Thursday, 24 June 2021

The contemporary importance of the idiographic in mental healthcare

In response to concerns about the subsuming of individuals under essential general psychiatric diagnostic categories, there have been calls for an idiographic component in person specific diagnostic formulations. The distinction between the idiographic and nomothetic was introduced by Windelband as his contribution to the Methodenstreit. However, as I have argued elsewhere, it is unclear what the distinction is supposed to comprise. In this chapter, I attempt to shed light on the motivation for the distinction by looking at a number of recent approaches to healthcare that share a concern with a focus on individuals. Despite this shared element in their motivation, I argue that none help to articulate the nature of the idiographic itself.

This chapter broadens the central claim of my chapter in the 2018 Yearbook of Idiographic Science, here drawing on a clue from Windelband’s student Rickert to argue that there is a role for the idiographic in healthcare though not as a form of judgement, understanding or intelligibility but rather a specific singular interest in an individual. It is this that also underpins developments in healthcare related to the individual or person..


One of the standing concerns expressed by mental health service users and clinicians alike about contemporary diagnosis in psychiatry is that it risks pigeon-holing subjects rather than respecting their individuality. As an anonymous reviewer of one of my papers once put it: ‘Time and time again the categorical, pigeon-holing, approach to diagnosis has to be bent in order to accommodate the individual account’ (Thornton 2008b). The suggestion seems to be that the criteriological model of diagnosis that lies at the heart of the Diagnostic and Statistical Manual and the International Classification of Diseases, is, by itself, inadequate to capture, and perhaps respect, patients and service users as people in all their individuality (American Psychiatric Association 2013; World Health Organization 1992).

This concern forms the motivation for proposals in psychiatry such as the World Psychiatric Association’s Idiographic (Personalised) Diagnostic Formulation which called for an ‘idiographic component alongside criteriological diagnosis’ (IGDA Workgroup, WPA, 2003: 55). It aimed ‘at understanding and formulating what is important in the mind, the body and the context of the person who presents for care’ (ibid: 55). Taking my lead from the word used by the World Psychiatric Association, I will call this concern for capturing the individual nature of the patient or service user a concern for ‘idiographic’ understanding. This, however, raises the question of the nature of the idiographic. As I will argue, it proves harder to analyse than it might first appear. Having looked at its origins in Wilhelm Windelband’s rectoral address, I will look at a number of contemporary approaches to healthcare that, I believe, are motivated by the same concern with the individual. I will argue, however, that none is able to shed light on the idea of idiographic understanding. At the end, I will suggest that the felt need for a special form of understanding can be met, instead, in a different way. It lies in an interest in individuals which is also hinted at by Windelband but also his student Rickert.

This chapter sketches a broad overall picture of a number of healthcare ‘philosophies’ seen through the conceptual lens of the idiographic. It thus writes a cheque that would need to be redeemed by careful and sober argument. That, however, will not be offered here.

Windelband and the idiographic

The first articulation of the idiographic was given by the post-Kantian philosopher Wilhelm Windelband in his 1894 rectoral address (Windelband 1980). Windelband worked in the broad tradition of the Methodenstreit, which concerned methodological distinctions between the natural and social sciences. It is usually associated with a distinction between understanding and explanation exemplified, for example, in Karl Jaspers’ General Psychopathology (Jaspers 1997). Understanding and explanation are supposed to be distinct ways of conceptualising their subject matters, with the former tied to human thoughts, feelings and actions and the latter to the totality of merely natural events.

Rather than understanding versus explanation, Windelband contrasts idiographic and nomothetic sciences. He links that distinction, primarily, to a very general distinction between the particular and the general. Such a distinction – between distinct forms of judgement in different disciplines – looks to be tailor-made to capture the contrast between a pigeon-holing approach implicit in general criteriological approaches in psychiatry and a form of judgement that captures patient and client individuality.

In their quest for knowledge of reality, the empirical sciences either seek the general in the form of the law of nature or the particular in the form of the historically defined structure. On the one hand, they are concerned with the form which invariably remains constant. On the other hand, they are concerned with the unique, immanently defined content of the real event. The former disciplines are nomological sciences. The latter disciplines are sciences of process or sciences of the event. The nomological sciences are concerned with what is invariably the case. The sciences of process are concerned with what was once the case. If I may be permitted to introduce some new technical terms, scientific thought is nomothetic in the former case and idiographic in the latter case. Should we retain the customary expressions, then it can be said that the dichotomy at stake here concerns the distinction between the natural and the historical disciplines. (Windelband 1980: 175-6)

Windelband remarks that the distinction he is attempting to frame is not based on a distinction of substances: sciences of nature or natural science (Naturwissenschaften), versus the sciences of the mind (Geisteswissenschaften). Such a distinction is hostage to the fortunes of that dualism. If the reductionist project of explaining mental properties in physical terms were successful then that contrast would be undermined. Instead it is a methodological distinction.

Even with these characterisations in play, however, the distinction as so far introduced is not clear. Consider the contrast between ‘what is invariably the case’ and ‘what was once the case’. There are three problems with using this contrast to characterise a notion of ‘idiographic’. First, it threatens to slip back from a methodological distinction of how a subject matter is approached to the underlying nature of the events in question (whether, as a matter of fact, they are invariant or unique). Second, a substantive distinction does not explain in what way an idiographic understanding differs from any other sort. Third, the uniqueness of its subject matter cannot separate the idiographic and nomothetic. The gravitational forces on a mass, for example, depend in principle on a vector sum of its relation with every other object in the universe and thus some of the events described by physics are likely to be unique.

Elsewhere I have suggested that the appeal of idiographic judgement stems from a recoil from subsuming human individuals under general conceptual categories – from pigeon-holing people – and hence instead attempting to understand them in other ways or other terms, a kind of ‘individualising intuition’ (Thornton 2008a, 2008b, 2010). The problem is then to explain what novel form of judgement would address this task. If judgement in general takes a subject predicate form – s is P – then there are two elements to consider: the referential element and the predicational element.

The referential element does not seem to be a hopeful place to look to draw a distinction between nomothetic and idiographic. Consider the traditional deductive-nomological model of explanation as an example (Hempel 1965). This contains general laws (hence the name). But it also refers to particular circumstances in the explanans. Whether an adequate formal model of explanation or not, since the DN model of explanation is designed to fit paradigmatically nomothetic sciences mere singular reference to particular circumstances is not sufficient to distinguish a different form of intelligibility.

But ‘individualising’ the predicational element seems equally unpromising albeit in a different way. Such a predicate would have to be designed for a particular single element carrying with it no possible application to, and hence comparison with, other individuals. What could such a predicate be? What property would be picked out such that it could not possible apply to other cases? The closest idea seems to be a kind of name designed for a specific individual (person or event). But that collapses this proposal back into the referential element of the judgement. In neither way can the ‘individualising intuition’ be satisfied through a novel form of judgement.

I think that the ‘individualising intuition’ is a widespread in recent responses to/against conventional psychiatric medicine. And so it may help to identify how it can be achieved by looking at other initiatives concerning healthcare. In what follows, I aim for breadth rather than depth. I will merely paint an abstract picture of the lie of the land. Justifying the connections I sketch breathlessly would require careful argument for which there is not space here.

Person Centred Medicine

The ‘individualising intuition’ is one of the motivations for the recent growing popularity of a long-standing approach to healthcare, in parallel with the growth over the last thirty years of evidence-based medicine (EBM), namely person-centred medicine (PCM). Though the roots of PCM lie in, among other places, Paul Tournier’s advocacy of ‘medicine for the person’, conceptions of the clinician-client relationship in psychotherapy, and models of patient-centred care, it has recently risen to prominence just as EBM has seized the clinical imagination. While EBM stresses the importance of evidence based on large scale population side studies, PCM presses the idea that the proper focus of healthcare should be on individual people construed as persons rather than, say, merely biological systems. The former emphasises the role of generalities in medicine, the latter individuals. This is not to say that there must be an incompatibility between looking to population-wide studies as the basis for reliable evidence and to individuals as the focus of such evidence-based care but the apparent need to re-emphasise the latter suggests an inchoate concern that the patient or client as an individual risks being lost from sight.

The nature of PCM is, however, particularly contested. For some authors, the contrast between persons and patients is key, for others not. For some, the main contrast with persons is sub-personal systems. For others, it is illnesses. For yet others, the contrast is a focus on the needs of patients rather than on the needs of clinicians. Despite having a particular focus on individual patients, understood as persons, conflicting claims are made about the values necessary either to maintain that focus or as a proper response to it.

Given these competing views, is there anything essential that all forms of PCM must hold? I have argued elsewhere that any plausible version of PCM must commit to two claims (Thornton forthcoming). 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. Do either of these claims shed light on the nature of the idiographic?

I think not. First, although the two commitments are distinct – because they concern ontology and epistemology respectively – with respect to the question addressed here, they can be reduced to one. What makes the knowledge specifically personal is the ontology known. This, I suggest, following the philosophers Wilfrid Sellars and John McDowell, is characterised by a distinction between two conceptual orders: the ‘space of reasons’ and the ‘realm of law’ (McDowell 1994; Sellars 1997). The irreducibility of the level of the person follows from the irreducibility of the space of reasons to the realm of law. The former is a normative realm of reasons, motives, rules that applies to rational subjects. The latter is a realm of mere generalities concerning mindless happenings in broader nature. So, does a characterisation of the space of reasons shed light on the idiographic? To consider this I will turn to narrative understanding.

Narrative medicine

The World Psychiatric Association suggests, as an alternative to the characterisation of ‘idiographic’, that what needs to be added to criteriological diagnosis in a more comprehensive model is a narrative formulation. Any such move faces a strategic choice. Is the very idea of narrative interpreted broadly to have wide application, even at the risk of evacuating it of specific content, or is it tied to particular literary notions of narrative, thus risking narrowing its application and making it inapplicable to non-literary contexts?

At its broadest, we might use ‘narrative’ to label the kind of intelligibility required for any exploration of the space of reasons: charting the reasons, motives, rules and actions that characterise the human realm. That would also be a way to fill out the ‘understanding’ side of the ‘understanding versus explanation’ contrast in the Methodenstreit. Understanding could be characterised as narrative understanding of the space of reasons and explanation could chart the nomological realm of law. If so, the normative structure of narrative offers a genuine complement to generality based criteriological diagnosis. It offers a view of the rational coherence of a subject’s thoughts and feelings, of why they think and feel what they do according to them, over and above what is merely generally or statistically the case, in accord with the realm of law.

Despite this difference, narrative accounts are nevertheless couched in general terms and consequently narrative understanding does not address the felt need for an essentially singular judgement purpose built for an individual. This is because they are conceptually structured and, according to a very plausible principle, concept mastery is an essentially general ability. The most famous statement of this is the philosopher Gareth Evans’ Generality Constraint.

It seems to me that there must be a sense in which thoughts are structured.... I should prefer to explain the sense in which thoughts are structured, not in terms of their being composed of several distinct elements, but in terms of their being a complex of the exercise of several distinct conceptual abilities.... Thus if a subject can be credited with the thought that a is F, then he must have the conceptual resources for entertaining the thought that a is G, for every property of being G of which he has a conception. (Evans 1980: 100-104)

Because narrative understanding of others rides piggy back on conceptual thought in general, it inherits the latter’s essential generality. This suggests, too, that narrowing down, or making more specific, the model of narrative would not change this fundamental point. Even if a person-specific diagnostic formulation were more closely modelled on what we might call a ‘story’, with the necessary dramatic components of that genre, still the basic elements would be general concepts, applicable to more than one person and hence not addressing the individualising intuition. The danger of pigeon-holing would continue to exist. An individual might be subsumed under an appealing narrative or story to which they do not fully fit.

Values-based practice

Like person-centred medicine, values-based practice (VBP) is another explicit attempt to complement to EBM (generalised from medicine to practice), which aims to promote the role of patients’ and clients’ values alongside (evidence of) facts in healthcare decisions. In the original and influential statement of VBP, in addition to arguing for the general importance of values, Bill Fulford asserts the central importance of the individual patient or client: ‘VBP’s ‘first call’ for information is the perspective of the patient or patient group concerned in a given decision (the ‘patient-perspective’ principle)’ (Fulford 2001). Unlike conventional bio-ethics, VBP is concerned with a full range of values and preferences that inform patient choices rather than concentrating on ethical values. And, again unlike most – though not all – approaches to medical ethics, Fulford places no great importance on principles, contra eg Beauchamp and Childress’ Four Principles approach (Beauchamp and Childress 2001).

On Fulford’s account, further, values are subjective. Value judgements are the preferences of individuals rather than answering to anything objective. The result is an essentially subjectivist account of values in healthcare decisions. The idea of a correct medical decision is replaced by proper deliberative procedure.

In VBP, conflicts of values are resolved primarily, not by reference to a rule prescribing a “right” outcome, but by processes designed to support a balance of legitimately different perspectives (the “multi-perspective” principle). (Fulford 2001: 206)

In the context of a contrast between the particular and the general, Fulfordian VBP suggests a complementary contrast between subjective and objective. Could this be used to explain a difference between idiographic and nomothetic?

There is a prima facie problem with this idea, however. A subjectivist version of VBP is susceptible to an objection from circularity. This can be illustrated by asking: what is the status of the claim that: in VBP conflicts of values are resolved primarily, not by reference to a rule prescribing a ‘right’ outcome, but by processes designed to support a balance of legitimately different perspectives? Note, first, that although Fulford says in the quotation above that conflicts of values ‘are resolved…’ this is in the context of Values Based Practice. So it should be read as saying: conflicts of values should be resolved by processes designed to support a balance of legitimately different perspectives. But now we can ask, why should they? (It may be an analytic truth that they are within Values Based Practice, but we are invited to adopt this approach.)

The worry, now, is that this seems to be a value of a different order from the values that should be put through the right process of balancing views. It seems to be a higher order value, inconsistent with Values Based Practice’s own approach. This then suggests a dilemma for radical VBP. It can either address the question of why we should value values in the way it suggests, but at the cost of violating its own principles, or it can attempt no such question, in which case it lacks the prescriptive force that gives it teeth (Thornton 2011, 2014).

The alternative favours an objective understanding of the subject matter of value judgements and hence a particularist, rather than a subjectivist, opposition to principlism (Dancy 1993). That leaves a different account of VBP’s account of the role of values. Although not governed by general principles, values are objective, albeit situation specific features of the world. Thus, VBP adds an emphasis on getting the values of a patient or service user right along with the biomedical facts. This is a genuine and important addition to the generalist underpinnings of EBM. But again, while a patient’s situation may be unique, the concepts used to describe it in both factual and evaluative terms are general. And hence the individualising intuition is again not met. Even acknowledging the general idea that psychiatric categories are value-laden as well as factual does not make them essentially tailored to the individual. The risk of pigeon-holing remains.

The biopsychosocial model

George Engel’s biopsychosocial model of healthcare shares with the more recent World Psychiatric Association’s comprehensive model of diagnosis the aim of a fuller picture of diagnosis and healthcare (Engel 1977). Drawing on some of the same historical forebears as PCM – some proponents of which explicitly draw on the biopsychosocial model in return – the biopsychosocial model is explicitly aimed at augmenting, though still including, the biomedical model. Its key metaphysical idea is that nature comprises a hierarchy of levels: from the subatomic to the societal. The biopsychosocial model augments the biomedical model by adding in factors from higher up the hierarchy.

To provide a basis for understanding the determinants of disease and arriving at rational treatments and patterns of health care, a medical model must also take into account the patient, the social context in which he lives, and the complimentary system devised by society to deal with the disruptive effect of illness, that is, the physician role and the health care system. This requires a biopsychosocial model. (Engel 1977).

The biopsychosocial model explicitly aims to accommodate a person-level account alongside the bio-medical underpinnings of disease diagnosis. Might it, by that very aim, also accommodate idiographic understanding?

The problem is that merely adding higher levels of organisation to basic levels of physics, chemistry and biology does little to address the underlying concerns that motivated the quest for idiographic understanding in the first place. Merely adding higher levels does nothing to address a concern about the use of general descriptions and the concern of a connection to pigeon-holing.

Idiographic as an interest

In this final section, I will set out a different response to the ‘individualising intuition’ drawing on incidental clues found in Windelband and his student Heinrich Rickert. In his rectoral address, Windelband comments:

[T]he more we strive for knowledge of the concept and the law, the more we are obliged to pass over, forget, and abandon the singular fact as such. We can see this disposition in the characteristically modern attempt ‘to make history into a natural science’ the project of the so-called positivist philosophy of history… In opposition to this standpoint, it is necessary to insist upon the following: every interest and judgment, every ascription of human value is based upon the singular and the unique... Our sense of values and all of our axiological sentiments are grounded in the uniqueness and incomparability of their object. (Windelband 1980: 181-2)

This passage suggests a contentious connection between values and uniqueness. It is contentious in both directions. With respect to the implication from values to uniqueness, Kant’s Categorical Imperative, for example, implies that love of the good has an essential generality. But the implication from uniqueness to values is also unclear. This, however, is the focus of Rickert’s general account of the relation between and contrast of natural and historical science in his The Limits of Concept Formation in Natural Science (Rickert 1986). I will briefly outline his broad methodological picture.

Rickert argues that, because concepts are general, they abstract away from the concrete details of the particular, individual and perceptual aspects of reality. This is the limit of generalised scientific conceptualisation, in the sense of what it cannot represent. Given that, at least according to our experience of it, reality is infinite in extent and infinitely complex or subdividable, the only way for concept formation following this generalising strategy to be possible is to look for abstract generalities and away from the perceptual and the real. There is thus a gap between a generalised conceptual account of the world and the world itself. This is called the ‘hiatus irrationalis’ in post-Kantian philosophy. It is an hiatus because the conceptual cannot capture every aspect of reality and it is irrational because it is only by being subsumed under concepts that we can have a rational understanding of reality.

The move to a generalised scientific account moves away from the real, individual and particular towards the general and conceptual. And hence generalised scientific concepts are emptied of their perceptual character and all its detail. Rickert points out that scientific laws have the form of conditional statements: if one thing occurs then so will another. And thus he asserts ‘It lies in the concept of law of nature that it has nothing to say about what really occurs here or there, now or then, with a uniqueness and an individuality that cannot be repeated.’ (ibid: 41)

Against the potential objection that the practical application of natural science to make specific predictions shows it deals with individuals, Rickert argues.

[T]he fact that we calculate the real in advance does not imply that the concepts of natural science comprehend its total contents… It is not a question of grasping individual and perceptual realities in their individuality and concrete actuality. We are able to say only that in the future, an object will appear that can be subsumed as a case under this or that general concept. But this does not give us knowledge of the individuality and concrete actuality of future objects. Should we be interested in this sort of knowledge, we are always obliged to wait until the objects are really at hand. (ibid: 42)

Given the hiatus irrationalis between abstract concepts and reality, generalised science cannot reproduce reality. It aims instead at valid judgement. The truth of a judgement, its validity, is distinct from a resemblance or reproduction.

The concepts of the natural sciences are true, not because they reproduce reality as it actually exists but because they represent what holds validly for reality. (ibid: 44)

But because science does not copy reality, it opens up the possibility of more than one relation between concepts and reality. The limit case of generalised natural science suggests one such alternative (in fact, the only other one). One can try to capture the individuality of the concrete, real, perceptual rather than the general.

There is a representation of reality that proceeds not by generalising but by individualising, a representation that is therefore able to satisfy the interest in the unique, individual event itself. (ibid: 51)

[T]he science of the unique and the individual is necessarily the science of the event that has occurred in the past… Every account of reality itself, every account that on the basis of the foregoing reasons, concerns the unique, individual event that takes place at a specific point in space and time, we call history. (ibid: 47-8)

But as Rickert emphasises, the arguments concerning the gap between concepts and reality apply just as much to history as to natural science.

History too, insofar as it is a science, can produce only a conception of reality based on a specific logical perspective. As a result, the immediacy of reality is necessarily destroyed, but that consideration does not alter the legitimacy of this point of departure for a logical investigation. (ibid: 53)

Hence he owes an account of the principles of concept formation that govern history analogously with the abstraction and framing of laws that governs the natural sciences. It turns out, however, that the question he answers is more specific. It is how historical subjects are selected rather than the nature of historical concepts. Subjects are selected because, in addition to being specific individuals (of which there are too many!), they are specific individuals of value. This resembles the quotation from Windelband above which highlights a connection between what we value and uniqueness. Rickert argues that history is concerned with ‘in-dividuals’ not just individuals. He offers a lengthy analysis of the nature of the values in play but given that it does not, after all, address a distinction in kind between an approach to generalities and individuals it is not relevant here. Of the concepts actually deployed in historical accounts, Ricket concedes that they are general and he merely qualifies the scope of the generality compared to the natural sciences.

Even though many, perhaps even most, historical concepts have a general content in the sense that they comprehend what is common to a plurality of individual realities, in the historical nexus of a unique developmental sequence this generality is always considered as something relatively specific and individual. (ibid: 63)

In other words, despite the philosophical framework he offers, Rickert does not provide a conceptual distinction between generalising and individualising accounts. Both lie on the conceptual side of the hiatus irrationalis and both deploy general concepts. In that respect, he is no more successful than Windelband in suggesting how the individualising intuition is to be met.

Despite that, one summarising passage in The Limits of Concept Formation in Natural Science suggests a clue.

There is a profusion of things and events that interest us not only because of their relationship to a general law or a system of general concepts but also because their distinctiveness, uniqueness, and individuality are significant to us. Wherever this interest in reality is present, we can do nothing with natural scientific concept formation. (ibid: 46 bold added)

Combining this with the suggestion from Windelband – that ‘every ascription of human value is based upon the singular and the unique’ – this suggests that the way to think about the individualising intuition is not that it requires a specific form of idiographic understanding or judgement, a specific conceptualisation. Rather it reflects an interest in individuals that might be met in any number of ways. It is not a novel form of judgement or intelligibility but rather is the nature of interest an inquiry takes in its subject matter. In some cases, one is interested in individuals because they are instances of generalities. In others, the interest is in them as individuals (Thornton 2019).

What is the nature of this interest? One element is suggested in an earlier quotation from Rickert: ‘Should we be interested in this sort of knowledge [knowledge of the individuality and concrete actuality of future objects], we are always obliged to wait until the objects are really at hand.’ This suggests that one mark of an interest in an individual is that the referential element of thoughts about them is fixed by singular or object-dependent component of the thought. The actual existence of an object is necessary to be able to think singular, as opposed to descriptive thoughts, about them. But singular thought is not sufficient for an individualising interest because one may also have singular thoughts about objects in which one has an interest merely because they are instances of a generality. Further, one may think of an object via a descriptive thought even if one has an individualising interest. Thus the nature of the interest is not determined by the logic of the thought even though the possibility of singularity is a necessary component.

Construing the idiographic as a specific form of interest, rather than a sui generis form of understanding, is liberating. It removes the need to try to formulate a novel form of concept especially tailored for the individual. Any kind of concept may, in the right context, serve the interest of shedding light on an individual. But it also helps contextualise the different approaches to healthcare discussed earlier in this chapter. The call for diagnostic formulations in addition to criteriological diagnoses, person centred medicine, the stress on personal narratives, values based practice and the bio-psycho-social model are all motivated by an interest in individuals. Each stresses different conceptual structures that might help in this but all are expressions of the same guiding concern. In response to the worry that generalities may, contingently, obscure the proper subject matter of healthcare, each of these concerns attempts to place the individual back at the centre of healthcare. That is the contemporary relevance of the idiographic, construed not as a form of judgement but as a value.


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