Book launch of the new Oxford Handbook of Philosophy and Psychiatry

“The Oxford Handbook of Philosophy and Psychiatry offers the most comprehensive reference resource for this area ever published and we are delighted to announce the launch as part of the Summer School. Sponsored by Oxford University Press, the launch will open with a short address from Dr Anita Avramides (Reader in Philosophy of Mind, University of Oxford).

The book is written and edited by an international team comprising world-leading philosophers and psychiatrists, resulting in an authoritative volume. We are very happy to welcome several of these team members to the Summer School where they will be delivering key sessions:

• Values in Mental Health Practice - Professor Bill Fulford (Emeritus Professor of Philosophy and Mental Health, University of Warwick, and Member of the Philosophy Faculty, University of Oxford)
• Ordering Disorder: Mental Disorder, Brain Disorder and Therapeutic Intervention - Professor George Graham (Professor of Philosophy and Neuroscience, Georgia State University)
• Karl Jaspers and the Ethics of Incomprehensibility - Professor Giovanni Stanghellini (Professor of Dynamic Psychology and Psychopathology, University of Chieti)

These sessions form part of an intensive programme delivered through keynote lectures and seminars offering opportunities for substantial dialogue between philosophers, scientists and mental health practitioners. The Summer School will take place at St Catherine’s College, Oxford (14 – 19 July 2013) and includes opportunities to network and socialise with fellow delegates, faculty members and invited speakers. Residential and non-residential options are available.”

Further details available: www.conted.ox.ac.uk/ox_ppss

Hopper, K. (2007) ‘Rethinking social recovery in schizophrenia'

The UCLan mental health reading group has started a series of recovery related papers in advance of a planned visit by Larry Davidson. We kicked off with Kim Hopper’s 2007 paper ‘Rethinking social recovery in schizophrenia: What a capabilities approach might offer’.

The paper starts with the pre-history of the recovery movement in mental healthcare, when the conception of recovery was, as one might have expected, simply getting better, sloughing off illness but when the best that seemed likely was, in Kraepelin’s phrase, ‘cure with defect’ (or ‘healing with scarring’). For example research in 1928 suggested a 20% recovery rate, meaning that that proportion were able to return to expected social roles. More recently, however, what Hopper calls ‘social recovery’ has been found to be more common than previously expected ‘outside the hospital, when measured by independent living and gainful employment’ [ibid: 869]. But he stresses the importance that targeted help can make to such social recovery. This in turn led to the development of a widespread literature about recovery with four key themes.

1.       Renewing a sense of possibility 

2.       Regaining competencies

3.       Reconnecting and finding a place in society

4.       Reconciliation work

But, Hopper argues, this list of themes significantly neglects social context: the difference that race, gender, poverty etc can make to mental health. The neglect of systematic treatment of such features undermines the right to call recovery a ‘model’.

To speak of a ‘model’ of recovery is thus misleading. Movements are not peer-reviewed. Mobilizing committed forces means hoisting rallying cries at odds with one another, tamping down potentially divisive demands, and capitalizing on working misunderstandings. In making the case against therapeutic nihilism, rethinking services, and embracing patients as active agents in their own recuperation, this inclusive approach served well, making common cause of potentially discordant constituencies. But the same medley of affirmation, reckless hope and wide appeal made for later difficulties when converting emancipating creed into actionable policy. [ibid: 871]

Hopper goes on to argue that the open ended and moral crusading aspects of recovery have prevented it from being put into practice. He gives the example of Jacobson’s anthropological study of Wisconsin in which institutional inertia has prevented significant change despite explicit support for recovery programmes.

It is difficult to escape the conclusion that operational specificity was unwisely sacrificed in the interest of more efficiently spreading the good news. The movement’s watchwords—voice, authenticity, process, settling old scores and filing fresh grievances—proved ill-matched to the grind of institutional sway and regulatory reform. Recovery had merit, morals and the tempered weight of science behind it and so it sashayed into political battle unarmed. [ibid: 873]

Thus the second half of the paper looks to try to address this lack by unpacking the notion of recovery in such a way that it can be ‘operationalised’. Hopper’s suggestion is to understand recovery on the lines of a capabilities approach. There seem to be two key elements to this.

First, a capabilities approach contrasts with an even (‘utilitarian’)distribution of resources by looking instead at needs.

Instead of satisfaction or utility or some package of ‘primary goods,’ Sen proposes that we consider not resources but rather the valued things people are able to do or to be as a result of having them—the capabilities they command. Actual welfare depends less on what I own or have access to than the real opportunities open to me as a result. [ibid: 874]

Second, mental health and illness are modelled on a two factor view of disability: on the one hand, original impairment (here, psychiatric disorder) and on the other, the disability which is constituted by the social reception and consequences of the impairment. Combined, this gives a model of recovery on these lines:

A capabilities-informed ‘social recovery’ will speak to citizenship as well as health. It will worry about what enables people to thrive, not simply survive... Recovery asks not what such people should be content with but what they should be capable of, and how that might be best achieved and sustained. [ibid: 874]

As my colleague, Karen Newbigging, pointed out, this gives a picture of recovery as not so much a model of healthcare but as a meta-level theory into which healthcare slots as one thing among others. Given the two-factor model, it also allows for a natural position for a technical, biological psychiatry to address the ‘original impairment’. That seems to be an interestingly conventional feature of his thinking. More radically, one might think that the ontological status of the first factor was derivative of the second. That is, one might think that there is no theory neutral set of original impairments. What is so deemed depends on social values.

Two other features of the way this broad structure is elaborated are notable. First, and reflecting the criticism in the first half of the paper, Hopper suggests that the capabilities version of the recovery movement has to be operationalised if it is to be effective and this requires some sort of universal, a priori list of human necessities:

Any application of capabilities must therefore first define/defend a (full or partial) list of valued functionings..., or specify a process for identifying/weighting them..., and then devise provisional means for assessing real opportunities for achieving them (capabilities proper). [ibid: 876]

The obvious worry this raises in the context of the history of mental healthcare is paternalism. Now, I think that that is a price worth paying (cf my criticism of Fulford’s pure procedural version of Values Based Practice) but others might not and Hopper does not seem to notice that this may be an issue. Further, it may be in tension, at least, with one of the things that he thinks will be on the list: the opportunity to exercise autonomy and agency. Here he suggests, in effect, the right to make unwise decisions.

With respect to formal interventions, a capabilities- informed approach to recovery would stress enhanced agency—not public safety, stable placements or reliable program-participation. This means asking under what circumstances exercising reasoned choice should be prized over foreseeable bad consequences in one’s life. Can a poor choice, assessed in terms of compromised well-being, be preferred if the foregone benefit could have been won only if imposed? [ibid: 877]

The tension is that the stress on agency and autonomy and the right to make unwise decisions at the level of the individual pulls against the idea that a policy maker might articulate a universal list of what is good for people. Now it seems plausible on an Aristotelian conception of flourishing, for example, that agency will be important, will be on any such list, but if so the value of agency has to be constrained by the other features of the list and vice versa.

This tension is present in a list of potential difficulties towards the end of the paper with the suggestion that ‘Deprivation and disgrace can so corrode one’s self worth that aspiration can be distorted, initiative undercut and preferences deformed’ [ibid: 877]. That seems right and suggests – correctly in my view – that there should be some element of normative assessment of individuals’ values (I am that paternalistic!). One may be wrong to value something. But Hopper continues: ‘Sensitive work will be needed to recover that suppressed sense of injustice and reclaim lost possibility’ which suggests that he already knows that if anyone, ever, thought that their mental healthcare had been good then they must be wrong. That seems overly paternalistic to me.

All that said, there is something admirable, and rare, about a paper which explicitly addresses the underlying conceptual model of recovery. By connecting recovery to a two factor model of disability and then addressing the consequences of this for what people do and should value, Hopper provides a model which is distinct from a conventional biomedical model.

Hopper, K. (2007) ‘Rethinking social recovery in schizophrenia: What a capabilities approach might offer’ Social Science & Medicine 65: 868–879

Essex Autonomy Project Summer School 2013

The Essex Autonomy Project is pleased to announce details of the Autonomy Summer School 2013, which will take place at the University of Essex on the 4 – 6 July 2013.

The Summer School is a three-day training course aimed at frontline professionals and researchers who face issues surrounding autonomy and mental capacity. The programme focuses on the key areas of:

The Legal Terrain

The Philosophical Terrain

Capacity Assessments

Best Interest Decision-Making

Deprivation of Liberty

Paternalism and Coercion

Teaching on the Summer School programme will be provided by staff from the Essex Autonomy Project and guest practitioners and there will be a dedicated ‘clinic’ time for exploring dilemmas in practice. The Autonomy Summer School is designed for professionals in medicine, psychiatry, social care, policing, law, researchers and students.

Fees: £650 – residential place

£495 – non-residential place

Further details of the Autonomy Summer School, including an on-line application form, are available on our website: http://autonomy.essex.ac.uk/summer-school

Bootstrapping normativity?

A work in progress...

In a post a couple of years ago, I expressed some suspicion of Hannah Ginsborg’s conception of primitive normativity. If I understand her, the idea is to locate a position which helps account for how concepts can be learnt and is poised thus between a merely dispositional account (which leaves too much of a gap still to be crossed to achieve full conceptual mastery) and a fully conceptual grasp (which begs the question of concepts can be learnt). The middle ground is a notion of ‘primitive normativity’:

“primitive normativity”: very roughly, normativity which does not depend on conformity to an antecedently recognized rule. [ibid: 233]

‘Conformity to an antecedently recognized rule’ corresponds to full blown conceptual normativity according to which:

the child says “42” after “40” because she recognizes, although without being able to put that recognition into words, that she has been adding two and that 40 plus two is 42. Her sense of the appropriateness of what she is saying thus derives from her recognition that it fits the rule she was following: a rule which she grasps, even though she is unable to articulate it. [ibid: 238]

Primitive normativity involves less than that. But it involves more than the merely reliable dispositional reactions of a suitable trained parrot.

unlike the parrot, [the child]... does not respond “blindly” to her circumstances. Even though she does not say “42” as a result of having grasped the add-two rule, nor a fortiori of having “seen” that 40 plus two is 42, she nonetheless “sees” her utterance of “42” as appropriate to, or fitting, her circumstances. [ibid: 237]

So even though the child lacks full blown conceptual mastery, she has a sense of appropriateness, fitting or belonging which merits the label ‘normativity’. Ginsborg gives a second example of sorting coloured objects before acquiring determinate colour concepts:

As she puts each green object in the designated box, it is plausible that she does so with a sense that this is the appropriate thing to do. She takes it that the green spoon “belongs” in the box containing the previously sorted green things and that the blue spoon does not, just as the child in the previous example takes 42 and not 43 to “belong” after 40 in the series of numerals. But her sense of the appropriateness of what she is doing does not, at least on the face of it, depend on her taking what she is doing to accord with a rule which she was following, for example, the rule that she is to put all the green things in the same box. For her grasp of such a rule would presuppose that she already possesses the concept green. [ibid: 235]

The objections to full blown conceptual normativity and to dispositionalism are clear (which is not to say I agree with them). What is less clear to me is just how primitive ‘primitive normativity’ is. My worry stems from a potential difference between two comments Ginsborg makes:

1: ‘she lacked any conception of what her saying “42” after “40” had in common with her having said “40” after “38”’ [ibid: 234 italics added]

and

2: ‘Rather, it seems plausible to imagine her insisting, with no less conviction than a child who was able to cite the add-two rule, that “42” was the right thing to say after “40”: that it “came next” in the series, or “belonged” after 40, or “fit” what she had been doing previously’ [ibid: 234 italics added]

The former states that the counting child has no conception of what one move has in common with a previous move. The second allows for the possibility of some conception that the next move fits or belongs (ie does have something in common) with the previous one in context. The latter allows for a conception albeit a local one. I am unsure which Ginsborg believes.

‘No conception’ primitive normativity

Before setting out why a local conception is a satisfactory thing to hold to, it is worth seeing whether there is reason to think Ginsborg believes in the more minimal version. One passage which might prompt it runs:

The utterance, from her point of view, is not appropriate to the context in virtue of its conforming to a general rule which the context imposed on her, for example, the add-two rule. Rather, she takes it to be appropriate to the context simpliciter, in a way which does not depend for its coherence on the idea of an antecedently applicable rule to which it conforms. [ibid: 234-5]

Now one way to interpret the phrase ‘antecedently applicable rule’ is a context-independent specification of a rule. In the context of a mathematical series, that is a plausible way of cashing out full blown conceptual normativity. And hence its rejection might allow for a demonstratively specified merely local conception of the demands of a rule. But it might be taken to mean, and hence to rule out, any conception. If so, the context imposes a sense of what move belongs with previous moves, of what next move is right, independently of any conception the child has of what she is doing. The way the quotation continues adds to this impression:

This is not to deny that the normativity depends on any facts about the context, since the appropriateness of “42” depends on her having recited that particular sequence of number words. But it is to deny that her claim to the appropriateness of “42” depends on her recognition of a rule imposed by the context in virtue of the relevant facts, or a fortiori on her recognition of “42” as a correct application of the rule. [ibid: 235]

The picture is thus one in which facts about the context external to the child’s conception of the demands of the rule make normative demands. The context of having counted up to 40 makes saying ‘42’ appropriate independently of her conception of what she is doing. ‘42’ belongs to what has gone before, is normatively connected to it, but she does not recognise that this is the demand that the rule makes.

A second paragraph provides a distinct argument for the no conception view if that is wedded to the idea of a local conception of what going on in the same way is.

the child’s recognition of similarity is not sufficient to account for her taking herself to be going on appropriately. She must not merely take herself to be going on the same way; she must also take it that going on the same way is the appropriate thing to do in the context, which is to say that she must grasp a rule with a content like go on the same way or do the same thing you were doing before. We are thus left with the problem of how to account for her grasp of this rule... [ibid: 240]

The argument is that grasp of what sameness comprises (and I am going to suggest that this is merely expressible demonstratively as going on like this) is insufficient for knowing how to continue. One would need to grasp the further rule that one should go on in the same way, that this is what the relevant normative demand is.

There is something to this. There seems little prospect of factoring grasp of a rule into grasp of sameness plus grasp that sameness is what one ought to aim at. As Wittgenstein stresses, sameness or agreement is internal and relative to the particular rule. Thus grasp of the rule and grasp of what agrees with it, what is relevantly the same in virtue of according with the rule, goes hand in hand. But this point applies equally to what Ginsborg does make explicit: that the child grasps that the next move fits, belongs or is appropriate to the context. Those notions are equally insufficient for going on correctly. (A rule could dictate that the next move should stand out from rather than fitting what has gone before.)

Objections to ‘no conception’ primitive normativity

An alternative: local conception normativity

Authenticity and the conception of other lives

I’ve not had time to think about a conversation I had with Gloria last week in our new favourite off-campus coffee shop (The Coffee Shop).The day before, I had seen a recording of a BBC4 programme about the lives of three men detained under the Mental Health Act.

One, Andrew, had bipolar disorder and, still in the more manic phase of his condition, could not disguise some wry pleasure in the event that prompted his detention: a high speed car chase followed by three panda cars. He seemed pleased by his own skills and the performance of his car even whilst, as a late middle aged retired consultant pathologist, somewhat embarrassed. He was equally enthusiastic about another recent decision: to leave his wife of 26 years and set up a new life by himself in a bungalow.

We followed the course of his treatment: some mood stabilisation but also a slide into a more depressed state and then later anti-depressants. We also saw him discharged to his bungalow and, a month later, saw that it remained unfurnished aside from a bed and television. (The way the film was shot suggested that he spent all his time on the bed watching TV.)

Throughout this, he commented on a key feature of his illness: that after making rash decisions in his manic state he would have to deal with their consequences when he returned to normal. But he distinguished the decision to separate from his wife from such cases. That is, he did not think it had been made when he was not in his right mind.

Towards the end of the film, however, he admitted that he had gone back to live with his wife and we saw him wearing a Christmas jumper, playing the piano, in a well furnished, comfortable home, in marked contrast to the dreary bungalow.

This was a documentary in which we had only a very small and apparently carefully edited snapshot of three lives so it seems somehow impertinent to speculate on Andrew’s actual relationship. But it prompts the question: what would it be for such a decision to be merely the product of not being in one’s right mind, as opposed to an authentic decision. On one reading of the events described and shown, he took the decision to separate around the time of manic and exuberant feelings and, despite his later claiming ownership of it, the decision was not backed up by much commitment to a new life (buying furniture etc) and was reversed within a few weeks. But on another reading, the consequences of just such a decision would always be daunting; it would be hard to organise a new house whilst depressed and unused to public transport; the run up to Christmas would tempt one back to the family home etc. That is, on the second reading, whilst the decision might come to nothing, it need not be inauthentic. So in what does the difference consist? What makes a life an authentically chosen life?

My suggestion in the Coffee Shop – which moved a bit under critical scrutiny – was that it needs a self-conscious conception behind it. In some sense to be unpacked, there has to be an element of choice, within what is practical, albeit: a sense that the life lived is one among other possibilities. But, of course, we do not reflect or exercise much choice when the alarm rings at 6:50am for work. Getting up and off is habitual. So the idea of a self-conscious chosen conception must allow for un-self-conscious habit. Gloria’s sceptical alternative was that for most people, for most of the time, habit dominates and there is little reason to postulate an underlying conception. In the face of this, I think that the most I can say is that there has to be a standing possibility of stepping back from an engaged habit or practice and, perhaps, to give such talk of a ‘possibility’ any content, it has to be exercised from time to time. (How often? No idea.)

Still, I don’t think that such an idea, now suitably weakened, is utterly implausible. Here are two popular cultural examples which suggest that people do have such conceptions and do think about them from time to time.

On house buying television programmes in which we get to hear the deliberation of potential purchasers, their discussion is not restricted to the kind of description and assessment that the estate agents might deploy as to the properties and qualities of the houses. Typically it includes that (rooms are light and spacious and have attractive views, or not). But we also hear comments about the kind of lives the house would allow the buyers to live: what they would do or not be able to do were they to buy it. Rooms are linked to possible uses in more than just the sense that a dining room ‘affords’ dining. So at least in the case of house buying, the conception of other lives becomes available.

The other example is familiar from interviews with successful (or unsuccessful) sports men and women after a key event when they are asked about subsequent training (eg. after immediate celebration and rest). Rowers are a particularly good example. They often express a dread of a return to early morning winter training but then reflect that it is probably worth it because of the prospect of success next year or at the next Olympics. It is not merely that the prospect of a medal is a telos which structures and explains their training behaviour. Having a telos might be part of an unreflective habit. (Perhaps they row to the rhythm of the phrase: ‘I am going to win a medal’.) But, in the post race interview, at least, they suggest occasional deliberation about the value of the habit, even if there is no place for such deliberation before dawn on cold rives on winter mornings.

Bio-medical vs social models of disability

Talking to Bill Penson this week about disability, I found myself trying to put forward something like Jerry Wakefield’s harmful dysfunction model as the best bet for a bio-medical model of disability. Bill’s basic objection was that it didn’t seem a promising way of capturing some of the important social features of disability, such as stigma. But I could imagine a bio-medical approach claiming that whilst those were important and unfortunate features, they were contingent effects of disability, not disability itself.

To rehearse familiar ground, such an approach has a key attraction. There is little hope of giving a merely statistically abnormal in the sense of unusual account of disability because it carries with it some notion akin to impairment. That notion suggests a normative or evaluative characterisation. But combined with the common neo-Humean view that norms and values are human inventions, merely subjective (even if intersubjective) features, that suggests that there could not be a science of impairment and hence disability. Now whilst it is true that the harmful dysfunction analysis does contain just such a value (harm), it also promises a central objective core condition: impairment requires biological dysfunction, cashed out through descriptive evolutionary theory.

I don’t think it is so descriptive. But let’s ignore that here.

What would be wrong with such analysis? Even if it seems to get the focus in the wrong place to some, because it is not an essentially social status, might it not captured the core idea: there is disability only where there is impairment and that that apparently normative notion reflects the biological norm of proper function?

One clue, which Bill suggested, comes from an analogy with the Deaf community: Deafness – if not deafness – can be claimed to be a cultural identity rather than a disability. It is a distinct form of subjectivity, a merely different (not impaired) take on being in the world. But the Wakefield position can accommodate this even if in a way which will not appeal to the Deaf. Deafness is a failure of biological function even if not, in the right context of community empowerment, a harmful one. Dysfunction is necessary but not sufficient, on this analysis, for disability.

But that suggests another question to ask. Is it really necessary? Do all disabilities require an impairment,  cashed out as failure of biological function? It may be that there is something more fundamental to disability than dysfunction and that dysfunction is just one way of partially filling this out.

So here is a thought which aims to capture the social dimension mentioned at the start, and stressed by Bill. Perhaps there can be disabilities where there is no dysfunction because they are purely socially constituted. This is following the idea that, to be disabled, something other than biology has to do the disabling. One is disabled by social context. (And thus, in a different context, it is not that one’s disability is ameliorated but rather expunged.)

So suppose that handedness played a much more important role in our artefactual and cultural life. All scissors were one way only. Driving and writing were virtually impossible in one chirality but fine the other. Handshakes were elaborate and required much one handed strength and dexterity (ho ho). We can now imagine a case where being one handed rather than another was not in itself functional or dysfunctional biologically. But it would be a grave disability to be of the minority handedness.

In such a case, there is something like ‘function’ playing a role. But it is an essentially social and relational version. If this is a possible approach it would explain why a biological dysfunctional approach would sometimes get the right answer but for merely derivative reasons. But we would need to work out in a generic account of what such social ‘functions’ and dysfunctions were.

Call for Participants: Concepts of Mental Health, University College London

Forwarded from Emily Crampton, Phd Candidate, Philosophy Department, University College London

"Call for Participants: Concepts of Mental Health

BPPA Masterclass 2013
April 12th-13th

Location: University College London

I am writing to offer a unique opportunity for graduate researchers within the field of philosophy and mental health. This year’s BPPA masterclass will be on concepts of mental health. A masterclass involves a mixture of seminars, group-workshops, presentations by students and experts and critical discussion. The small number of participants (8-10) means that all will have a chance to speak and discuss their research as well as getting to know others working in similar areas. It is an excellent way of deepening and broadening understanding of a given area and further developing one’s own research. 

This year’s masterclass will be led by experts committed to furthering interdisciplinary research into mental health issues, combining philosophical training with clinical experience. Professor Bill Fulford is Emeritus Professor of Philosophy and Mental Health at the University of Warwick and is a Member of the Philosophy Faculty at the University of Oxford. His previous posts include Honorary Consultant Psychiatrist at the University of Oxford and Special Adviser for Values-Based Practice in the Department of Health. Dr Hanna Pickard is a fellow of All Souls College at the University of Oxford and a Wellcome Trust Biomedical Clinical Ethics Research Fellow in the Department of Philosophy at the University of Oxford. She also holds a clinical post as a therapist at the Complex Needs Service with the Oxford Health NHS Foundation Trust. The experts will be leading group-workshops and seminars and will present on their own research over the course of the masterclass.

The broad focus of the masterclass will be on exploring the varying conceptions of mental health and illness and the assumptions accompanying and lying behind these conceptions. The aim is to explore the assumptions and often false dichotomies which shape perceptions of mental health, from the perceptions of those in the field of psychiatry to those found amongst other medical professionals and the non-medical public. Topics we expect to be discussed include, but are not restricted to: free will, responsibility and related notions and their applications and misapplications within understanding of mental health problems, in particular in relation to addiction; The effect of neurological research on conceptions of mental health; The distinction between cognitive disorders and personality disorders; The extent to which mental illness can and ought to be understood within the framework of physical illness. The precise content of the masterclass will be in part determined by the research interests of the participants and there will be opportunities for 6 participants to present their own research.

To apply, please send an academic CV (including any relevant clinical or practical experience) with a cover letter stating your area of research, the relevance of your research to the masterclass and what you could contribute to the masterclass (500 words max). Please also state whether you would like to present on your research (presentations will be brief, about 20minutes each). Please also attach a reference from your supervisor (if applicable), confirming your interest and that you would make a valuable contribution to the masterclass.

The masterclass will be held at University College London. Breakfast and lunch will be provided on both days and accommodation if coming from outside of London. There may also be some small travel bursaries available. 

Deadline for applications: February 15th

Please send applications and any queries to: bppamasterclass2013@gmail.com

Website: https://sites.google.com/site/bppamasterclass2013/ 
Follow us on Twitter @BPPAmasterclass"