement of this in the following passage which starts with a brisk re-iteration of the advantages of his narrative account for describing psychopathology but also mentions the alternative to which it stands opposed.
We sometimes encounter psychological disorders, or surgically created disunities, where the only way to interpret or make sense of them is to posit in effect two centers of gravity, two selves. One isn’t creating or discovering a little bit of ghost stuff in doing that. One is simply creating another abstraction. It is an abstraction one uses as part of a theoretical apparatus to understand, and predict, and make sense of, the behavior of some very complicated things. The fact that these abstract selves seem so robust and real is not surprising. They are much more complicated theoretical entities than a center of gravity. And remember that even a center of gravity has a fairly robust presence, once we start playing around with it. But no one has ever seen or ever will see a center of gravity. As David Hume noted, no one has ever seen a self, either. [ibid: 114]
Dennett here supports his account by reinforcing the apparent robustness and reality of narrative selves on the basis of a comparison with the robustness of centres of gravity. Nevertheless they are ‘created’ abstractions. And this contrasts with the other possibility: ‘creating or discovering a little bit of ghost stuff’. I take it that more important alternative here is ‘discovering a little bit of ghost stuff’ which stands in as a brisk summary of a Cartesian account.
It should come as no surprise that Dennett’s main opponent is a form of Cartesianism, whether of a traditional immaterialist kind or a form of materialism which shares a key feature. That feature, and a key target of his Consciousness Explained, is the idea that ‘somewhere, conveniently hidden in the obscure ‘centre’ of the mind/brain, there is a Cartesian Theatre, a place where ‘it all comes together’ and consciousness happens’ [Dennett 1993: 39]. Even if Descartes’ immaterialism is rejected, this idea can remain implicit in thinking about the brain.
Let’s call the idea of such a locus in the brain Cartesian Materialism, since it’s the view you arrive at when you discard Descartes’s dualism but fail to discard the imagery of a central (but material) Theatre where ‘it all comes together’. The pineal gland would be one candidate for such a Cartesian Theatre… [Dennett 1993: 107].
I take it that an immaterial centre might constitute a self and a material centre could at least underpin one. Dennett rejects any such approach and deploys the narrative account as (part of) his alternative. This also explains his comment (above) that ‘[a]s David Hume noted, no one has ever seen a self’. He continues by quoting with approval Hume’s doomed attempt to spot his own self among his mental states.
For my part, when I enter most intimately into what I call myself, I always stumble on some particular perception or other, of heat or cold, light or shade, love or hatred, pain or pleasure. I never can catch myself at any time without a perception, and never can observe anything but the perception.... If anyone, upon serious and unprejudiced reflection, thinks he has a different notion of himself, I must confess I can reason no longer with him. All I can allow him is, that he may be in the right as well as I, and that we are essentially different in this particular. He may, perhaps, perceive something simple and continued, which he calls himself; though I am certain there is no such principle in me. [Hume 1978: 252]
Hume’s final comment is clearly meant to be ironic. Introspection, Hume suggests, reveals nothing that could stand in the sort of relation to one’s mental states that a self is supposed to do. This leads him to advocate a minimalist ‘bundle theory’ of mind. The self is identified simply with the mental states encountered in instrospection and not with an ego which stands in a relation to them.
Dennett shares Hume’s opposition to a Cartesian ego but he adds a principle of organisation to the mental states gathered together via narrative. The self is not just a bundle of states but states structured in a narrative. Given his related account of mental states there is no tension between primitively real mental states and mere fictional selves. Both mental states and the narrative structure that adds up to a self are theoretical constructs. But it is also important to note that there is no antecedently understood author to the narrative. That idea would correspond to a substantial, pre-narrative self. Dennett’s idea, by contrast, is that the self just is the structured narrative.
Given the choice between Cartesian ‘ghost stuff’ and a narrative account, then the latter is obviously the more attractive. It also seems to receive support as descriptively accurate from both Hume’s introspection and Dennett’s ‘hetero-pheomenological’ method which at least takes account of first person reports (whilst not uncritically according them apodictic certainty). But the choice is, nevertheless, a forced choice.
If Schechtman’s narrative constitution account is viewed through the prism of Dennett’s account, then it can be seen as answering the more austere question of basic identity, rather than to the richer notion of the nature of the moral self. Schechtman seems to take a narrative answer to the characterization question to be a rival to the reductionist version of the neo-Lockean account of basic identity. Sniffy about traditional accounts that argue that the different temporal stages of a person are unified by overlapping chains of memory, she raises a prior question: ‘what unites even at a given temporal stage the experiences that are those of a particular individual?’ answering narrative. Narrative unites at a given time. But it also unites over time because narratives are temporally extended wholes. Further, it suggests a nice distinction. On a narrative account, temporal elements are abstractions from a whole rather than free-standing elements needing uniting together. They are more like the pitch and timbre of a note than like the individual bricks that can be combined to make a wall.
Dennett, too, deploys narrative as a basic principle of organisation to unite actions, experiences, and traits in a single person. But although it is austere, it is nevertheless radical. Fully assessing such a radical claim about the connection between self and narrative lies outside the scope of this paper. But it is worth noting that, influential though it has been, it faces at least three significant difficulties:
First, what is the claim actually being made? Are selves narratives or are they the authors of narratives? They cannot be both. But in many published accounts, these two ideas are not consistently distinguished. Baldwin, for example, blurs both together because, in addition to the claim above that selves are stories, he also says:
If we are narrative beings and the primary narrative of our life is the one we construct for ourselves in relationship with others, then the maintenance of narrative agency takes on major importance. [Baldwin 2005: 1025, italics added]
According to this second passage, we construct, or are authors, of the narrative rather than being the narrative itself. Similarly, in the quotation above, Dennett says ‘In fact we have to posit selves for ourselves as well’ (italics added). But if selves are authors of narratives then what constitutive work is the idea of narrative doing, after all?
Second, if selves are, literally, narratives then how do narratives have meaning? A narrative is made up of a collection of signs (written or spoken). So how can those signs come to carry a meaning? The problem is this. Most plausible account of how linguistic meaning is possible presuppose an embodied agent whose beliefs and actions are appealed to to explain meaning. Gricean theories, for example, explain linguistic meaning by appeal to a speaker’s intentions to communicate his or her beliefs by such and such signs [Grice 1969]. But a narrative account of self inverts that order of priority and thus must, somehow, explain the meaning of a narrative without appealing to agents. And that seems a difficult venture.
Third, if selves are constituted by narratives then the component elements of the narratives must not presuppose any concept of self. But it is difficult to see how a narrative account of self could avoid including elements which correspond to psychological states. A narrative which avoided all mention of mental phenomena would be useless to explain the notion of a self. But if the narrative presupposes psychological states, then that will surely, illicitly, presuppose a concept of self of whom the psychological states are states [Thornton 2003].
I think that the difficulties Dennett’s account faces are endemic in substantive narrative accounts of the metaphysics of the self. If this is a strand in Schechtman’s narrative account, so much the worse for it.
- The lives of persons are narrative in form
Schechtman also invokes a distinct idea: the lives of persons are narrative in form. One philosopher she invokes in support of this idea is Alasdair MacIntryre. This idea, while still contentious, is much less radical than the idea that selves just are narratives. MacIntryre, for example, is led to it through a consideration of the way action explanation iterates.
It is a conceptual commonplace, both for philosophers and for ordinary agents, that one and the same segment of human behavior may be correctly characterized in a number of different ways. To the question ‘What is he doing?’ the answers may with equal truth and appropriateness be ‘Digging’, ‘Gardening’, ‘Taking exercise’, ‘Preparing for winter’ or ‘Pleasing his wife’. Some of these answers will characterize the agent’s intentions, other unintended consequences of his actions, and of these unintended consequences some may be such that the agent is aware of them and others not. What is important to notice immediately is that any answer to the questions of how we are to understand or to explain a given segment of behavior will presuppose some prior answer to the question of how these different correct answers to the question ‘What is he doing?’ are related to each other. [MacIntryre 1981: 206]
MacIntryre argues that the interconnection between different explanations of actions appealing to narrower or broader contexts has the form of a narrative. Actions are intelligible insofar as they can be fitted into an intelligible narrative and this process iterates. Making sense of one action by citing a broader context of action into which it fits itself presupposes that that broader context makes sense. And hence, MacIntryre concludes, it presupposes a narrative view of the whole of a life, which he connects to the idea of personal identity or selfhood.
What the narrative concept of selfhood requires is thus twofold. On the one hand, I am what I may justifiably be taken by others to be in the course of living out a story that runs from my birth to my death; I am the subject of a history that is my own and no one else’s, that has its own peculiar meaning. I am not only accountable, I am one who can always ask others for an account, who can put others to the question. I am part of their story, as they are part of mine. The narrative of any one life is part of an interlocking set of narratives… To be the subject of a narrative that runs from one’s birth to one’s death is, I remarked earlier, to be accountable for the actions and experiences which compose a narratable life. [MacIntryre 1981: 217]
If Schechtman’s narrative constitution account is viewed through the prism of MacIntryre’s account, then it can be seen as answering to the richer notion of the nature of the moral self rather than to more austere question of basic identity because, as MacIntryre acknowledges, his is a modest and anti-reductionist account of selfhood or personal identity.
I am not arguing that the concepts of narrative or of intelligibility or of accountability are more fundamental than that of personal identity. The concepts of narrative, intelligibility and accountability presuppose the applicability of the concept of personal identity... [MacIntryre 1981: 218]
The account charts a connection between selves as subjects or agents, their actions and the broader narratives into which these fit. It does not provide an independent way to characterise selves, persons or personal identity.
There is reason, too, to believe that this is the sense of identity that Radden and Fordyce have in mind.
New terms and contrasts have been introduced to separate the more political, and more recent, types of identity discourse. Marya Schechtman speaks of identity as concerning characterization (Schechtman 1996) (The identity associated with earlier theorizing in the Lockean tradition she designates reidentification identity, in contrast.)... The notion of characterization identity captures other presuppositions found in less formal discussions of identity as well, particularly those associated with the politics of recognition. [Radden and Fordyce 2006: 73]
But does a narrative account of a richer notion of identity, associated with identity politics and identity crises, and on the model of MacIntryre’s account, support their radical con-constructivist claims?
There is no reason to think it does. MacIntryre’s account is a generalisation from action explanation by reasons concerning which neither constructivism nor co-constructivism seem plausible. The ascription, or avowal, of a reason for action answers to the facts about motivation rather than constructing them. First person reports can be sincere or insincere because of that. While first person privilege attaches to reports of motivation, as it does for other aspects of mental life, this is not where the element of truth in constructionism applies to action explanation specifically. That element consists in the fact that actions are constituted – created, perhaps – by agents. Decisions are made – constructed, perhaps – by subjects and, if they are practical, executed. But subsequent explanations of actions answer to those facts. Co-construction may thus apply to decisions for action jointly arrived at but that provides no grounds for thinking co-constructivism is true of action explanations. And hence there is no reason to think it anything other than a distortion of a narrative conception of the whole of a life, and hence a self, on MacIntyre’s view. Co-constructivism is not only dangerously paternalistic in the case of dementia but it is also implausible as any account of personal identity.
A positive use of narrative in dementia?
Despite this sceptical view of narrative as a means of co-constructing identity in the face of dementia, it may, nevertheless have some role. Consider the case of the offspring who asks of their elderly and confused father: ‘Is he still my dad? Is he still him?’ Such a question is not a question about what Schechtman calls basic identity, which might be asked by a long-lost offspring in order to find which unrecognised person in a nursing home, for example, is their father. Rather, if the question is asked of a particular person, whether he is still their father, it carries a different sense.
I suggest that it is a question about whether there is still sufficient continuity of character to count as the same person in a richer but quite specific sense (see below). This is not simply the characterization question as reconstructed using MacIntrye’s narrative concept of selfhood (and certainly not as asking about the basic sense of identity in the style of Dennett’s account of narrative centres of gravity). It is asked in a context in which, despite the person concerned being the same person – in the basic sense – who used to be a loving father or fugitive Nazi, or, strangely, both, the ravages of memory loss call into question one sense of (Lockean) forensic identity. In the case where the father is a fugitive Nazi, there may be no reason to punish a confused old man who has no understanding of that for which he is being punished. But neither the clear answer: ‘Yes: he is the same person in the basic sense of identity’ nor the answer ‘No: he should not be held forensically responsible for past actions because he has lost his memory of them’ is appropriate for this question. And yet it is a question that can seem pressing.
That questions asked with the same words may call for quite different answers is nicely illustrated in a discussion of Wittgenstein’s critique of Frazer’s Golden Bough.
Someone bereaved might exclaim, ‘Why did she die?’ Such a question, uttered in a particular tone and under particular circumstances, would only be taken by the most obtuse as requests for an explanation – as being satisfied by the sort of response appropriate to the question in the context, say, of a coronial enquiry. [Redding 1987: 264.]
In such a case, what looks like a question may not be one at all but an expression of loss clothed in interrogative form. By contrast, in the case I have in mind, I do think that the apparent question “Is he still my dad?” is a genuine question meaning something like: “Is he still the same person that I remember” but in such a way that the notion of sameness is not captured by either the basic or the forensic senses set out above.
I suggest that the asking of this question in this context stands to those senses in the way that Wittgenstein describes as ‘secondary sense’ [Wittgenstein 2009 [1953] ptII sec xi]. The first instance he gives is the attitude most of us have towards words. We feel that a word carries its meaning somehow immediately with it. It can lose this kind of meaning if repeated. Wittgenstein describes this kind of immediate perception of the meaning of a word in isolation as a form of understanding meaning. Since Wittgenstein’s official recommendation is to think of understanding as grasp of a practice, the use of the words ‘understanding’ and ‘meaning’ in the case at hand is not straightforward. It is not a metaphor, however, because nothing can be said to explain why we want to use these words for this kind of experience. But whilst this is not a metaphorical use it is nevertheless a secondary use: one which we find natural given the primary use, but which is discontinuous with, and could not be used to teach, the primary use.
Another example Wittgenstein gives is the use of ‘fat’ in the claim that Wednesday is fat.
Given the two concepts ‘fat’ and ‘lean’, would you be inclined to say that Wednesday was fat and Tuesday lean, or the other way round? (I am strongly inclined towards the former.) Now have “fat” and “lean” some different meaning here from their usual one? – They have a different use. – So ought I really to have used different words? Certainly not. – I want to use these words (with their familiar meanings) here… Asked “What do you really mean here by ‘fat’ and ‘lean’?”, I could only explain the meanings in the usual way. I could not point them out by using Tuesday and Wednesday as examples… The secondary meaning is not a ‘metaphorical’ meaning. If I say, “For me the vowel e is yellow”, I do not mean: ‘yellow’ in a metaphorical meaning a for I could not express what I want to say in any other way than by means of the concept of yellow. [Wittgenstein 2009 pt II §§274-278]
Secondary sense as introduced is neither a metaphor nor a simile because there is no way to begin to justify the use by articulating the similarity with the literal sense. It is spontaneous extension of the paradigmatic meaning of a word but reliant on that meaning.
Whilst experiencing the meaning of a word or ascribing a width to days of the week may seem to be of limited interest, the Wittgensteinian philosopher Oswald Hanfling argues that the secondary use of words is widespread (Hanfling, 1991). In aesthetics, he argues, words such as ‘sad’ applied to music are used in secondary sense. (The music need not make a hearer sad, does not sound like a sad person etc.). In the description of feelings, phrases such as ‘pins and needles’, ‘butterflies in the stomach’ and ‘stabbing pains’ are all used in this way. Wittgenstein’s own description of ‘feelings of unreality’ in which ‘everything seems somehow not real’ is also secondary.
Wittgenstein himself gives an example of an aesthetic description of a piece of music which seems to be a case of secondary sense:
If I say for example: Here it’s as if a conclusion were being drawn, here as if something were confirmed, this is like an answer to what went before—then my understanding presupposes a familiarity with inferences, with confirmations, with answers [Wittgenstein 1967 §175]
The application to music of language whose primary use concerns the description of arguments lacks a justification through an appeal to objective similarities. Someone who was mystified by this deployment of language need have made no mistake. But that is not to say that for those for whom this extension comes naturally there are no aesthetic justifications for hearing a particular phrase as a conclusion of a previous passage of music or as answering a previous phrase. Such justifications might consist in playing the music with a particular emphasis or stripped of some of its detail. So while there is no justification for the whole extension of a language of argument to music, for those who do find it natural there can be justifications or points of disagreement for specific applications. Nevertheless, even in this case, the justifications can come to an end without agreement and again implying no cognitive shortcoming. One may simply disagree with hearing a theme as the conclusion.
Aesthetic discussions [are] like discussions in a court of law, where you try to “clear up the circumstances” of the action which is being tried, hoping that in the end what you say will “appeal to the judge”... if by giving reasons of this sort you make another person “see what you see” but it still “does not appeal to him” that is “an end” of the discussion. [Moore 1955: 19]
This combination of (unjustified) spontaneous extension but piecemeal partial justification captures the case at hand. The offspring who asks whether their father is still their father, still the same person, still their ‘dad’, even though already having answers to the basic question and the forensic question is pressing the notion of sameness in a novel way. ‘Same’ in this case is used in secondary sense.
In this context, narrative can provide the material for a response which does not simply answer to the facts. Imagine a case in which the elderly person in question cannot recall who his children are but, despite that, he reacts to them with affective warmth. Perhaps hearing a once familiar tune prompts jovial attempts to whistle the refrain. Perhaps he is visibly calmer in the presence of his offspring, instinctively reaching out a hand. In such a case, a narrative account may weave together these affective responses in a such a way to trump cognitive failings. Perhaps the offspring sees in a single gesture, or hears in a single characteristic utterance, sufficient sign of the presence of the remembered father to be reassured and to answer the question in the affirmative.
In such case, the mark of the success of the narrative in conveying an answer to the question – whether happily positive or sadly negative – is not simply answering to neutral facts. Rather, it is the response, to the proffered narrative answer, of the person who asks the question, akin to Wittgenstein’s account of aesthetic justification. The success of the narrative answer lies in part at least in the affective response of the person who asks the question. What constitutes the success of the narrative in affirming or denying that the person still is the father is not its objectively successfully marshalling the facts but rather its being accepted as significant by the questioner.
That is, I suggest, the very limited truth in a constructionist approach to a narrative form of identity in dementia, one which carries no risk of insidious paternalism.
References
Baldwin, C. (2005) ‘Narrative, ethics and people with severe mental illness’ Australian and New Zealand Journal of Psychiatry 39: 1022-1029
Baldwin, C. (2008) ‘Narrative(,) citizenship and dementia: The personal and the political’ Journal of Aging Studies, 22: 222–228
Dennett, D. (1992) ‘The Self as a Center of Narrative Gravity’ in Kessel, F. and Cole, P. and Johnson, D., Eds. Self and Consciousness: Multiple Perspectives. Hillsdale, NJ: Erlbaum reprinted at cogprints.ecs.soton.ac.uk/archive/00000266/
Grice, H.P. (1969) ‘Utterer’s meaning and intentions’ Philosophical Review 78: 147-77
Hanfling, O. (1991). I heard a plaintive melody. In A. Philips Griffiths, (Ed.), Wittgenstein centenary essays. Cambridge: Cambridge University Press
Hume, D. (1978) A Treatise of Human Nature, Oxford: Oxford University Press
Keady, J., & Williams, S. (2005) ‘Co-constructed inquiry: A new approach to the generation of shared knowledge in chronic illness’ Paper presented at RCN International Research Conference. Belfast.
Locke, J. (1975) An Essay Concerning Human Hnderstanding, Oxford: Oxford University Press
MacIntyre, A. (1981) After Virtue, Notre Dame, Indiana: University of Notre Dame Press
McDowell, J. (1998) Mind value and reality, Cambridge, Mass.: Harvard University Press
Moore, G.E. (1955) ‘Wittgenstein’s Lectures in 1930-33’ Mind 64: 1-27
Radden, J. and Fordyce, J. (2005) ‘Discursive psychology, social constructionism and dementia’ in J. Hughes, S. Louw and S. Sabat (eds) Dementia: Mind, Meaning and the Person Oxford: Oxford University Press
Redding, P. (1987) ‘Anthropology and ritual: Wittgenstein’s reading of Frazer’s The Golden Bough’, Metaphilosophy 18: 264.
Schechtman, M. (1996) The Constitution of Selves, New York: Cornell University Press
Schechtman, M. (2014) Staying Alive: Personal Identity, Practical Concerns,and the Unity of a Life, Oxford: Oxford University Press
Thornton, T. (2003) ‘Psychopathology and two varieties of narrative account of the self’ Philosophy Psychiatry and Psychology 10: 361-367
Wittgenstein, L. (1967) Zettel, Oxford: Blackwell
Wittgenstein, L. (2009 [1953]) Philosophical Investigations, Oxford: Blackwell
Subscribe to:
Posts (Atom)
