Introduction
Perhaps the most influential model of psychiatric kinds is the mechanical property cluster model of psychiatrist Ken Kendler and philosophers Peter Zachar and Carl Craver, itself developed from the philosopher Richard Boyd’s homeostatic property cluster model [Boyd 1991; Kendler et al 2011]. It seems to be a plausible fit to the kind of kinds found in the Diagnostic and Statistical Manual. Less strict than many models of natural kinds, it serves as a plausible account of the inductive inferences that psychiatric kinds can support. The model serves to vindicate psychiatric taxonomy.
But there is a contrasting account of kinds that has been developed to fit psychiatry by the philosopher of science Ian Hacking: looping or interactive kinds. These promise provide a more nuanced support of psychiatric taxonomy. To assess the very idea of looping kinds I will first provide an overview of the context, then look to what looping might comprises and then argue that there is nothing here in logical space.
Looping kinds and social constructionism
Hacking starts his paper ‘Making up people’ with the following question drawing on Arnold Davidson.
Were there any perverts before the latter part of the nineteenth century? According to Arnold Davidson, ‘The answer is NO… Perversion was not a disease that lurked about in nature, waiting for a psychiatrist with especially acute powers of observation to discover it hiding everywhere. It was a disease created by a new (functional) understanding of disease.’ Davidson is not denying that there have been odd people at all times. He is asserting that perversion, as a disease, and the pervert, as a diseased person, were created in the late nineteenth century. Davidson’s claim, one of many now in circulation, illustrates what I call making up people. [Hacking [1986] 1991: 161]
He goes on to connect both Davidson and his own work to Foucault: ‘there is a currently more fashionable source of the idea of making up people, namely, Michel Foucault, to whom both Davidson and I are indebted’ [ibid: 164].
Foucault’s account of the history of mental illness and hence the latter’s constitution as mental illness turns on two key socio-political shifts. In the seventeenth century there occurred a ‘Great Confinement’ in which alongside beggars, criminals, layabouts and prostitutes, the mad were separated from productive members of society using facilities that had previously been used to segregate lepers. Whereas previously, the mad had been tolerated as eccentric within society and even displayed in royal courts, they were now removed from the view of productive society.
The necessity, discovered in the eighteenth century, to provide a special regime for the insane, and the great crisis of confinement that shortly preceded the Revolution, are linked to the experience of madness available in the universal necessity of labor. Men did not wait until the seventeenth century to ‘shut up’ the mad, but it was in this period that they began to ‘confine’ or ‘intern’ them, along with an entire population with whom their kinship was recognized. Until the Renaissance, the sensibility to madness was linked to the presence of imaginary transcendences. In the classical age, for the first time, madness was perceived through a condemnation of idleness and in a social immanence guaranteed by the community of labor. This community acquired an ethical power of segregation, which permitted it to eject, as into another world, all forms of social uselessness. It was in this other world, encircled by the sacred powers of labor, that madness would assume the status we now attribute to it. [Foucault 1989: 54]
Later, according to Foucault, there was a second transformation at the end of the eighteenth century in which the mad were now confined in hospitals under the supervision of medical doctors. But Foucault’s claim is less that these changes were responses to the nature of mental illness as that the idea of mental illness, by contrast with a broader notion of madness and social eccentricity, was a response to broader social and economic forces.
[T]he constitution of madness as a mental illness, at the end of the eighteenth century, affords the evidence of a broken dialogue, posits the separation as already effected, and thrusts into oblivion all those stammered, imperfect words without fixed syntax in which the exchange between madness and reason was made. The language of psychiatry, which is a monologue of reason about madness, has been established only on the basis of such a silence. [Foucault 1989: xii]
The historian Andrew Scull offers a similar story [Scull **]. According to him an intellectual battle in the nineteenth century between a moral view of mental illness and a medical view was decided by in favour of the latter by social and political factors. Crucially, the growth of capitalism required a distinction be drawn between those who genuinely could not work in factories but deserved support and those, perhaps malingers, who chose not to work. A medicalised view of mental illness and its management fitted the bill.
On this family of approaches, the very notion of mental illness was invented as a way to help structure society in support of the rise of capitalism. This – contested – historical account offers reason to think that the apparently real and worldly property of ‘having a mental illness’ is not after all such an objective matter [for a very critical opposing voice see Shorter **]. Rather, it is, in part at least, a projection onto the world of the needs of (capitalist) society. We call people ‘mentally ill’ so as to impose social and political structures on them, not because we are responding to a real division in nature. Of course, there must be some behavioural and experiential differences that serve as the prompting for the projection but in some sense they do not naturally comprise illness features. Calling them an ‘illness’ – on the understanding of illness as a medical condition – is not just responding to prior biological or medical facts.
This account has been contested. Edward Shorter summarises it and his rejection of it thus:
Dominating the field for the past two decades have been scholars who doubt the very existence of psychiatric illness, believing it to be socially constructed. These writers have attempted to trivialize the illnesses of the inmates and to make the case that capitalist society was venging itself on the patients for their unwillingness to work, for a Bohemian lifestyle, or even for a revolt against male authority. Thus society’s growing intolerance of deviance is said to have led to the confinement of ever greater numbers of ‘intolerable’ individuals. It is astonishing that this interpretation could have achieved such currency as there is virtually no evidence on its behalf. [Shorter 1997: 54]
It will be helpful, in order to contextualise Hacking’s looping kinds to offer an exaggerated, sharp distinction between what I will call ‘debunking’ and ‘non-debunking’ social historical accounts of natural scientific disputes. I will do this using an example from the recent history pf physics, which has, as a matter of fact, been much discussed by in the social history of science [**].
In the 1980s it was claimed by one laboratory that nuclear fusion reaction could take place in test tube conditions at room temperatures. Other laboratories were not able to replicate the results. There was ongoing dispute for a while. Now it is generally accepted that the initial results were mistaken. Why not?
On a debunking social history of science approach, there is a story to be told about the social and political organisation of competing laboratories and how some were more able to publicise and impose their views, eventually shutting out competitor views. And hence the debate came to an end with the claims about nuclear fusion that are now accepted: namely that it is not possible under everyday conditions. Our accounts of the relevant physical facts are thus explained using those resulting beliefs and merit the label social ‘constructionism’.
On a non-debunking or vindicatory account, all of the above may be true except the last sentence. There is also a further explanatory fact in addition to the social historical account. If asked why we no longer believe in ‘cold’ nuclear fusion, on this approach it is explanatory to say: cold nuclear fusion is impossible. We no longer believe in it partly because it does not happen. That physical fact stands at the start of all sorts of evidential chains. It explains why the experiments that seemed to suggest it were possible were not replicated. A vindicatory social historical account is an explanation of the social factors that enabled a physical or natural scientific fact to come into view.
What makes a debunking or social constructionist social historical account debunking is that physical or natural scientific facts are not deployed to explain our beliefs about them. The explanation runs the other way. The explanans are social-historical not physical or natural scientific.
I have suggested an interpretation of the family of approaches to the history of mental illness mentioned above in which the proper explanation of the increase in diagnosis and medical treatment of mental illnesses is not greater understanding of these pre-existing conditions. Rather, the locution ‘there really is such an illness’ is given what limited truth it has by the social historical story about the rise of capitalism.
This stark contrast is made more complex by the caveat mentioned above: that there must be some behavioural and experiential differences that serve as the prompting for the ascription ‘mental illness’. On a debunking account, there is a mismatch between the differences as described in the social historical account and the kind ascribed. On the vindicatory account, the social historical account explains how a sensitivity to underlying kinds correctly reflected in the ascribed kinds came about.
This is the background to Hacking’s looping or interactive kinds. Hacking attempts to offer a middle ground between a vindicatory and a debunking story. Looping kinds stand in contrast to natural kinds. In The Social Construction of What? much the same contrast is made using ‘interactive kinds’ and ‘indifferent kinds’ [Hacking 1999]. Looping or interactive kinds are meant to be in some sense less objective than natural kinds. They inherit something of the debunking story. At the same time, they are real kinds.
Looping?
Why ‘looping’ or ‘interactive’? Because the existence of the label directly affects those subjects who fall under it.
‘Interactive’ is a new concept that applies not to people but classifications… that can influence what is classified… We are especially concerned with classifications that, when known by people or those around them, and put to work in institutions, change the ways in which individuals experience themselves—and may even lead people to evolve their feelings and behavior in part because they are so classified. [Hacking 1999: 103–104]
Hacking claims that the very existence of such a kind can ‘make people’ ie make people into kinds. In the paper ‘Making up people’, one example is multiple personality disorder (MPD).
I claim that multiple personality as an idea and as a clinical phenomenon was invented around 1875: only one or two possible cases per generation had been recorded before that time, but a whole flock of them came after. [Hacking [1986] 1991: 162]
The existence of the diagnosis MPD, eg., has an effect on people in such a way as to make people fit the diagnosis. Hacking does not offer a clear a priori account of looping kinds. He says: ‘
I do not think that there is a general story to be told about making up people. Each category has its own history [Hacking [1986] 1991: 168]
But the nature of the looping is something like this:
(1) Introduction of the concept of multiple personality along with the associated label.
(2) Certain people are classified as having multiple personality or as falling under that kind and are treated accordingly.
(3) Some of these people come to identify with the kind multiple personality (whether consciously or not).
(4) These people (or some of them) become further distinguished from other people, often acquiring new properties.
(5) The kind multiple personality comes to be associated with a new set of properties, which leads us to modify our concept of multiple personality or the theoretical beliefs associated with it. [Khalidi 2010: 337]
Problems
Despite both the intuitive attraction of looping or interactive kinds and despite the various historical accounts Hacking and others have offered using this notion, I do not think it serves as a plausible way to shed light on psychiatric kinds.
First, as a number of critics have pointed out, there can be feedback effects on the things that instantiate natural kinds [Bogen 1988, Cooper 2004]. As Cooper agues: ‘the characteristics of domestic livestock change over time because particular animals are classified as being the ‘Best in Show’ and are used in selective breeding–sheep and pigs would now look very different if it weren’t for our classificatory practices’ [Cooper 2004: **]. So the key question is how such feedback occurs for looping kinds. The key suggestion Hacking makes links this to Elizabeth Anscombe’s book Intention [Anscombe 2001*].
Anscombe stresses the idea that an action is the action it is in virtue of the description under which it falls. Consider an example suggested by the philosopher of action Donald Davidson.
A man moves his finger, let us say intentionally, thus flicking the switch, causing a light to come on, the room to be illuminated, and a prowler to be alerted. [Davidson 1980: 53]
In the details of the example, flicking the switch, turning on the light and illuminating the room are all intentional. They are all appropriate descriptions of the man’s action. But without knowing it, he has also alerted the prowler. But while he did that, it was not his action. He did not set out to alert the prowler. Thoughts of the prowler played no role in his motivation. On Anscombe’s account, briskly mentioned by Hacking, actions are constituted as the actions they are by the descriptions under which they fall.
Having a way to think about the world opens up possibilities of action. A cat, unaware of how lights work, could never – as an action – turn on a light. Only those who know its rules can attempt to avoid an offside trap in football. Knowing the rules opens up a space of actions. So one way a kind might ‘loop’ is by introducing a social role and rules. Given the kind MPD, an actor eg., can now act having MPD.
This idea can also generate a distinct distinction between natural and human kinds following Peter Winch [Winch **]. The rules that govern social interaction, unlike the physical laws that govern the movement of billiard balls, are known and intentionally followed by those they govern, who thus act in accord with their own conception of the rules. Billiard balls, by contrast, do not intentionally follow the laws of Newtonian mechanics. So social ‘science’ is, at the very least, different from natural science. Winch argues this disbars the very idea of a social science.
But this idea does not fit the cases of looping Hacking mentions in which it is not so much that new ways of acting are proposed by new social and linguistic rules in the way that players might adapt to a new version of the offside rule. The phenomena Hacking exposes seem much less self-conscious. They seem more like sub-conscious placebo or perhaps nocebo effects. An Anscombian account of action sheds light on what it would be to act as if one had MPD but would not explain why more people chose to ‘play by these rules’.
Shorn of the explicit link to action explanation and Anscombe then the arguments by critics of Hacking such as Cooper that the existence of natural classifications can lead to changes in those entities picked out undermine the idea that ‘looping’ is of any metaphysical significance.
In The Social Construction of What? Hacking attempts to perform a shotgun wedding of looping or interactive kinds and natural or indifferent kinds. He suggests that the looping kinds of mental illnesses might be found to be neurological kinds in the way that water was found to be a chemical kind H2O. His suggestion is that while the stereotype for a kind might be looping, its underlying nature might have an underlying essence. It is far from clear how the latter aspect does not undermine any metaphysical significance of ‘looping’.
What can be concluded? What makes a debunking sociological account debunking is that physical facts never explain, they are always explained. Perhaps the problem of Hacking’s account is that it attempts not to have to choose between a kind of vindicatory history of psychiatry in which mental illnesses are discovered by mainly nineteenth century German psychiatrists and a Foucauldian sceptical story in which the same illnesses were ‘made up’ to serve some other purpose. Perhaps we do need to look closely at the details of every historical case. Some kinds will be real. Others will be fake. None will be looping.
References
Anscombe, E. (2000) Intention, Cambridge,Mass.: Harvard University Press
Bogen, J. (1988) ‘Comments on “The Sociology of Knowledge about Child Abuse”’, Nous, 22: 65-
Boyd R (1991) ‘Realism, antifoundationalism and the enthusiasm for natural kinds’ Philosophical Studies 61: 127–148.
Cooper, R. (2004) ‘Why Hacking Is Wrong about Human Kinds’, The British Journal for the Philosophy of Science, 55: 73-85.
Davidson, D. (1980) Essays on Actions and Events, Oxford: Oxford University Press.
Foucault, M. (1989) Madness and Civilisation, London: Routledge
Hacking, I. [1986]: ‘Making up People’, in T. C. Heller and C. Brooke-Rose (eds), 1986, Reconstructing Individualism: Autonomy, Individuality, and the Self in Western Thought, Palo Alto, CA: Stanford University Press, pp. 222-36. Reprinted in M. Biagioli (ed.), 1999, Science Studies Reader, New York, NY: Routledge, pp. 161-**
Hacking, I. (1999) The Social Construction of What?, Cambridge, MA: Harvard University Press.
Kendler KS, Zachar P, Craver C. (2011) ‘What kinds of things are psychiatric disorders?’.Psychol Med. 41: 1143-1150
Khalidi, M. (2010) ‘Interactive Kinds’ The British Journal for the Philosophy of Science, 61: 335-360.
Shorter, E. (1997). A History of Psychiatry: from the era of the asylum to the age of Prozac, New York: John Wiley and Sons.
Winch, P. ([1958] 1990). The Idea of a Social Science and its Relation to Philosophy, London: Routledge
Thursday, 18 June 2020
Monday, 8 June 2020
Ontological and Epistemological Bases of Person Centered Medicine
One of the strange things about working in an interdisciplinary area is that one gets commissions that do not entirely fit philosophical disciplinary norms. One such, in this case, is the imposition of co-authors who, it turns out, have - quite reasonably! - somewhat different approaches to things. Here, therefore, is the core of a chapter I drafted and I will have to see what happens in the co-authoring process. We are trying - with collective good will - to work out how best to augment some of my first draft into a multi-voiced final chapter. (My hunch is to make it explicitly multi-voiced and not to try to arrive at some banal agreed view.)
Another difference from philosophical norm is the top-down suggestions for title and two main sub-heads. I have tried just to run with them.
Ontological and Epistemological Bases of Person Centered Medicine
Abstract
Person Centred Medicine is a substantial and contentious view of healthcare that carries both ontological and epistemological presuppositions. This chapter examines two key aspects: that the person is a central, basic irreducible element in ontology and that person-level knowledge is both important and possible. Some reasons for holding both of these are sketched.
10 key words
epistemology, normativity, ontology, persons, reductionism, rationality, self, space of reasons
Introduction
The precise nature of Person Centered Medicine (PCM) is contested. What are its implicit contrasts? Person versus patient or person versus sub-personal body part, for example? What are its essential features? Does it, for example, presuppose a specific set of person-level values? Such potential choices and conflicting claims, addressed in other chapters of this book, have consequences for articulating the bases for PCM.
‘Base’ itself suggests two meanings. It may mean the justification or rationale for advancing PCM. Here, we offer a more minimal reading and leave the main work of justification for other chapters. We take the ‘bases’ of PCM to be its presuppositions: specifically, the kinds of ontological and epistemological claims it presupposes to be true. As will become clearer, however, this does offer some partial account of its rationale, too.
We take it that, however its precise nature is articulated, PCM assumes the following broad claims. Ontologically, the level of the person is an irreducible and significant feature of ontology and a proper focus for healthcare. Epistemologically, not only is knowledge of the human person (human beings, people) possible and significant in healthcare, there are also irreducible forms of person-level knowledge which are important to healthcare. A commitment to PCM is thus a substantive commitment to ontological and epistemological claims. We will examine these commitments in order.
Objectives
Our aim is to clarify the implicit conceptual or philosophical commitments (in ontology and epistemology) of subscribing to PCM. We take it as a premiss that to subscribe to PCM is to assume the genuine existence of persons, for example. A fully worked out account of that commitment might require a completely satisfactory philosophical analysis of ‘person’ and refutation of all rival accounts. But that is an unrealistic account of what is required to support PCM. In this short chapter we will restrict ourselves to the sort of claims presupposed for PCM. A full philosophical defence of PCM might be possible but would also require narrowing down to a precise specification of what PCM is. Our aim is more modest but therefore of broader application to a range of views of what PCM involves.
Approaches to fulfil the objectives and knowledge base #1: The ontological presuppositions of PCM
At the very least, PCM presupposes the existence of persons. Further, it assumes that the ‘level’ of the person is important and irreducible in healthcare. That is, truths about persons are not reducible without loss to truths at a more basic level, such as the biochemical functioning of the body and its parts. If such truths were reducible, there would be no need to complement or contrast conventional biomedical approaches with something distinct.
PCM need not reject the importance of bio-medical medicine so much as complement it. A proper knowledge of the functioning of bodily systems seems to be an essential feature of anything recognisable as general medicine by contrast, for example, with a discipline focussed solely specific forms of mental pathology or distress, such as psychotherapy. On the other hand, to count as person centred, PCM must resist the claim that the concept of the person reduces without loss into a set of component bodily systems.
Given the success of modern science in explaining larger systems by decomposing them into the behaviour of smaller scale, simpler systems, what would rationalise the presupposition that the person is a basic feature of ontology and irreducible to smaller scale biology?
One once influential answer – and a helpful illustration here – is provided by Cartesian substance dualism. Descartes’ own account of the bulk of the natural world was that of a mechanical ‘plenum’: a packed world of direct causal pushes and pulls. Responding to the rise of mechanical natural philosophy – corresponding with the rise of modern science – Descartes assumed that mechanical models would apply very generally. At the same time, however, he exempted the mind from this domain. His dualism divides the world into two realms of different sorts of substance: res extensa – the domain of direct causal interaction – and res cogitans, the mental realm. Despite this distinction, the mental realm appears to be modelled on the mechanical philosophy in one sense: mental states are free-standing states in the mental realm, acting as though akin to causal factors [McDowell 1998a: 237-243]. This is one of the features that makes accounting for everyday mental phenomena: for example, the capacity for thoughts to be relational rather than free-standing, about things, to possess ‘intentionality [ibid: 242-3]. Another is the problem Descartes himself recognised of accounting for the apparent interaction of the mental and extended realms.
If we put those objections to one side for the moment, however, Cartesian substance dualism would provide a rationale for PCM by explaining one of its presuppositions. Substance dualism implies that persons – possessors of both mental and physical attributes – cannot be entirely made of extended matter. The mental belongs to a distinct non-bodily realm. But subscription to what now seems an outmoded approach to the mind would be a high price to pay for subscribing to PCM. So if not that, why else might one take the concept of the person to be irreducible?
One lesson of academic philosophy of mind since the 1970s is that there are many (epistemically, apparently) possible models of the relation of mind and body [Fulford et al 2006: 653]. At one end of a spectrum is substance dualism. At the other is eliminativism: the view that there are no mental states because the mental is a failed theory of the physical. Between are varieties of forms of property dualism, more or less closely tethered by supervenience, and reductionist physicalism. Thus, a commitment to PCM requires a rejection of eliminativism and reductionist physicalism but leaves open a variety of other ontological positions. But what might motivate that choice however precisely it might be realised?
Within analytic philosophy of mind, two main lines of argument have been stressed. One concerns the irreducibility of the qualitative aspects of mental states and experiences: their qualia. One such argument is Frank Jackson’s thought experiment concerning Mary the neuroscientist, locked in a black and white room but knowing the full physics and neurophysiology of colour vision [Jackson 1986]. Surely, runs the line of thought, she learns something new when presented for the first time with a red object? But if so, there is at least one fact to be learnt that cannot be captured within physical and neurophysiological theory. So reductionism of the mental to the physical is false.
A second line of argument, associated with Donald Davidson, concerns the irreducibility of the structure of rationality to mere lawlike relations between natural events [Davidson 1980: 229-44]. On the twin assumptions that the mental is essentially tied to rationality, and that rationality cannot be captured in physical theory, then the mental is irreducible to physical properties.
Such arguments – or the premises of such arguments however precisely formalised: the appeal to qualia or to rationality – supply plausible motivations for subscribing to a view of the irreducibility of the mental to something physical of bodily. But what of the centrality of the person?
There is a line of thought in philosophy dating back to David Hume which would motivate scepticism about its importance, focusing on the the nature of the self: something mental able to unify experiences as the experiences of a particular subject. Hume suggests that an introspective search for such a self, as the subject of thoughts and experiences, yields nothing.
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 introspection and not with an ego which stands in a relation to them. Philosophers since Hume have adopted a variety of responses that concede the basic point. Daniel Dennett argues that the self is an abstraction: a narrative structure of mental states. ‘A self is also an abstract object, a theorist’s fiction.’ [Dennett 1992]. Others have denied the existence of self in favour of underlying neurological structures [Hofstadter 2007; Metzinger 2003; Taylor 1999]
There is, however, a different line of thought dating back to Kant that grants an important basic status to the person. Peter Strawson offers an explicitly Kantian account [Strawson 1959, 1966]. To earn the right to the idea that experiences are unified as the experiences of a particular subject, there has to be some way to specify or identify that subject. Without some such criteria, the idea of a single subject is vacuous. But as Hume’s description of introspection reveals, conscious experience does not yield any criteria to identify a subject for one’s experiences. It reveals only the experiences themselves. From this, Hume concludes that there is no substantial self. But there are criteria for the identification of a subject available elsewhere: third-person criteria for the ascription of experiences to fellow human beings on the basis of what they say and do.
Strawson suggests that these can provide substance to the idea of a self even though they are not appealed to in self-ascriptions of experiences. This is because, whereas self-ascription of experiences is made without any appeal to these (or any other) criteria to identify a subject, it is still in accord with them. As Strawson puts it, ‘The links between criterionless self-ascription and empirical criteria of subject-identity are not in practice severed’ [Strawson 1966: 165]. Thus, it is because we are identifiable from a third person perspective as embodied subjects located within the world that we can also self-ascribe experiences without appeal to, but still in accord with, those criteria. The third-person criteria substantiate the idea of a subject.
Strawson goes on to argue that the person is a basic feature of ontology. Persons have, essentially, both physical and mental predicates. It is this combination that underpins the kind of subjective perspective to which Hume appeals but which cannot, by itself, constitute a self. As the contemporary philosopher John McDowell puts it:
The alternative [to a purely mental construal of the self as subject of experience] is to leave in place the idea that continuity of “consciousness” constitutes awareness of an identity through time, but reject the assumption that that fact needs to be provided for within a self-contained conception of the continuity of “consciousness”. On the contrary, we can say: continuous “consciousness” is intelligible (even “from within”) only as a subjective angle on something that has more to it than the subjective angle reveals, namely the career of an objective continuant with which the subject of the continuous “consciousness” identifies itself. The subjective angle does not contain within itself any analogue of keeping track of something, but its content can nevertheless intelligibly involve a stable continuing reference, of a first person kind; this is thanks to its being situated in a wider context, which provides for an understanding that the persisting referent is also a third person, something whose career is a substantially traceable continuity in the objective world. [McDowell 1998b: 363]
We do not wish to suggest, in this brief chapter, that a Kantian account of the nature of the person and a Strawsonian justification of its ontologically basic status is a necessary presupposition of PCM. But it provides a worked example of the kind of account to which PCM is committed: to the existence and importance of persons as a basic feature in ontology.
Approaches to fulfil the objectives and knowledge base #2: The epistemological presuppositions of PCM
Just as PCM presupposes that the person is a proper part of ontology – an irreducible level of description of the natural world – so it also carries epistemic presuppositions. Centrally, it is possible to have knowledge of persons. To clarify this point, think of the more normal English plural. It is possible to have knowledge of people. Well of course it is! A biomedical perspective that explicitly rejected the principles of PCM would still claim knowledge of the bodies, of their functions and dysfunctions, of people. Thus, to arrive at a presupposition that marks PCM out as a distinct substantive and risky approach, it is necessary to say something more. It is not just that knowledge of persons is possible, for example, of their bodies, but that knowledge of persons as persons is possible.
The previous section, however, mentioned one way to substantiate just such a claim. Descriptions of mental phenomena answer to a distinct constitutive principle that ‘finds no echo in physical theory’: the Constitutive Ideal of Rationality [Davidson 1980: 223]. To adopt a different metaphor: even without subscribing to a dualism of substances, one might still recognise a distinction between two conceptual spaces or modes of intelligibility: the space of reasons and the realm of law [Sellars 1997]. The former has application at the level of the person and captures a normative or evaluative character in the assessment of reasons for belief or action. Thus, part of the way in which PCM earns the right to claim a sui generis level of knowledge of persons as persons is to commit to the importance and irreducibility of placing subjects in the logical space of reasons.
This link opens up connections to other areas often taken to be part of PCM when less narrowly approached. (Recall that this chapter has adopted a narrow approach in order to explore the central ontological and epistemological presuppositions of any plausible view of PCM.) The space of reasons is also the space of values. Thus, any version of PCM that argues for the moral and ethical consequences or presuppositions of treating patients as persons will have to trade in this space: the space of evaluating the Good and the True.
But while sketching the logical space of knowledge of persons as persons helps show the nature of the ambition for PCM it does not address one specific worry that, while philosophically-influenced, can occur in reflective moments inspired by everyday life. It is the worry that desirable that knowledge of other people – as persons – is, it is strictly impossible. One can never achieve good enough reasons to justify claims about another’s mental life. Such is the worry. Here is a way to seem – misleadingly! – to ground it. Consider again the Cartesian substance dualist picture of the relation of mind and body. If mind and body occupy different dimensions – the physically extended and the thinking – then it seems that no form of perception based on causal receptivity in the physical world can yield awareness of other minds. How therefore is knowledge of others as persons so much as possible? Surely one can never bridge the gap between one’s own experience of another person and their actual thoughts and feelings? This worry then seems to float free of the specially Cartesian dualist background.
During the last 30 years, there have been two dominant philosophical answers to this question. One approach argues that such knowledge is akin to scientific theoretically mediated knowledge of unobservable entities: ‘theory theory’ [Davies and Stone 1995a]. Its main rival starts from the idea of empathic projection: one imaginatively places oneself in the position of the other and imagines one’s thoughts and experiences: ‘simulation theory’ [Davies and Stone 1995b]. It is worth noting in practice how unsatisfactory either is to ground the idea that one can ever have genuine knowledge of how another person – a patient or service user, perhaps – is feeling. We do not seem to know the theory presupposed by the former approach while the act of imagination outlined by the second seems inadequate for knowledge.
PCM need presuppose no particular account of how person-level knowledge of persons as persons is possible. Its commitment is not to any specific explanation of how but to the more generic claim that it is possible. However, it is worth noting that the very idea that there is a problem to be solved may be more philosophical – albeit longstanding – artefact than common sense.
A helpful alternative view stems from the same account of the basic role of persons we highlighted in the previous section which is both essentially mental and physical. If one starts from that perspective rather than the dualistic separation of mind and body then there is no need to deny the common-sense idea that human minds can express themselves in human behaviour and hence be known by others by contrast with the ‘alienated’ conception of our relation to others that underpins a Cartesian view of human bodies. If so, one can have a form of almost direct knowledge of another’s mental states. It is direct knowledge of the expression of the mental state. As John McDowell argues, experience of other people is not limited to their bare behaviour, with mentality hidden behind it. The idea of almost direct knowledge can be applied:
in at least some cases of knowledge that someone else is in an “inner” state, on the basis of experience of what he says and does. Here we might think of what is directly available to experience in some such terms as “his giving expression to his being in that ‘inner’ state”; this is something that, while not itself actually being the “inner” state of affairs in question, nevertheless does not fall short of it in the sense I explained. (McDowell 1998a.: 387)
Although one person’s inner states do not themselves fall within the direct perceptual experience of another person (hence ‘almost’), the fact that they express them can. This idea of expression is not one that is consistent with the absence of the inner state. So McDowell replaces an account in which all that is visible to an observer is another person’s intrinsically brute or meaningless behaviour, standing in need of further interpretation and hypothesis, with one in which that behaviour is charged with meaning and expression.
This particular philosophical ‘diagnosis’ of the implicit error behind the thought that it can seem that direct person-level knowledge is impossible provides one rationale for thinking that epistemological strand of PCM is fully justifiable. But it is not necessary to accept this to subscribe to PCM. The epistemological mark of PCM is merely that there is a form of knowledge couched at the level of the person that is a key component of healthcare alongside more basic knowledge of bodily functions and dysfunctions.
Practical Implications
The practical implications of adopting a PCM approach will be explored more directly in other chapters of this book. The purpose of this conceptual and theoretical chapter is to clarity the presuppositions and suggest the logical space for such a distinctive view. Only if some things are ruled out by it does PCM have any content. We have argued that what is ruled out is the idea that person-level claims can be reduced without loss to lower level bio-medical claims and that there is no distinctive person-level knowledge. We have also offered a brief route map to escape the pessimistic thought that it is simply impossible to have knowledge of other people’s mental states.
Discussion and conclusions
Person Centred Medicine is a substantial and contentious view within the philosophy and practice of healthcare. The mark of its substance is that it rules some things out. It is incompatible with some other views of nature and hence healthcare. In this chapter, we have explored its main broad presuppositions concerning ontology and epistemology. Its commitment to the existence of the person as a basic and irreducible element within ontology stands in opposition to views that deny that by, for example, promising to reduce the concept of the person to more basic phenomena. Thus, it stands opposed to various reductionist views. Its commitment to there being a form of person level knowledge and it being achievable stands in opposition both to claims that there is no such irreducible level or sceptical claims that it is impossible to attain. Although advocates for PCM need not have a fully worked out philosophy of the person or person-level knowledge, we have sketched the nature of this sort of commitment and made some suggestions for how they might be supported.
References
Davidson, D. (1980) Essays on Actions and Events, Oxford: Oxford University Press
Davies, M. and Stone, T. (ed.) (1995a) Folk Psychology: a guide to the theory of mind debate. Oxford: Blackwell.
Davies, M. and Stone, T. (ed.) (1995b) Mental Simulation: evaluations and applications. Oxford: Blackwell.
Dennett, D. (1992) The self as a center of narrative gravity. In Self and consciousness: multiple perspectives, ed. F. Kessel, P. Cole, and D. Johnson. Hillsdale, NJ: Erlbaum. Reprinted at URL: cogprints.ecs.soton.ac.uk/archive/00000266/
Fulford, K.W.M., Thornton, T. and Graham, G. (2006) Oxford Textbook of Philosophy and Psychiatry, Oxford: Oxford University Press
Hofstadter, D. (2007) I am a strange loop. New York: Basic Books.
Hume, D. (1978) A treatise of human nature. Oxford: Oxford University Press.
Jackson, F. (1986) ‘What Mary didn't know’ Journal of Philosophy 83:291-295
McDowell, J. (1985) Functionalism and anomalous monism. In Actions and events: perspectives on the philosophy of Donald Davidson, ed. E. LePore and B. P. McLaughlin. Oxford: Blackwell.
McDowell, J. (1998a) Meaning knowledge and reality. Cambridge, Mass: Harvard University Press
McDowell, J. (1998b) Mind value and reality. Cambridge, Mass: Harvard University Press.
Metzinger, T. (2003) Being no one – The self-model theory of subjectivity. Cambridge, MA: The MIT Press.
Sellars, W. (1997) Empiricism and the Philosophy of Mind. Cambridge, MA: Harvard University Press.
Strawson, P. F. (1959). Individuals. London: Methuen.
Strawson, P. F. (1966) The bounds of sense. London: Methuen.
Taylor, J.G. (1999) The race for consciousness. Cambridge, MA: The MIT Press.
Another difference from philosophical norm is the top-down suggestions for title and two main sub-heads. I have tried just to run with them.
Ontological and Epistemological Bases of Person Centered Medicine
Abstract
Person Centred Medicine is a substantial and contentious view of healthcare that carries both ontological and epistemological presuppositions. This chapter examines two key aspects: that the person is a central, basic irreducible element in ontology and that person-level knowledge is both important and possible. Some reasons for holding both of these are sketched.
10 key words
epistemology, normativity, ontology, persons, reductionism, rationality, self, space of reasons
Introduction
The precise nature of Person Centered Medicine (PCM) is contested. What are its implicit contrasts? Person versus patient or person versus sub-personal body part, for example? What are its essential features? Does it, for example, presuppose a specific set of person-level values? Such potential choices and conflicting claims, addressed in other chapters of this book, have consequences for articulating the bases for PCM.
‘Base’ itself suggests two meanings. It may mean the justification or rationale for advancing PCM. Here, we offer a more minimal reading and leave the main work of justification for other chapters. We take the ‘bases’ of PCM to be its presuppositions: specifically, the kinds of ontological and epistemological claims it presupposes to be true. As will become clearer, however, this does offer some partial account of its rationale, too.
We take it that, however its precise nature is articulated, PCM assumes the following broad claims. Ontologically, the level of the person is an irreducible and significant feature of ontology and a proper focus for healthcare. Epistemologically, not only is knowledge of the human person (human beings, people) possible and significant in healthcare, there are also irreducible forms of person-level knowledge which are important to healthcare. A commitment to PCM is thus a substantive commitment to ontological and epistemological claims. We will examine these commitments in order.
Objectives
Our aim is to clarify the implicit conceptual or philosophical commitments (in ontology and epistemology) of subscribing to PCM. We take it as a premiss that to subscribe to PCM is to assume the genuine existence of persons, for example. A fully worked out account of that commitment might require a completely satisfactory philosophical analysis of ‘person’ and refutation of all rival accounts. But that is an unrealistic account of what is required to support PCM. In this short chapter we will restrict ourselves to the sort of claims presupposed for PCM. A full philosophical defence of PCM might be possible but would also require narrowing down to a precise specification of what PCM is. Our aim is more modest but therefore of broader application to a range of views of what PCM involves.
Approaches to fulfil the objectives and knowledge base #1: The ontological presuppositions of PCM
At the very least, PCM presupposes the existence of persons. Further, it assumes that the ‘level’ of the person is important and irreducible in healthcare. That is, truths about persons are not reducible without loss to truths at a more basic level, such as the biochemical functioning of the body and its parts. If such truths were reducible, there would be no need to complement or contrast conventional biomedical approaches with something distinct.
PCM need not reject the importance of bio-medical medicine so much as complement it. A proper knowledge of the functioning of bodily systems seems to be an essential feature of anything recognisable as general medicine by contrast, for example, with a discipline focussed solely specific forms of mental pathology or distress, such as psychotherapy. On the other hand, to count as person centred, PCM must resist the claim that the concept of the person reduces without loss into a set of component bodily systems.
Given the success of modern science in explaining larger systems by decomposing them into the behaviour of smaller scale, simpler systems, what would rationalise the presupposition that the person is a basic feature of ontology and irreducible to smaller scale biology?
One once influential answer – and a helpful illustration here – is provided by Cartesian substance dualism. Descartes’ own account of the bulk of the natural world was that of a mechanical ‘plenum’: a packed world of direct causal pushes and pulls. Responding to the rise of mechanical natural philosophy – corresponding with the rise of modern science – Descartes assumed that mechanical models would apply very generally. At the same time, however, he exempted the mind from this domain. His dualism divides the world into two realms of different sorts of substance: res extensa – the domain of direct causal interaction – and res cogitans, the mental realm. Despite this distinction, the mental realm appears to be modelled on the mechanical philosophy in one sense: mental states are free-standing states in the mental realm, acting as though akin to causal factors [McDowell 1998a: 237-243]. This is one of the features that makes accounting for everyday mental phenomena: for example, the capacity for thoughts to be relational rather than free-standing, about things, to possess ‘intentionality [ibid: 242-3]. Another is the problem Descartes himself recognised of accounting for the apparent interaction of the mental and extended realms.
If we put those objections to one side for the moment, however, Cartesian substance dualism would provide a rationale for PCM by explaining one of its presuppositions. Substance dualism implies that persons – possessors of both mental and physical attributes – cannot be entirely made of extended matter. The mental belongs to a distinct non-bodily realm. But subscription to what now seems an outmoded approach to the mind would be a high price to pay for subscribing to PCM. So if not that, why else might one take the concept of the person to be irreducible?
One lesson of academic philosophy of mind since the 1970s is that there are many (epistemically, apparently) possible models of the relation of mind and body [Fulford et al 2006: 653]. At one end of a spectrum is substance dualism. At the other is eliminativism: the view that there are no mental states because the mental is a failed theory of the physical. Between are varieties of forms of property dualism, more or less closely tethered by supervenience, and reductionist physicalism. Thus, a commitment to PCM requires a rejection of eliminativism and reductionist physicalism but leaves open a variety of other ontological positions. But what might motivate that choice however precisely it might be realised?
Within analytic philosophy of mind, two main lines of argument have been stressed. One concerns the irreducibility of the qualitative aspects of mental states and experiences: their qualia. One such argument is Frank Jackson’s thought experiment concerning Mary the neuroscientist, locked in a black and white room but knowing the full physics and neurophysiology of colour vision [Jackson 1986]. Surely, runs the line of thought, she learns something new when presented for the first time with a red object? But if so, there is at least one fact to be learnt that cannot be captured within physical and neurophysiological theory. So reductionism of the mental to the physical is false.
A second line of argument, associated with Donald Davidson, concerns the irreducibility of the structure of rationality to mere lawlike relations between natural events [Davidson 1980: 229-44]. On the twin assumptions that the mental is essentially tied to rationality, and that rationality cannot be captured in physical theory, then the mental is irreducible to physical properties.
Such arguments – or the premises of such arguments however precisely formalised: the appeal to qualia or to rationality – supply plausible motivations for subscribing to a view of the irreducibility of the mental to something physical of bodily. But what of the centrality of the person?
There is a line of thought in philosophy dating back to David Hume which would motivate scepticism about its importance, focusing on the the nature of the self: something mental able to unify experiences as the experiences of a particular subject. Hume suggests that an introspective search for such a self, as the subject of thoughts and experiences, yields nothing.
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 introspection and not with an ego which stands in a relation to them. Philosophers since Hume have adopted a variety of responses that concede the basic point. Daniel Dennett argues that the self is an abstraction: a narrative structure of mental states. ‘A self is also an abstract object, a theorist’s fiction.’ [Dennett 1992]. Others have denied the existence of self in favour of underlying neurological structures [Hofstadter 2007; Metzinger 2003; Taylor 1999]
There is, however, a different line of thought dating back to Kant that grants an important basic status to the person. Peter Strawson offers an explicitly Kantian account [Strawson 1959, 1966]. To earn the right to the idea that experiences are unified as the experiences of a particular subject, there has to be some way to specify or identify that subject. Without some such criteria, the idea of a single subject is vacuous. But as Hume’s description of introspection reveals, conscious experience does not yield any criteria to identify a subject for one’s experiences. It reveals only the experiences themselves. From this, Hume concludes that there is no substantial self. But there are criteria for the identification of a subject available elsewhere: third-person criteria for the ascription of experiences to fellow human beings on the basis of what they say and do.
Strawson suggests that these can provide substance to the idea of a self even though they are not appealed to in self-ascriptions of experiences. This is because, whereas self-ascription of experiences is made without any appeal to these (or any other) criteria to identify a subject, it is still in accord with them. As Strawson puts it, ‘The links between criterionless self-ascription and empirical criteria of subject-identity are not in practice severed’ [Strawson 1966: 165]. Thus, it is because we are identifiable from a third person perspective as embodied subjects located within the world that we can also self-ascribe experiences without appeal to, but still in accord with, those criteria. The third-person criteria substantiate the idea of a subject.
Strawson goes on to argue that the person is a basic feature of ontology. Persons have, essentially, both physical and mental predicates. It is this combination that underpins the kind of subjective perspective to which Hume appeals but which cannot, by itself, constitute a self. As the contemporary philosopher John McDowell puts it:
The alternative [to a purely mental construal of the self as subject of experience] is to leave in place the idea that continuity of “consciousness” constitutes awareness of an identity through time, but reject the assumption that that fact needs to be provided for within a self-contained conception of the continuity of “consciousness”. On the contrary, we can say: continuous “consciousness” is intelligible (even “from within”) only as a subjective angle on something that has more to it than the subjective angle reveals, namely the career of an objective continuant with which the subject of the continuous “consciousness” identifies itself. The subjective angle does not contain within itself any analogue of keeping track of something, but its content can nevertheless intelligibly involve a stable continuing reference, of a first person kind; this is thanks to its being situated in a wider context, which provides for an understanding that the persisting referent is also a third person, something whose career is a substantially traceable continuity in the objective world. [McDowell 1998b: 363]
We do not wish to suggest, in this brief chapter, that a Kantian account of the nature of the person and a Strawsonian justification of its ontologically basic status is a necessary presupposition of PCM. But it provides a worked example of the kind of account to which PCM is committed: to the existence and importance of persons as a basic feature in ontology.
Approaches to fulfil the objectives and knowledge base #2: The epistemological presuppositions of PCM
Just as PCM presupposes that the person is a proper part of ontology – an irreducible level of description of the natural world – so it also carries epistemic presuppositions. Centrally, it is possible to have knowledge of persons. To clarify this point, think of the more normal English plural. It is possible to have knowledge of people. Well of course it is! A biomedical perspective that explicitly rejected the principles of PCM would still claim knowledge of the bodies, of their functions and dysfunctions, of people. Thus, to arrive at a presupposition that marks PCM out as a distinct substantive and risky approach, it is necessary to say something more. It is not just that knowledge of persons is possible, for example, of their bodies, but that knowledge of persons as persons is possible.
The previous section, however, mentioned one way to substantiate just such a claim. Descriptions of mental phenomena answer to a distinct constitutive principle that ‘finds no echo in physical theory’: the Constitutive Ideal of Rationality [Davidson 1980: 223]. To adopt a different metaphor: even without subscribing to a dualism of substances, one might still recognise a distinction between two conceptual spaces or modes of intelligibility: the space of reasons and the realm of law [Sellars 1997]. The former has application at the level of the person and captures a normative or evaluative character in the assessment of reasons for belief or action. Thus, part of the way in which PCM earns the right to claim a sui generis level of knowledge of persons as persons is to commit to the importance and irreducibility of placing subjects in the logical space of reasons.
This link opens up connections to other areas often taken to be part of PCM when less narrowly approached. (Recall that this chapter has adopted a narrow approach in order to explore the central ontological and epistemological presuppositions of any plausible view of PCM.) The space of reasons is also the space of values. Thus, any version of PCM that argues for the moral and ethical consequences or presuppositions of treating patients as persons will have to trade in this space: the space of evaluating the Good and the True.
But while sketching the logical space of knowledge of persons as persons helps show the nature of the ambition for PCM it does not address one specific worry that, while philosophically-influenced, can occur in reflective moments inspired by everyday life. It is the worry that desirable that knowledge of other people – as persons – is, it is strictly impossible. One can never achieve good enough reasons to justify claims about another’s mental life. Such is the worry. Here is a way to seem – misleadingly! – to ground it. Consider again the Cartesian substance dualist picture of the relation of mind and body. If mind and body occupy different dimensions – the physically extended and the thinking – then it seems that no form of perception based on causal receptivity in the physical world can yield awareness of other minds. How therefore is knowledge of others as persons so much as possible? Surely one can never bridge the gap between one’s own experience of another person and their actual thoughts and feelings? This worry then seems to float free of the specially Cartesian dualist background.
During the last 30 years, there have been two dominant philosophical answers to this question. One approach argues that such knowledge is akin to scientific theoretically mediated knowledge of unobservable entities: ‘theory theory’ [Davies and Stone 1995a]. Its main rival starts from the idea of empathic projection: one imaginatively places oneself in the position of the other and imagines one’s thoughts and experiences: ‘simulation theory’ [Davies and Stone 1995b]. It is worth noting in practice how unsatisfactory either is to ground the idea that one can ever have genuine knowledge of how another person – a patient or service user, perhaps – is feeling. We do not seem to know the theory presupposed by the former approach while the act of imagination outlined by the second seems inadequate for knowledge.
PCM need presuppose no particular account of how person-level knowledge of persons as persons is possible. Its commitment is not to any specific explanation of how but to the more generic claim that it is possible. However, it is worth noting that the very idea that there is a problem to be solved may be more philosophical – albeit longstanding – artefact than common sense.
A helpful alternative view stems from the same account of the basic role of persons we highlighted in the previous section which is both essentially mental and physical. If one starts from that perspective rather than the dualistic separation of mind and body then there is no need to deny the common-sense idea that human minds can express themselves in human behaviour and hence be known by others by contrast with the ‘alienated’ conception of our relation to others that underpins a Cartesian view of human bodies. If so, one can have a form of almost direct knowledge of another’s mental states. It is direct knowledge of the expression of the mental state. As John McDowell argues, experience of other people is not limited to their bare behaviour, with mentality hidden behind it. The idea of almost direct knowledge can be applied:
in at least some cases of knowledge that someone else is in an “inner” state, on the basis of experience of what he says and does. Here we might think of what is directly available to experience in some such terms as “his giving expression to his being in that ‘inner’ state”; this is something that, while not itself actually being the “inner” state of affairs in question, nevertheless does not fall short of it in the sense I explained. (McDowell 1998a.: 387)
Although one person’s inner states do not themselves fall within the direct perceptual experience of another person (hence ‘almost’), the fact that they express them can. This idea of expression is not one that is consistent with the absence of the inner state. So McDowell replaces an account in which all that is visible to an observer is another person’s intrinsically brute or meaningless behaviour, standing in need of further interpretation and hypothesis, with one in which that behaviour is charged with meaning and expression.
This particular philosophical ‘diagnosis’ of the implicit error behind the thought that it can seem that direct person-level knowledge is impossible provides one rationale for thinking that epistemological strand of PCM is fully justifiable. But it is not necessary to accept this to subscribe to PCM. The epistemological mark of PCM is merely that there is a form of knowledge couched at the level of the person that is a key component of healthcare alongside more basic knowledge of bodily functions and dysfunctions.
Practical Implications
The practical implications of adopting a PCM approach will be explored more directly in other chapters of this book. The purpose of this conceptual and theoretical chapter is to clarity the presuppositions and suggest the logical space for such a distinctive view. Only if some things are ruled out by it does PCM have any content. We have argued that what is ruled out is the idea that person-level claims can be reduced without loss to lower level bio-medical claims and that there is no distinctive person-level knowledge. We have also offered a brief route map to escape the pessimistic thought that it is simply impossible to have knowledge of other people’s mental states.
Discussion and conclusions
Person Centred Medicine is a substantial and contentious view within the philosophy and practice of healthcare. The mark of its substance is that it rules some things out. It is incompatible with some other views of nature and hence healthcare. In this chapter, we have explored its main broad presuppositions concerning ontology and epistemology. Its commitment to the existence of the person as a basic and irreducible element within ontology stands in opposition to views that deny that by, for example, promising to reduce the concept of the person to more basic phenomena. Thus, it stands opposed to various reductionist views. Its commitment to there being a form of person level knowledge and it being achievable stands in opposition both to claims that there is no such irreducible level or sceptical claims that it is impossible to attain. Although advocates for PCM need not have a fully worked out philosophy of the person or person-level knowledge, we have sketched the nature of this sort of commitment and made some suggestions for how they might be supported.
References
Davidson, D. (1980) Essays on Actions and Events, Oxford: Oxford University Press
Davies, M. and Stone, T. (ed.) (1995a) Folk Psychology: a guide to the theory of mind debate. Oxford: Blackwell.
Davies, M. and Stone, T. (ed.) (1995b) Mental Simulation: evaluations and applications. Oxford: Blackwell.
Dennett, D. (1992) The self as a center of narrative gravity. In Self and consciousness: multiple perspectives, ed. F. Kessel, P. Cole, and D. Johnson. Hillsdale, NJ: Erlbaum. Reprinted at URL: cogprints.ecs.soton.ac.uk/archive/00000266/
Fulford, K.W.M., Thornton, T. and Graham, G. (2006) Oxford Textbook of Philosophy and Psychiatry, Oxford: Oxford University Press
Hofstadter, D. (2007) I am a strange loop. New York: Basic Books.
Hume, D. (1978) A treatise of human nature. Oxford: Oxford University Press.
Jackson, F. (1986) ‘What Mary didn't know’ Journal of Philosophy 83:291-295
McDowell, J. (1985) Functionalism and anomalous monism. In Actions and events: perspectives on the philosophy of Donald Davidson, ed. E. LePore and B. P. McLaughlin. Oxford: Blackwell.
McDowell, J. (1998a) Meaning knowledge and reality. Cambridge, Mass: Harvard University Press
McDowell, J. (1998b) Mind value and reality. Cambridge, Mass: Harvard University Press.
Metzinger, T. (2003) Being no one – The self-model theory of subjectivity. Cambridge, MA: The MIT Press.
Sellars, W. (1997) Empiricism and the Philosophy of Mind. Cambridge, MA: Harvard University Press.
Strawson, P. F. (1959). Individuals. London: Methuen.
Strawson, P. F. (1966) The bounds of sense. London: Methuen.
Taylor, J.G. (1999) The race for consciousness. Cambridge, MA: The MIT Press.
Friday, 5 June 2020
Anhedonia in the time of C-19
During the C-19 restrictions our lives seems to have shrunk
to the sort of weird attenuated existence that – if my fallible memory is right
– used to happen regularly on Star Trek (TNG). One or other crew member would end
up the only one left in an episode in which all other crew members slowly vanished
but those initially left denying, in the meantime, that anyone else had ever
been on the ship or that the ship had ever comprised more than the captain’s
ready-room’s ensuite facilities. Or whatever. It’s not suffering under enemy
bombs (though more people have died). The panic buying subsided and there’s
been only the most minor of informal rationing. But still, it seems to me that,
like everyone else, what my life encompasses has shrunk.
At the same, however, my anhedonia seems to have eased. Why
is this?
By anhedonia I mean…
Let me go back a bit. My parents died in 2014 in what ended
up a rather horrible year. It began with the best Liptonian explanation –
according to my consultant – of my sudden deafness being a life-threatening brain
tumour. I didn’t cope well with this for the days I waited news. In the week
that I got the all-clear, my mother was rushed to hospital and died both
suddenly and slowly a few weeks later of leukaemia. My father, for whom she’d
been a key informal carer, lived a precarious existence for the next 4 months
rescued from death by diabetic coma on 4 occasions by visiting nurses breaking
in. He died the day I went to spend three dark and gloomy months in a room in a
castle in Durham weirdly shunned by the other members of the college. I
underwent a thorough grief period for the rest of 2014 and then the first half
of 2015. And then I slipped into depression, anxiety attacks and intrusive compulsive
thoughts.
Four years later and after a variety of talking cures, much
of all that has improved. But the one thing that showed no sign of lifting
was a kind of anhedonia which had two key elements.
1) A loss of the ability to be struck by happiness.
2) A loss of anticipatory happiness.
By 1) I mean that while it would be absurd to say that when in a flow activity I was unhappy, I could not experience the happiness as happiness. I never had the kind of glad start of thinking: Gosh isn’t the sun on my back rather lovely! That slightly self-conscious, meta-level happiness in one’s happiness stopped. By 2) I mean that while I had a cognitive attitude to the likelihood of the kind of happiness permitted by 1) a day later when next in the pub with friends, that induction, that belief, had no effect on my mood beforehand. I had never noticed before that the prospect of future happiness permits a kind of borrowing of happiness itself. One can be happy in virtue of and in advance of later happiness.
1) A loss of the ability to be struck by happiness.
2) A loss of anticipatory happiness.
By 1) I mean that while it would be absurd to say that when in a flow activity I was unhappy, I could not experience the happiness as happiness. I never had the kind of glad start of thinking: Gosh isn’t the sun on my back rather lovely! That slightly self-conscious, meta-level happiness in one’s happiness stopped. By 2) I mean that while I had a cognitive attitude to the likelihood of the kind of happiness permitted by 1) a day later when next in the pub with friends, that induction, that belief, had no effect on my mood beforehand. I had never noticed before that the prospect of future happiness permits a kind of borrowing of happiness itself. One can be happy in virtue of and in advance of later happiness.
I realised last week that I didn’t feel burdened by either
of these notions. I don’t think it’s because I’ve regained the spontaneous
experience of my state as a state of happiness but its lack doesn’t seem such a
problem. Nor does an attenuated weekend fill me with Thursday morning glee. I'm not more happy, in other words.
Might it be this? I don’t think that the C-19 form of life would
allow for that much of what I’m lacking anyway? In which case, I’ve got the
phenomenology of my anhedonia wrong. The lack isn’t either 1 or 2 but a lack of self-conscious enjoyment of what’s missing in both cases. So for 1, I don’t miss a
reflective awareness of my happiness, I miss a meta-level enjoyment of a
capacity for a meta-level enjoyment of my happiness. To be honest, it wouldn’t
surprise me at all if it had ended up as indirect as this. Should have stuck to physics.
The implications of the loss of self-respect for the recovery model in mental healthcare
A couple of months later, I'm revising this paper for Human Affairs (the official organ of the Slovak Academy of Sciences, Slovakia). One addition they've asked for is an account of why paternalism is wrong.
Here's my thought: paternalism is wrong because it relies on a standing status. On a traditional model of child-rearing, the father figure owns the child and can impose eg sailor-suits simply because that is his desire. He is the father - the pater - and that abiding status fixes the right choice: whatever he wants. The element of rightness in paternalism in actual parenting is this: quite often the father (and mother, obvs!) knows rather better than their children what's best for them and in cases where this matters should thus trump their children's foolish wishes (children shouldn't be allowed to play on busy roads even if they want to). But the good basic idea is that a parent may be an expert in objective matters: may be able to do a risk assessment of the objective facts of danger, say, or better grasp what cruelty is or meanness. They have to earn this - though not in the court of their children's early feelings - by being right. They answer to those facts, not the other way round. It doesn't follow from the status of just being a parent. The idea that it might is what's wrong with paternalism. And hence - when that word is used outside parenting - that's what's wrong with it: authority granted by status not earned by expertise. (Cf the two readings of the euthyphro paradox: the right side has the gods as moral experts not the setters of arbitrary fashions).
This is also what's wrong with the phrase 'expert by experience'.
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 [Thornton and Lucas 2010, Thornton 2012, 2017].
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 associated with the promotion of the novel view of recovery with which I am here concerned confusingly coincided with greater optimism within biological psychiatry of the efficacy of medicines. Both elements played a role in raising the possibility of recovery in mental healthcare, 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 both with a value-free conception of healthcare as aimed at returning patients to statistically normal or biologically functional states but also with paternalistic models of health service provision which are guided by the choices of clinicians on behalf of patients.
Why is paternalism of such concern in mental healthcare? I suggest that three factors play a role. First, the stakes are higher in the case of mental illness because a diagnosis of mental illness can serve as a reason to detain and treat a person against their will. Second, because of that connection, there remains a greater tendency for clinicians simply to assume a paternalist role in mental by contrast with physical healthcare. Third, as Bill Fulford has forcefully argued, even if – as he holds – physical and mental illness are both essentially value laden, the value-ladenness of the latter is more obvious because the values involved are much more contested [Fulford 1989]. As a matter of contingent fact, there is much more agreement about the contrasts of physical health and illness than mental health and illness. Thus paternalism in mental health care presents a much greater risk of imposing a value on a patient or service user that they do not themselves hold. These three points fit a further key aspect of paternalism to which I will return at the end of the paper and which holds the key to reconciling the aim of the recovery model – in opposing paternalism – with the tension I will unfold below.
To counter paternalism, 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 also feelings of shame can both 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-esteem (between which he did not distinguish) and what he calls ‘moral shame’ which fits well with Darwall’s account of appraisal 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 the link between shame and a lack of appraisal self-respect 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 explicit failure of (appraisal) self-respect of the form Rawls sets out.
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 both 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 unfortunate symptoms of mental illness but threaten the very idea of the current central aim in mental healthcare.
The links between both self-respect and shame and agency are 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]
Here shame seems to be connected to a lack of appraisal self-respect: a feeling of unworthiness to act.
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.
Tension or fatal flaw?
I have argued that there is a tension in the recovery model in that it presupposes agency in the specific case of people who suffer illnesses that can undermine agency via a failure of self-respect and by instilling shame. Why, however, think of this as a mere tension rather than a fatal flaw in the recovery model (as one referee of this paper suggested)?
The answer turns on a nuance of the notion of paternalism hinted at earlier and to which I now return. Probably the most famous model of medical ethics, Beauchamp and Childress’s four principles approach, attempts to capture a tension between two prima facie virtues or reasons for action: respect for beneficence and respect for the autonomy of the patient [Beauchamp and Childress 2001]. These can conflict and, depending on the context, either can be the more important. Thus, according to this framework, it can be ethically correct to override someone’s autonomy in order to do them (other) good. I think that this is correct. It accords with an aspect of moral reason particularism: context is all [Dancy 1993, Thornton 2006]. This does not, however, imply that paternalism is sometimes correct. Paternalism is not the mere trumping of a person’s autonomy – for good particularist reasons – it is also the reason why that is done. Paternalism is status driven: the clinician as father.
I take it that the ethos of the recovery model in mental healthcare is anti-paternalist in this sense. The grounding of the judgement that the authorship of a recovery narrative or agenda by someone with a mental illness may have been impaired by the illness, and is thus not authentic, is not that it is wrong by the standards of the clinician simpliciter but that it is wrong, in the clinician’s (and other relevant parties) views, in virtue of the subject’s own non-illness limited desires. The difference between the two cases is that in the former paternalist case clinical views set the standard for correctness. In the latter, they attempt to track the subject’s real wishes. One visible sign of the difference is the different kinds of evidence (such as advanced directives or family testimony) relevant in either case.
Hence the tension set out in this paper is a tension rather than a fatal flaw because paternalism can still be countered even given the tension. Kim Hopper uses the phrase ‘sensitive work’ to suggests a hermeneutic task, unfolding over time, of attempting to recover authentic wishes. Elsewhere, I have argued that narratives have a role in this [Thornton 2017]. Narrative coherence as perceived by the subject provides one test of the diachronic self-understanding of a patient recovering from severe mental illness. If the final test of a suggestion for a goal for recovery of a patient by a clinician is its adoption into the patient’s own narrative, that suggests that it is neither a paternalist imposition of a brutely external value nor the distorted effect of the lack of self-respect and shame that is often a product of mental illness.
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Thornton, T. (2012) ‘Is recovery a model?’ in Rudnick, A. (ed) The Recovery of People with Mental Illness Oxford University Press: 236-51
Thornton, T. (2017) ‘Recovery, paternalism and narrative understanding in mental healthcare’ Freda, M.F. and De Luca Picione, R. (eds) Cultural Construction of Social Roles in Medicine, Information Age Publishing: Charlotte, N.C.
Thornton, T. and Lucas, P. (2010) ‘On the very idea of a recovery model for mental health’ J Med Ethics 37: 24-8
Unzicker, R. (1989) ‘On my own: a personal journey through madness and re-emergence’ Psychosocial Rehabilitation Journal 13: 70-77
Here's my thought: paternalism is wrong because it relies on a standing status. On a traditional model of child-rearing, the father figure owns the child and can impose eg sailor-suits simply because that is his desire. He is the father - the pater - and that abiding status fixes the right choice: whatever he wants. The element of rightness in paternalism in actual parenting is this: quite often the father (and mother, obvs!) knows rather better than their children what's best for them and in cases where this matters should thus trump their children's foolish wishes (children shouldn't be allowed to play on busy roads even if they want to). But the good basic idea is that a parent may be an expert in objective matters: may be able to do a risk assessment of the objective facts of danger, say, or better grasp what cruelty is or meanness. They have to earn this - though not in the court of their children's early feelings - by being right. They answer to those facts, not the other way round. It doesn't follow from the status of just being a parent. The idea that it might is what's wrong with paternalism. And hence - when that word is used outside parenting - that's what's wrong with it: authority granted by status not earned by expertise. (Cf the two readings of the euthyphro paradox: the right side has the gods as moral experts not the setters of arbitrary fashions).
This is also what's wrong with the phrase 'expert by experience'.
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 [Thornton and Lucas 2010, Thornton 2012, 2017].
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 associated with the promotion of the novel view of recovery with which I am here concerned confusingly coincided with greater optimism within biological psychiatry of the efficacy of medicines. Both elements played a role in raising the possibility of recovery in mental healthcare, 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 both with a value-free conception of healthcare as aimed at returning patients to statistically normal or biologically functional states but also with paternalistic models of health service provision which are guided by the choices of clinicians on behalf of patients.
Why is paternalism of such concern in mental healthcare? I suggest that three factors play a role. First, the stakes are higher in the case of mental illness because a diagnosis of mental illness can serve as a reason to detain and treat a person against their will. Second, because of that connection, there remains a greater tendency for clinicians simply to assume a paternalist role in mental by contrast with physical healthcare. Third, as Bill Fulford has forcefully argued, even if – as he holds – physical and mental illness are both essentially value laden, the value-ladenness of the latter is more obvious because the values involved are much more contested [Fulford 1989]. As a matter of contingent fact, there is much more agreement about the contrasts of physical health and illness than mental health and illness. Thus paternalism in mental health care presents a much greater risk of imposing a value on a patient or service user that they do not themselves hold. These three points fit a further key aspect of paternalism to which I will return at the end of the paper and which holds the key to reconciling the aim of the recovery model – in opposing paternalism – with the tension I will unfold below.
To counter paternalism, 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 also feelings of shame can both 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-esteem (between which he did not distinguish) and what he calls ‘moral shame’ which fits well with Darwall’s account of appraisal 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 the link between shame and a lack of appraisal self-respect 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 explicit failure of (appraisal) self-respect of the form Rawls sets out.
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 both 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 unfortunate symptoms of mental illness but threaten the very idea of the current central aim in mental healthcare.
The links between both self-respect and shame and agency are 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]
Here shame seems to be connected to a lack of appraisal self-respect: a feeling of unworthiness to act.
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.
Tension or fatal flaw?
I have argued that there is a tension in the recovery model in that it presupposes agency in the specific case of people who suffer illnesses that can undermine agency via a failure of self-respect and by instilling shame. Why, however, think of this as a mere tension rather than a fatal flaw in the recovery model (as one referee of this paper suggested)?
The answer turns on a nuance of the notion of paternalism hinted at earlier and to which I now return. Probably the most famous model of medical ethics, Beauchamp and Childress’s four principles approach, attempts to capture a tension between two prima facie virtues or reasons for action: respect for beneficence and respect for the autonomy of the patient [Beauchamp and Childress 2001]. These can conflict and, depending on the context, either can be the more important. Thus, according to this framework, it can be ethically correct to override someone’s autonomy in order to do them (other) good. I think that this is correct. It accords with an aspect of moral reason particularism: context is all [Dancy 1993, Thornton 2006]. This does not, however, imply that paternalism is sometimes correct. Paternalism is not the mere trumping of a person’s autonomy – for good particularist reasons – it is also the reason why that is done. Paternalism is status driven: the clinician as father.
I take it that the ethos of the recovery model in mental healthcare is anti-paternalist in this sense. The grounding of the judgement that the authorship of a recovery narrative or agenda by someone with a mental illness may have been impaired by the illness, and is thus not authentic, is not that it is wrong by the standards of the clinician simpliciter but that it is wrong, in the clinician’s (and other relevant parties) views, in virtue of the subject’s own non-illness limited desires. The difference between the two cases is that in the former paternalist case clinical views set the standard for correctness. In the latter, they attempt to track the subject’s real wishes. One visible sign of the difference is the different kinds of evidence (such as advanced directives or family testimony) relevant in either case.
Hence the tension set out in this paper is a tension rather than a fatal flaw because paternalism can still be countered even given the tension. Kim Hopper uses the phrase ‘sensitive work’ to suggests a hermeneutic task, unfolding over time, of attempting to recover authentic wishes. Elsewhere, I have argued that narratives have a role in this [Thornton 2017]. Narrative coherence as perceived by the subject provides one test of the diachronic self-understanding of a patient recovering from severe mental illness. If the final test of a suggestion for a goal for recovery of a patient by a clinician is its adoption into the patient’s own narrative, that suggests that it is neither a paternalist imposition of a brutely external value nor the distorted effect of the lack of self-respect and shame that is often a product of mental illness.
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Thursday, 4 June 2020
On not being very interested in natural kinds in psychiatry
I’m writing one of these new short format (25-30,000 words) mini-books on mental illness. Having plotted the first 60%, I’m struggling to work out how to approach the final 40%, an outline of which I submitted as part of the proposal.
I took some time out to write a paper on dementia and narrative identity (which seems to have gone ok), a 5,000 word entry on tacit knowledge for an edited book on implicit knowledge (the editor didn’t like the line I took in the first version so I’ve drafted a second) and a misguided chapter on the saying-showing distinction in the later Wittgenstein (I sent the editor a 4 paragraph outline, warning that I couldn’t write what he really wanted – on the saying-showing distinction in the early Wittgenstein - but could offer this; he accepted the outline as ‘fitting the concept’ of the book but when, only 10 days later, I submitted the chapter, he rejected it in a single sentence email as not ‘fitting the concept’; oh well). But I ought to be back to the mental illness booklet.
It has taken me a few days to understand my resistance to returning to the CUP mini-book. I now realise that it is is an emotional response.
When I think like a university lecturer about what should be included for the sake of the reader/student, I think it should include some discussion of the kind of kinds that might properly belong to psychiatric taxonomy. There has been much discussion of this from both psychiatrists thinking of the revisions of the DSM and philosophers. Abstract models have been put forward. Perhaps the most influential one right now is a renamed version of Boyd’s homeostatic property clusters: mechanistic property clusters. Such a model relaxes any essentialist assumptions on kinds. There are also related issues such as whether we should look at a level lower than whole syndromes / DSM diagnoses as RDoC suggests and to cross level causal factors.
But the fact that there may be cross level causal factors (and perhaps therefore no such thing as levels) that constitute kinds of some sort via such clusters isn’t why I got into philosophy. And yet that is seen as the most legitimate of philosophy of psychiatry activities. I’m not really interested but I don’t have a ready way to show that I have any right not to be interested. What would be such a right?
Here’s a thought: showing that it at least might be missing the point. We know that the RDoC isn’t really interested in dysfunction but function and causal explanations across many putative levels of ‘symptoms’ rather than syndromes. (I scare quote because the interest in function rather than dysfunction counts against the word ‘symptom’.) So it isn’t going to help with the very idea of mental pathology. Nor does a relaxed model of kinds help with the status of DSM diagnoses. There might be homeostatic / mechanistic property clusters underpinning aspects of ADHD but there might be for same sex sexual attraction or for political dissent in the USSR. That there might be H/MPCs solves a different problem to the one that strikes me as worth philosophising about. My interest does not lie in whether there might be mixed bottom up and top down explanations of some aspects of human experience so much as why we want to categorise conditions as mental illnesses. It’s that top down question rather than causal explanations of how such conditions, once we’ve identified them, are sustained that seems the proper object of philosophical inquiry. But I feel distinctly old fashioned in not finding the possibility of relaxed natural kinds really interesting in itself.
I took some time out to write a paper on dementia and narrative identity (which seems to have gone ok), a 5,000 word entry on tacit knowledge for an edited book on implicit knowledge (the editor didn’t like the line I took in the first version so I’ve drafted a second) and a misguided chapter on the saying-showing distinction in the later Wittgenstein (I sent the editor a 4 paragraph outline, warning that I couldn’t write what he really wanted – on the saying-showing distinction in the early Wittgenstein - but could offer this; he accepted the outline as ‘fitting the concept’ of the book but when, only 10 days later, I submitted the chapter, he rejected it in a single sentence email as not ‘fitting the concept’; oh well). But I ought to be back to the mental illness booklet.
It has taken me a few days to understand my resistance to returning to the CUP mini-book. I now realise that it is is an emotional response.
When I think like a university lecturer about what should be included for the sake of the reader/student, I think it should include some discussion of the kind of kinds that might properly belong to psychiatric taxonomy. There has been much discussion of this from both psychiatrists thinking of the revisions of the DSM and philosophers. Abstract models have been put forward. Perhaps the most influential one right now is a renamed version of Boyd’s homeostatic property clusters: mechanistic property clusters. Such a model relaxes any essentialist assumptions on kinds. There are also related issues such as whether we should look at a level lower than whole syndromes / DSM diagnoses as RDoC suggests and to cross level causal factors.
But the fact that there may be cross level causal factors (and perhaps therefore no such thing as levels) that constitute kinds of some sort via such clusters isn’t why I got into philosophy. And yet that is seen as the most legitimate of philosophy of psychiatry activities. I’m not really interested but I don’t have a ready way to show that I have any right not to be interested. What would be such a right?
Here’s a thought: showing that it at least might be missing the point. We know that the RDoC isn’t really interested in dysfunction but function and causal explanations across many putative levels of ‘symptoms’ rather than syndromes. (I scare quote because the interest in function rather than dysfunction counts against the word ‘symptom’.) So it isn’t going to help with the very idea of mental pathology. Nor does a relaxed model of kinds help with the status of DSM diagnoses. There might be homeostatic / mechanistic property clusters underpinning aspects of ADHD but there might be for same sex sexual attraction or for political dissent in the USSR. That there might be H/MPCs solves a different problem to the one that strikes me as worth philosophising about. My interest does not lie in whether there might be mixed bottom up and top down explanations of some aspects of human experience so much as why we want to categorise conditions as mental illnesses. It’s that top down question rather than causal explanations of how such conditions, once we’ve identified them, are sustained that seems the proper object of philosophical inquiry. But I feel distinctly old fashioned in not finding the possibility of relaxed natural kinds really interesting in itself.
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