Cross-cultural psychiatry and validity in DSM-5

I hope that this is the final version of this draft chapter.

Introduction

The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual, DSM-5, puts greater emphasis than previous editions on cross-cultural factors affecting mental illness [APA 2013]. Diagnostic criteria have been revised to take account of cross-cultural variation, there is a more specific cultural formulation and a glossary lists nine ‘Cultural Concepts of Distress’. But the DSM does not present a clear view of whether it assumes that mental illnesses are universal and apply across all cultures or whether they can be specific and local to particular cultures. Nor does it give an account of the relation of the cultural concepts to the rest of the taxonomy of disorders or the extent to which they are put forward as valid diagnoses.

The first section of this chapter outlines the ways that cultural factors have been included in Diagnostic and Statistical Manual DSM-5 [APA, 2013]. It introduces one particular example: khyal cap or wind attacks, a syndrome found among people living in Cambodia. The second section sets out three possible views of the nature of such cultural concepts of distress. On one view, which dates back to the German psychiatrist Karl Birnbaum, an underlying universal ‘pathogenic’ component is overlain by a variable ‘pathoplastic’ cultural shape [Birnbaum 1923]. This combination suggests the conceptual possibility of two single factor models in which either factor is set to zero: pathogenic-only and pathoplastic-only. The final section returns to the example of khyal cap. On inspection, none of the three models helps accommodate its own incompatible aetiological theory with the biomedical view of the rest of the DSM. This suggests that the very idea of cultural concepts of distress fits uneasily with the aspirations to validity of the rest of DSM-5.

Cultural factors in DSM-5

The fourth edition of the Diagnostic and Statistical Manual DSM-IV introduced guidelines for a ‘cultural formulation’ and a ‘Glossary of Culture-Bound Syndromes’ [APA, 1994]. The cultural formulation ‘supplement[ed] the nomothetic or standardized diagnostic ratings with an idiographic statement, emphasizing the patient’s personal experience and the corresponding cultural reference group’ [Mezzich et al., 1999; P459]. The ‘culture-bound syndromes’ were described as ‘locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category’ [APA, 2000; P898].

These new elements in the DSM reflected, firstly, awareness of the need for it to address growing cultural diversity within North America since ‘[i]mmigrants bring with them their own indigenous patterns and conceptions of mental illness, some of which are structured into cultural syndromes’ [Guarnaccia and Rogler, 1999: 1322]. Secondly, the DSM needed to contain cross-cultural material because of its increasing global use.

DSM-5 offers a more extended treatment of cultural factors in psychiatric diagnosis than DSM-IV [APA, 2013]. Throughout the manual, diagnostic criteria have been revised to reflect cross-cultural variations in presentations of disorders. The discussion of the ‘Cultural Formulation’ in section III now sets out a semi-structured interview. In the Appendix, there is a ‘Glossary of Cultural Concepts of Distress’ which describes nine common conditions. The Introduction warns how cultural factors might affect diagnosis and prognosis and thus should be investigated in a cultural formulation [APA, 2013; P14]. The manual suggests that culture can affect any of the following:

·         The boundaries between normality and pathology for different types of behaviour.

·         Vulnerability and suffering (for example, by amplifying fears that maintain panic disorder).

·         The stigma of, or the support for, mental illness.

·         The availability of coping strategies.

·         The acceptance or rejection of a diagnosis and treatments, affecting the course of illness and recovery.

·         The conduct of the clinical encounter itself and how this affects the accuracy of diagnosis, acceptance of treatment, prognosis and clinical outcomes.

The Introduction to DSM-5 also summarises (in fact at greater length than the later discussion of the cultural formulation in the main text) three distinct ways that culture can impact on diagnoses [APA, 2013]. The single idea of culture-bound syndromes from DSM-IV is replaced by three notions: cultural syndromes, cultural idioms of distress and cultural explanations (or perceived causes) of illnesses (or symptoms). It is worth quoting the summary in full:

1. Cultural syndrome is a cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community, or context (e.g. ataque de nervios). The syndrome may or may not be recognized as an illness within the culture (e.g. it might be labelled in various ways), but such cultural patterns of distress and features of illness may nevertheless be recognizable by an outside observer.
2. Cultural idiom of distress is a linguistic term, phrase, or way of talking about suffering among individuals of a cultural group (e.g. similar ethnicity and religion) referring to shared concepts of pathology and ways of expressing, communicating, or naming essential features of distress (e.g. kufiingisisa). An idiom of distress need not be associated with specific symptoms, syndromes, or perceived causes. It may be used to convey a wide range of discomfort, including everyday experiences, subclinical conditions, or suffering due to social circumstances rather than mental disorders. For example, most cultures have common bodily idioms of distress used to express a wide range of suffering and concerns.
3. Cultural explanation or perceived cause is a label, attribution, or feature of an explanatory model that provides a culturally conceived etiology or cause for symptoms, illness, or distress (e.g. maladi moun). Causal explanations may be salient features of folk classifications of disease used by laypersons or healers. [ibid: P14]

Although the authors distinguish between these different ideas, they concede that the same elements may play a role in all three categories. For example, depression is used as an idiom of distress whether of: 1) an illness or pathology, or 2) normal but significant sadness. It is also recognised as a mental illness syndrome gathering together a number of symptoms. Finally, it is taken to be the cause of those symptoms. Just as depression can play the role of syndrome, idiom of distress and explanation, so can other concepts local to other cultures.

Given this complication, although the ‘Glossary of Cultural Concepts of Distress’ describes nine common cultural syndromes, the concepts described may also play a role as idioms of distress and purported explanations or causes of experiences. The ‘Cultural Concepts of Distress’ described are khyal attacks or khyal cap, ataque de nervios (‘attack of nerves’), dhat (‘semen loss’), kufungisisa (‘thinking too much’), maladi moun (‘humanly caused illness’) nervios (‘nerves’), shenjing shuairuo (‘weakness of the nervous system’), susto (‘fright’), taijin kyofusho (‘interpersonal fear disorder’). Each is related to similar but different concepts found in other cultures and also to the illness categories set out in the main body of DSM-5. Khyal cap, for example, is linked to panic disorder.

In the years leading up the publication of DSM-5, much emphasis was placed on the attempt to increase the validity of psychiatric diagnostic categories. The book A Research Agenda for DSM-V which comprises a series of papers on different aspects of DSM-5 starts with this thought [Kupfer et al 2002].

Those of us who have worked for several decades to improve the reliability of our diagnostic criteria are now searching for new approaches to an understanding of etiological and pathophysiological mechanisms—an understanding that can improve the validity of our diagnoses and the consequent power of our preventive and treatment interventions. [Kupfer et al 2002: Pxv]

This passage expresses the worry that whilst work had been done to improve the reliability of DSM-III and DSM-IV, not enough attention had been paid to the validity of the syndromes within psychiatric taxonomy. This aim for the rest of DSM-5 suggests the following question about the ‘Glossary of Cultural Concepts of Distress’: What is its relation to the rest of the taxonomy, to the other diagnostic categories set out in the main body of the book? There seem to be three general possibilities. 1) The status of the glossary and the main body might be intended to the same and both aim at validity: describing real universal mental illness categories. 2) The status of both could be intended to be the same and all diagnostic categories be thought to be culturally specific. 3) The appendix might be intended to have a distinct lesser status, not aimed at validity but rather charting the theoretical errors of other cultures.

The second option is the most conceptually fraught. It requires, not just that the rates or prevalence of an illness that can apply universally varies between cultures but rather that the validity of a diagnosis, the very idea of an illness, is in some sense true only of or for a particular culture. The paradox of such relativism is that it is unclear that one can assert its general truth. But asserting its merely relative truth does not seem enough. To adopt this view of the main body of the DSM is to adopt a self-consciously ironic or relativist view. One possibility – obviously not taken in DSM-5 – is that some diagnoses from the main section belong in the appendix. Perhaps anorexia nervosa is somehow specific to European and North American cultures whilst schizophrenia is universal. So can the aim of cultural sensitivity exemplified in the Cultural Formulation and the articulation of cultural idioms of distress go hand in hand with the scientific ambitions of twenty-first century psychiatry? Or are the two ventures somehow in tension?

These general questions can be illustrated through one example. One of the nine items in the ‘Glossary of Cultural Concepts of Distress’ is khyal cap which is described thus.

Khyal cap
‘Khyal attacks’ (khyal cap), or ‘wind attacks,’ is a syndrome found among Cambodians in the United States and Cambodia. Common symptoms include those of panic attacks, such as dizziness, palpitations, shortness of breath, and cold extremities, as well as other symptoms of anxiety and autonomic arousal (e.g., tinnitus and neck soreness). Khyal attacks include catastrophic cognitions centered on the concern that khyal (a windlike substance) may rise in the body—along with blood—and cause a range of serious effects (e.g., compressing the lungs to cause shortness of breath and asphyxia; entering the cranium to cause tinnitus, dizziness, blurry vision, and a fatal syncope). Khyal attacks may occur without warning, but are frequently brought about by triggers such as worrisome thoughts, standing up (i.e., orthostasis), specific odors with negative associations, and agoraphobic type cues like going to crowded spaces or riding in a car. Khyal attacks usually meet panic attack criteria and may shape the experience of other anxiety and trauma- and stress or related disorders. Khyal attacks may be associated with considerable disability.
Related conditions in other cultural contexts: Laos (pen lom), Tibet (srog rlunggi nad), Sri Lanka (vata), and Korea (hwa byung).
Related conditions in DSM-5: Panic attack, panic disorder, generalized anxiety disorder, agoraphobia, posttraumatic stress disorder, illness anxiety disorder. [ibid: P834]

The belief that illness can be caused by a dysfunction of a wind-like substance, described using the same word as for wind, seems to be common in parts of Asia [Hinton et al., 2010; P245]. Khyal is thought normally to flow alongside the blood supply and can pass out of the body through the skin. But the flow can become disturbed ‘surging upward in the body toward the head, often accompanied by blood, to cause many symptoms and possibly various bodily disasters’ [ibid: P245]. It is thought to be caused by, for example, ‘worry, standing up, a change in the weather and any kind of fright, such as being startled or awakening from a nightmare [ibid: P246]. Local treatments include dragging a coin along the skin giving rise to characteristic abrasions.

To ‘coin,’ the person dabs the tip of a finger in khyal ointment (preing kenlaa), a Vaseline-like substance containing camphor and menthol, and then drags the fingertip along the skin to create a streak 5 or 6 inches in length. Next a coin is grasped by the fingers and the edge pushed down slightly against the skin at the proximal beginning of the streak; the coin is then dragged outward along the streak of khyal ointment. This is then repeated. [ibid: P271]

Despite the overlap of symptoms, it is clear that the framework of beliefs that surround the conception of khyal attack differs from that of biomedical psychiatry. What then is its supposed status in DSM-5? This question calls for a general understanding of the ways in which culture might affect concepts of illness and whether any model can simultaneously aim for validity whilst admitting cultural variation. Thus the next section will outline three general ways of thinking about the cultural dependence of mental illness categories, the possible role of cultural formulation and hence the different cultural concepts of distress in DSM-5.

Three models of cultural concepts of distress

A two-factor pathogenic-pathoplastic model

One way to understand how culture affects mental illness would be to think of the expression of mental illness as the result of two-factors: an invariant endogenous factor and a local cultural appearance: ‘pathogenic’ versus ‘pathoplastic’ factors [Birnbaum 1923]. The psychiatrist and anthropologist Roland Littlewood stresses the connection between this distinction and the long-standing distinction in psychiatry between the form and content of mental illness.

To deal with variations in the symptoms between individuals, while maintaining the idea of a uniform disease, clinical psychiatry still makes a distinction between the essential pathogenic determinants of a mental disorder – those biological processes which are held to be necessary and sufficient to cause it – and the pathoplastic personal and cultural variations in the pattern. Those two are still distinguished in everyday clinical practice by the particularly nineteenth century German distinction between form and content. [Littlewood, 2002: P5]

This distinction needs handling with some care. Littlewood suggests that the pathogenic factor is a necessary and sufficient cause of mental disorder. But the notion of cause suggests a state distinct from the mental disorder it causes. Further, the requirement of a sufficient cause is difficult to attain as causes are only sufficient relative to an assumed causal field [Mackie, 1993]. The connection to the distinction of form and content suggests a better interpretation is not what causes mental disorder but what constitutes it. The pathogenic factor is then the set of essential properties of disorders, the properties that are necessary and sufficient for a state to count as a disorder. The pathoplastic factor is the contingent variation of inessential properties of the disorder.

Littlewood reports that in the biomedical view of psychiatry the pathogenic factor is a biological process. In other words, the essential features of mental disorder can be described in biological terms. Such a view fits an influential analysis of mental disorder in general articulated and defended by Jerome Wakefield [Wakefield, 1999]. According to Wakefield, a disorder is a harmful dysfunction, where function and hence dysfunction is picked out in accordance with evolutionary theory. Evolutionary theory specifies the biological functions of the traits of the human mind and body. Note that the focus on social dysfunction in the DSM is not the same as biological dysfunction. In fact, it better accords with Wakefield’s invocation of harm. But central to his attempt to offer a unified account of both mental and physical illness, biological functions include evolutionarily selected mental functions, both cognitive and affective. On this model, the essential or pathogenic properties of a disorder can be described not just in biological terms but, more specifically, as biological dysfunctions explicated through evolutionary theory. (The mental character of the biological dysfunctions which constitute mental disorders will be discussed shortly.) In the case of illnesses where there remains ignorance of biological mechanisms, the idea of a pathogenic factor is an article of faith: a commitment to there being some universal underlying nature to the illness in question.

Although biomedical psychiatry favours a biological characterisation of pathogenic factors, other candidates are possible. Consider Louis Sass’ account of Schreber’s delusions in Paradoxes of Delusion [Sass, 1994]. Schreber was a German judge diagnosed with dementia praecox, now classed as schizophrenia, who wrote a first person account of his illness, including his delusions, called Memoirs of My Nervous Illness, at the start of the twentieth century. Sass attempts to shed light on the nature of Schreber’s delusions by comparing them to philosophical solipsism.

Solipsism is the view that the only thing that exists in the world is the self of the person who thinks about it. It is expressed in the necessarily first person thought: ‘Only I and my mental states exist’. Everything else is merely an idea (for me: one of ‘my ideas’). Solipsism is thus a form of idealism – according to which only ideas exist – taken to the logical limit. If everything that exists is merely an idea only the first person subject of thought (for me: ‘I’) can have those ideas. So only one person exists. This paradoxical thought is used by Sass to shed light on the paradoxical quality of schizophrenic delusions.

[Schreber’s] mode of experience is strikingly reminiscent of the philosophical doctrine of solipsism, according to which the whole of reality, including the external world and other persons, is but a representation appearing to a single, individual self, namely, the self of the philosopher who holds the doctrine… Many of the details, complexities, and contradictions of Schreber’s delusional world… can be understood in the light of solipsism. [ibid: P8]

The elucidation or understanding that Sass seeks isn’t merely aimed at one particular delusional experience or even at all of Schreber’s experiences considered as a whole. It is meant to shed light more generally on the nature of schizophrenia itself. The reason it can (according to Sass) is that the experiences that characterise schizophrenia derive from a general and abstract feature of rationality:

[Madness] is, to be sure, a self-deceiving condition, but one that is generated from within rationality itself rather than by the loss of rationality. [ibid: P12]

Although a general feature of rationality, Sass himself does not think that the failure within rationality that amounts to schizophrenia is culturally universal. Rather, he thinks that is the result specifically of modernism [Sass, 1992]. But if, contra Sass, solipsism were not merely the product of recent European culture but rather a standing universal possibility suggested by the abstract structure of rationality itself, then its corresponding disorder - schizophrenia – would be a risk for any rational subject, human or alien, whatever their biology or evolutionary history. The pathogenic factor is, on this model, an abstract feature of rationality rather than a particular biological process or dysfunction.

Whether the pathogenic factor is thought of as a biological or a more abstract feature of rationality, on the pathogenic-pathoplastic model variation in general and cultural variation specifically (the focus here) enters with the pathoplastic factor. Culturally invariant pathologies of underlying human nature are overlaid by local cultural variation in how they are expressed. ‘Expressed’ could carry either of two meanings. First, it might mean that standing possibilities for biological dysfunction or failings of rational subjectivity might be differently prompted or caused by different social or geographical contexts. The idea that mental illness has social determinants is, however, akin to socially caused variation in heart disease rates in different cultures and hardly merits the label ‘cultural concept’.

The more interesting idea is that variation in ‘expression’ picks out the way in which underlying pathologies might be plastic to the different self-interpretations that people in different cultures possess and thus the way the pathologies are experienced and avowed. This would be an example of a cultural idiom of distress in the vocabulary of the DSM-5. But whereas for physical illness, how one understands one’s illness might be thought to be an accidental superficiality compared with the real underlying condition (as understood, perhaps, by the medical profession), one might argue that for mental illness its esse is percipi: how it is perceived at least partly constitutes it.

On a two-factor pathogenic-pathoplastic model, mental illnesses either are, or are underpinned by, pathologies of some sort of universal substrate. The difference between these options is the difference between thinking that the alloy of an invariant underlying pathology and a varying cultural overlay itself comprises what we mean by a mental illness, and on the other hand thinking that the mental illness proper is identical with the pathogenic factor only.

One might think, for example, that khyal cap and panic disorder have the same underlying biological mechanism but that the characteristic way in which, in the former, subjects think of their distress through the conceptual lens of a dysfunction of the flow of wind-like substance is sufficient to mark it off as a different kind of mental illness from the latter. Biological dysfunction is then the common component of two distinct illnesses depending on cultural context. Christopher Boorse’ distinction between disease and illness where the latter is tied to the subject’s experience of it implies a difference in illness in such a case [Boorse 1975]. On the other hand, one might think that the real illness is whatever is common to khyal cap and panic disorder: the pathogenic factor. It is merely that the appearance that the single illness takes can vary.

Whichever view is taken of whether the pathogenic factor is the illness or merely the common disease underpinning of different illnesses, a two-factor pathogenic-pathoplastic view of cultural concepts of mental illness suggests a particular view of the aim of a cultural formulation in psychiatric diagnosis. It is a way of inferring, from locally divergent symptoms, the universal underlying nature of mental illness. The aim of sensitivity to cultural difference would be to find a way to penetrate beneath it to a common substrate appropriate for scientific psychiatric research.

This seems to be the view of the ex-president of the World Psychiatric Association Juan Mezzich et al. (2009) in their discussion of ‘Cultural formulation guidelines’ when they say:

The cultural formulation of illness aims to summarize how the patient’s illness is enacted and expressed through these representations of his or her social world. [Mezzich et al 2009; P390]

and

Performing a cultural formulation of illness requires of the clinician to translate the patient’s information about self, social situation, health, and illness into a general biopsychosocial framework that the clinician uses to organize diagnostic assessment and therapeutics. In effect, the clinician seeks to map what he or she has learned about the patient’s illness onto the conceptual framework of clinical psychiatry. [ibid: P391]

These passages suggest that there is a division between how an illness is enacted and expressed and the underlying biological mechanisms explored by biomedical psychiatry. The former is culturally shaped, the latter is invariant. On Mezzich et al.’s (2009) account, the only positive role cultural factors can then play is as a source of contingent health promoting resources:

The aim is to summarize how culturally salient themes can be used to enhance care and health promotion strategies (e.g., involvement of the patient’s family, utilization of helpful cultural values). [ibid: P399]

In other words, ‘culturally salient themes’ do not reveal the shape of mental illnesses in themselves but can, contingently, be used to promote health because of their effects on how people understand their own illnesses. All this suggests that the underlying view of the role of cultural formulation is determined by a two-factor view. Such a view is, however, merely one of several possible. I will argue that it is a half way house between two more radical views of the possibilities for cultural psychiatry both of which are versions of a single factor which I will now outline.

Two single factor models of cultural variation: pathoplastic-only and pathogenic-only

A two-factor pathogenic-pathoplastic model of the nature of transcultural psychiatry requires a distinction between surface appearance and underlying pathology. But it might be that this distinction cannot be drawn. The various ways one might attempt to flesh out the contrast between underlying pathology – for example as biological or some other underpinning notion of universal human nature – and surface appearance might fail.

Consider the first suggestion for the pathogenic factor outlined above: a biological process which, if Wakefield is right, can be more precisely specified as a harmful dysfunction analysed using evolutionary theory. Drawing a distinction between this and the surface appearance in the way a two-factor model requires might seem unproblematic for some illnesses. It requires that a common underlying biological dysfunction can be identified despite different culturally imposed behaviours or experiences. But in the case of some mental dysfunctions there may be no principled way of drawing a distinction between an underlying dysfunction and the surface appearance.

To illustrate this, consider the role of biological processes. It seems plausible to assume mental functions and dysfunctions depend, in potentially complicated ways, on human brains. Thus there may be common biological processes underpinning common mental dysfunctions. But one cannot treat just any shared biological process as the first factor of a mental illness. The biological process has to be a mental process: a failure of a mental function. It is then much less clear how there can be shared mental dysfunctions between different manifestations. The dysfunction may be located only at the surface mental level.

The potential difficulty of dividing between underlying pathology and surface appearance can also be described without talk of mental functions. The philosopher John McDowell argues that human nature can be divided between two distinct levels: biological nature and a 'second nature' that has to be developed through education and enculturation [McDowell 1994; P183]. A good example is initiation into a first language. Whilst the ability to develop a second nature is contingent on biological first nature, biology alone is not enough. This suggests the possibility of two kinds of mental illness. So called ‘organic’ illnesses, such as dementia or alcohol syndromes, are those with a clear biological or first nature component. But ‘functional’ disorders are, on this view, disorders only of second nature. In the latter case, it is unclear how to distinguish between the surface appearance of mental illness, its characteristic experiences or manifestations, for example, and an underlying mental process. Mental illness – or at least some mental illnesses – may be features of the surface appearance of our second nature.

If the distinction between the two levels on which the two-factor pathogenic-pathoplastic model depends cannot be drawn for at least some mental illnesses that leaves only a single factor. There are, however, two possible one-factor models depending on whether one thinks of illness as all pathogenic or all pathoplastic.

A one-factor model need not imply that there is any substantial cultural variation of mental illness beyond prevalence rates. Cultural factors might play a role in causing different rates of illness in different communities without this making the nature of illness in any sense relative to a culture. Using McDowell’s vocabulary, this might be because human second nature is itself universal. Or, using Wakefield’s model, it might be because the mental dysfunctions that constitute illnesses are universal. A pathogenic-only model holds that illness varies only in external features such as rates and superficial and unimportant local understandings of it. Any apparent deeper variation would be a mark of our ignorance, our misdiagnosis. So a pathogenic-only model has no need for a cultural formulation to extract or excavate the underlying commonalities because they are open to view.

But, following the account suggested in this chapter of the distinction between pathogenic and pathoplastic not in terms of the causes of mental illness but their essential and universal properties, it is possible to articulate a radical pathoplastic-only model. According to this, there might be no shared pathogenic factor between apparently different mental illnesses in different cultures. Cultural variation might go ‘all the way down’. Genuinely different forms of mental illness would emerge from different ways of living in different societies. It would thus be a ‘category fallacy’, in Arthur Kleinman’s phrase, to assume that a form of illness found in one culture must, in principle, have application in another [Kleinman, 1977].

To flesh this example out it will be helpful to consider again Sass’ account of schizophrenia. The symptoms of schizophrenia are a kind of lived experience of the philosophical theory of solipsism. Sass thus claims that schizophrenic delusion is generated from within rationality itself rather than by the loss of rationality. That basic idea can be used to illustrate both the pathogenic-only and the pathoplastic-only models of cultural idioms of distress.

If one thinks that the history of Western philosophy merely illustrates and unpacks conceptual connections implicit in the rationality of any possible thinker – human or even alien – then solipsism is also a standing possibility for anyone and hence, on Sass’ account, so is schizophrenia as its lived version. That is the pathogenic-only model. Any apparent culturally determined local variation in the experience of schizophrenia, such as the specific contents of delusions by contrast with invariant forms, would be merely superficial, requiring no great cultural sensitivity to detect. It is the thought that it is merely or trivially superficial which distinguishes this from a two-factor model with its demand for a cultural formulation to penetrate surface features.

If, on the other hand, one thinks with Sass himself, that Western philosophy has been driven not merely by the abstract demands of rationality but by historically contingent assumptions about the nature of mind, world and subjectivity then the temptation towards solipsism will seem to be a merely local cultural matter. At the risk of over simplifying Sass’ view, if the intellectual movement of Modernism had not existed then there would have been no such thing as schizophrenia [Sass 1992]. This is a pathoplastic-only view because it implies that there need be no common elements to the mental illnesses experienced in different cultures. (This is not to say that such illness is uncaused. On the gloss offered in this chapter, pathogenic versus pathoplastic concerns what is essential and universal versus what is accidental rather than what causes mental illness.)

The pathoplastic-only model is more radical than the two-factor model even though both agree on the need for some sort of cultural formulation. A pathoplastic-only version of a cultural formulation does not enable one to dig beneath surface difference to find underlying common pathologies but would instead be an articulation of the genuinely different ways people can be ill in different cultures. According to it, there are genuinely different forms of mental illness which need have nothing substantial in common across different cultures. The virtues of the validity of a psychiatric taxonomy and its universality diverge.

In fact, sympathy for a pathoplastic-only view of mental illness sometimes seems to go hand in hand with a view that questions the illness-status of cultural idioms of distress. For example, Littlewood’s anthropological comparison of female overdosing in Anglo-American society with the behavioural patterns of women in ‘less pluralistic small-scale societies’ looking ‘not just at the person involved but at the local meaning of the act in the political context in which it happens’ suggests a social function rather than an individual pathology [Littlewood 2002: P36]. It may be that the pathoplastic-only model requires an anthropological stance and that such a stance looks for and tends to find social order rather than individual illness or disorder. But that is not an essential feature of a pathoplastic-only approach. There is nothing inconsistent with the idea that a pathoplastic-only model is a model of illness.

The status of khyal cap

The first section of this chapter introduced but left hanging the question of whether the presence in the DSM-5 of the ‘Glossary of Cultural Concepts of Distress’ implied a kind of anthropological relativism or whether it is consistent with the privileging of a particular cultural standpoint: that of twenty-first century biomedical psychiatry. The example of khyal cap was used to highlight the issue since it involves a distinct view of physiology which includes the flow of a wind-like substance along the blood vessels and normally, harmless, out through the skin.

In its case, at first sight no such relativism seems necessary given the definitions of cultural syndrome, idiom of distress and explanation set out in DSM-5 [APA 2013: 14]. Khyal cap can serve as an ‘idiom of distress’: the conception of an experience had by a subject. If someone describes their experience as the rising up of a wind-like substance then that is simply an anthropological fact about the culture. It can serve as a ‘cultural explanation’ because, again, that is a fact about how a culture explains particular experiences without implicit endorsement of that theory of aetiology by the sufferer?. But, by the standards of twenty-first century western psychiatry, it can even be described as a ‘cultural syndrome’ since that is defined as ‘a cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community, or context’. If, for whatever reason, the symptoms described co-occur then it is reasonable to call them ‘khyal cap’. In other words, the sincere use of ‘khyal cap’ by a cross-cultural psychiatrist need not cause any intellectual difficulty.

But such a reading of the description carries some implications when it comes to understanding the nature of culturally sensitive psychiatry. If the concept of a khyal attack is only ever used within the context of what someone from that culture believes – his or her conception of the nature and explanation of their experiences – rather than as an objective description of what is really causing the attack, then that suggests a distinction of kind between cultural concepts of distress and the main elements of DSM-5’s taxonomy.

Consider the question asked from a biomedical psychiatric standpoint: ‘But from what are they really suffering?’. The description above suggests a ready answer selected from the list of related conditions in DSM-5: ‘Panic attack, panic disorder, generalized anxiety disorder, agoraphobia, posttraumatic stress disorder, illness anxiety disorder’. Such a response suggests that a culturally sensitive psychiatry might be merely a sensitivity to other cultures’ errors: the truthful ascription of a false belief about the causes of abnormal experiences.

With that worry in the background, consider the example of khyal attack through the range of options explored above. Recall Mezzich et al’s (2009) suggestion that the role of a cultural formulation is to ‘map what he or she has learned about the patient’s illness onto the conceptual framework of clinical psychiatry’. This reflects a two-factor model. If applied to this case, the underlying invariant pathogenic factor is whatever is picked out by ‘panic attack, panic disorder, generalized anxiety disorder, agoraphobia, posttraumatic stress disorder, [or] illness anxiety disorder’. The varying local cultural shape is the ‘catastrophic cognitions centered on the concern that khyal (a windlike substance) may rise in the body’. Fitting khyal attack into the two-factor model does nothing to address the underlying worry, however, because there remains an asymmetry between it and panic attack. From the perspective of the rest of the DSM, the former, but not the latter, involves an error about the real aetiology of the condition. Dividing the condition between two-factors does nothing to change this perspective.

Nor does it help to adopt the pathogenic-only model. That model presents a stark choice for any putative newly discovered mental illness. Cultural syndromes such as khyal cap can have either of two statuses. They are either really other names for universal conditions also picked out by the vocabulary of biomedical psychiatry such as ‘panic disorder’. Or they do not exist. For example, if it is an essential part of the theoretical apparatus of khyal cap that it is caused by the rising up of a wind-like substance then given that on our best account of physiology there is no such substance then, equally, there is no such condition. Those who self-report it, or its characteristic symptoms, are in some sense in error about their own conditions. Again the underlying worry is not addressed.

Could khyal cap be understood in accord with the pathoplastic-only model? In rejecting the traditional two-factor model of cross-cultural psychiatry (then generally called ‘transcultural psychiatry’ [Littlewood 1986a: 38]) anthropologically minded psychiatrists such as Roland Littlewood and Arthur Kleinman have implicitly favoured a pathoplastic-only model [eg Littlewood 1985, 1986, 2002].

[C]ulture-bound syndromes are representations in the individual of symbolic themes concerning social relations and which occur in certain personal and historical situations. They articulate both personal predicament and public concerns by means of which women and other depressed categories exert mystical pressure upon their superiors in circumstances of deprivation and frustration when few other sanctions are available to them’ [Littlewood 1985: 704]

Such a view plays down the illness status of the behaviour and emphasises instead its positive social function in addressing an imbalance of power. In his paper ‘The culture-bound syndromes of the dominant culture’, Littlewood applies the same style of analysis onto diagnoses found in the main sections of DSM. Agoraphobia, for example, is argued to serve an adaptive function for a woman against her husband without open defiance, binding them both together at home [Littlewood and Lipsedge 1986: 262-3].

So it might seem that a pathoplastic-only approach can address a worry about the asymmetric treatment of syndromes in the main body of the DSM and the appendix. If the same pathoplastic-only approach is taken to the syndromes set out in the rest of DSM-5 then it seems that those in the ‘Glossary of Cultural Concepts of Distress’ have the same status. But there is a cost to this. It is not that an ironic attitude to the cultural concepts is avoided. It is rather that it is generalised to include diagnoses favoured by biomedical psychiatry for example: agoraphobia, anorexia nervosa. In any case, debunking psychiatric syndromes set out in the main body of the DSM by arguing that they are really meaning-laden adaptive strategies rather than genuine pathologies may be plausible in some cases (perhaps ADHD, personality disorder, depression following bereavement). But it seems implausible across the board. A globally critical attitude to every mental illness syndrome is a high price to pay for affording cultural concepts equal status.

But, as was argued above, a pathoplastic-only approach need not deny the pathological status of conditions in favour of adaptive social functions. An anthropological investigation could be of different forms of illness. On a pathoplastic-only approach, this requires some universal concept of illness in general whilst denying that illnesses need be universal. Jerome Wakefield analysis of illness as harmful dysfunction provides one such universal standard [Wakefield 1999]. Bill Fulford argues that illness is value-laden failure of ordinary doing [Fulford 1989]. Either of these general accounts of the concept of illness could serve for an anthropological investigation of cultural variations in forms of illness. Behaviour which amounts to agoraphobia in the UK might involve no failure of ordinary doing in a culture in which a sub-population is not expected to venture outside, for example.

Despite the possibility of a pathoplastic-only approach to local conceptions of pathology (rather than socially adaptive functions), this does not help in the case of khyal cap. The problem is that it involves not just a description of a local failure of function or action. In fact, the possibility of construing it as a variant of panic attack or disorder suggests a continuity of the kind of failure of function or action that it embodies with those recognised in the main body of the DSM. Rather, the main difference lies within the local aetiological theory. But this is not merely different from but rather incompatible with the view of the body contained within biomedical psychiatry. Espousing both a traditional biomedical view in the main body of the text and an incompatible view in the appendix threatens the validity of one or the other. They cannot both be set out as true accounts.

Conclusion

One of the criticisms of western psychiatry has been its cultural narrow mindedness, reflecting a particular socio-cultural perspective but without realising this. Littlewood, for example, argues in Pathologies of the West, that psychiatry has often assumed that experience of mental illness in America and Europe is more purely pathogenic whilst other cultures embody a kind of error: ‘a poor imitation of European forms’ [Littlewood 2002: 10]. The fact that DSM-5 has more explicitly addressed the nature of cultural idioms of mental distress than previous editions might suggest progress has been made in addressing this criticism.

Despite this, however, there remain tensions within the DSM in accommodating the cultural concepts of distress. As the example of khyal cap illustrates, they can be framed in local aetiological theories or local accounts of physiology which are incompatible from the views of biomedical psychiatry expressed in the main body of the text. None of the three models of the relation of disorder to culture helps.

To summarise: on a pathogenic-only view, cultural idioms of distress accord with DSM categories, correct or augment them or embody errors. But the model rules out the idea of cultural variation. The traditional two factor pathogenic-pathoplastic model allows that khyal cap may contain a genuine pathogenic core, which reflects diagnostic categories from the main body of the DSM, but the difference in physiological theory corresponding to the idea of windflow along the blood vessels is a local, pathoplastic error. Whilst it is true that those self-ascribing khyal cap are distressed it is not true that this results from dysfunction of an inner wind. The more radical pathoplastic-only model suggests the possibility of genuinely distinct conditions in virtue of different conceptions of flourishing, or ordinary actions, or societal functions (depending on the view taken of the concept of disorder). Such a view contains a variety of relativism. To be ill is relative to the practices or functions or actions of a local culture. But there is no reason to think that the truths of human physiology are in that sense relative to local cultures. And hence the pathoplastic-only model is no help in accommodating khyal cap.

This result is, perhaps, unsurprising. Although these cultural concepts of distress are flagged in the Introduction and discussed in the main body of DSM-5, their articulation and description is restricted to an appendix. They do not form a part of the taxonomy of mental illnesses proper whose aims include validity.

Discussion of the abstract models of ‘Glossary of Cultural Concepts of Distress’ does, however, suggest two different approaches to the relation between future psychiatric taxonomies and anthropological investigation. On a pathogenic-only or a two-factor pathogenic-pathoplastic view, a completed psychiatric taxonomy would contain a finite number of underlying universal conditions, overlain, according to the latter view by different culturally imposed appearances. But on a pathoplastic-only model there are as many possible illnesses as there are ways of being unable to take part in local ways of life or local conceptions of flourishing. This challenges the idea of universal diagnostic categories. A compendious version of the DSM would have to chart conditions that, by virtue of their local cultural origins, would not be applicable globally. Given that the arguments for or against any one of the different views of cultural concepts do not produce clear results, this remains a live possibility.

Acknowledgement

This chapter was written whilst a fellow of the Institute for Advanced Study, University of Durham. My thanks both to the IAS, Durham and the University of Central Lancashire for granting me research leave.

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Dialogues in Philosophy, Mental and Neuro Sciences

I see that there is a new issue of this online journal.

Here.

Delivering training to post graduate students?

After a chance comment at a Graduate Research Student Forum to one of the senior administrators I got an email today from someone asking whether I’d be prepared to convene a session on publication on the basis of my role as Senior Editor of Philosophy, Psychiatry & Psychology.

All fine and dandy. But I was struck by the title of the email which talked of ‘delivering training to post graduate students’ and a slight shiver ran up my spine. Why? Well obviously I should look to the philosophy of education and training but my remaining PhD annual progression monitoring forms for this evening won’t write themselves so there’s no time. In the absence of scholarship, I think my inchoate thought about the nature of training runs as follows.

Training is possible where the gap between the training and the activity trained is predictably crossable. Those driving schools that offer guarantees of free retests on failure after so many hours of instruction clearly take the logical gap between training and success to be empirically and inductively manageable.

At the other end of the spectrum – still with my inchoate thought – are activities which, whilst they have their roots in instruction require an exercise of judgement which seems to go beyond what was directly conveyed in the instruction. Perhaps character has been moulded, eyes opened to tracts of the space of reasons, but the judgement is in part an act of self creation. I’d like to call this ‘education’.

Even these rough thoughts do not work very well, however, to mark out clear divisions. I sometimes think that students can be trained to explain Descartes’ method of doubt. (Perhaps it helps in coping with the logical gap between training and success to start with those people who show up to a philosophy class in the first place, however.) But we provide an education for those who can see both the force of his arguments but also how to turn such sceptical doubts aside. Equally, in the School of Health, I’m sure we train nurses how to take temperatures, and train them in the necessary mental health law but we hope to educate them in the sensitivities that will allow them to take the temperature of someone detained against their will with minimal further indignity.

In this case, I am not sure it would be possible to train someone to get published although it is, probably, possible to train them out of willed failures to follow formatting guidelines. Anyway, for the second time in a week, I find my delicate sensibilities as a university lecturer easily offended by a quite standard and proper use.

Motivational speaking as instant enlightenment

Every year my School (a subdivision of the University) organises a ‘School Conference’ with various speakers, workshops etc as a piece of CPD. I make an effort to go and, despite the other things I could get done, it is generally worth it. This year’s started with a motivational speaker speaking to a title ‘Resilience’ but outlining – in a spirit influenced by the UK cycle team's aggregation of marginal gains – a number of small improvements for organisational performance. I say ‘organisational’ but they were aimed at individuals: ten or twelve plus a few other changes we might make to our own habits of thought and practice which would improve what we did not least by avoiding mental breakdown (hence resilience). As the speaker made explicit, they were mainly taken from a book on depressive illness by the psychiatrist Tim Cantopher and they had echoes of the Positive Psychology movement.

I should say that his comic timing was just right and many of the series of anecdotes he told, mainly encouraging of encouragement rather than negative criticism, were very funny. At the end, in the final five minutes, he quoted some pre-advertised bullet points from Cantopher’s book and so I guess it would be unfair to say that there wasn’t any content. But I am not sure that there was enough content for a 90 minute session. So that prompts the question: what was the relation supposed to be between the first 85 minutes and the end?

One thought is that the anecdotes illustrated or perhaps justified what was to come: only if we hear a story of a daughter who doesn’t dare ask questions in a maths class because of a bad experience five years before, will we be ready to hear that encouragement is better than criticism. The one justifies or exemplifies the generality of the other. But then, like Wittgenstein’s comment, it seems that invented examples would do as well as real ones and none of the stories were anything other than platitudinous.

My hunch is that the purpose was other: to make, causally rather than dialectically, the audience complicit in lowered expectations. After an enjoyable series of comic monologues, we embrace some brief suggestions, which could be jotted down, as an acceptable escape from complete vacuity. This Stockholm Syndrome reading of the situation was rather reinforced by the speaker’s insistence - and our compliance with this - that we gave him a standing ovation. This insistence might have been funny in a kind of meta, PoMo way but on the day seemed merely anxious and grubby.

But I think that all of this reflects a real difficulty with motivational speaking. If the aim is to change long standing habits and practices through a one off address, how could that be done? One thought is that this is what charismatic religion aims to do. By the end of the ceremony or service, we should all want to testify (or in this case applaud). But equally it reminds me of the 1970s hope that secular enlightenment might be merely one encounter group session away. Surely, however, that isn’t a sustainable model for good academic practice. I suspect that the only way to change ingrained habits is through practice and criticism and the only way a purely linguistic intervention could sustain that would be through the provision not of propaganda but standing reasons for aiming at that change. That, however, would require a more pedagogic rather than evangelical relation between speaker and audience. Perhaps as a university lecturer I would say that.

I am and I do.

Rereading Zen and the Art of Motorcycle Maintenance after 32 years

My old friend Derek, who spends his days repairing a couple of aging Moulton bicycles, reminded me by email of a scene in Zen and the Art of Motorcycle Maintenance in which the motorcycle maintaining narrator alienates his friend John by offering to repair the latter’s expensive BMW with a beer can shim [Pirsig 2009]. John, we are told, prizes the appearance of things, or ‘romantic quality’ and thus cannot see the ‘classical’ quality that attaches to underlying form, to a properly functioning motorcycle with non-wobbly handlebars.

Not being able to recall the point of the scene, I glanced back at the book over an Armagnac late last night. This was one of my favourite books in my teens and must have been an influence on me becoming interested in philosophy. I had forgotten that it contains an account of Hume and Kant and a discussion of the philosophy of science. But its central metaphysics of quality was something that I never thought to find in academic philosophy and so, weirdly, I have rather forgotten about it for thirty odd years.

So ignoring all the present tense adventure on a motorbike, the following themes struck me on a quick review.

There is an appeal to a general cultural difference – between what is hip or groovy and what is square – illustrated by the shim story. Some people are alienated from technology and cannot see its underlying formal beauty. Immediately after the shim scene, Pirsig/the narrator remarks:

What emerged in vague form at first and then in sharper outline was the explanation that I had been seeing that shim in a kind of intellectual, rational, cerebral way in which the scientific properties of the metal were all that counted. John was going at it immediately and intuitively, grooving on it. I was going at it in terms of underlying form. He was going at it in terms of immediate appearance. I was seeing what the shim meant. He was seeing what the shim was. [ibid: 59]

This leads to the following key early distinction between romantic and classical.

I want to divide human understanding into two kinds—classical understanding and romantic understanding. In terms of ultimate truth a dichotomy of this sort has little meaning but it is quite legitimate when one is operating within the classic mode used to discover or create a world of underlying form. The terms classic and romantic, as Phaedrus used them, mean the following: A classical understanding sees the world primarily as underlying form itself. A romantic understanding sees it primarily in terms of immediate appearance. ... The romantic mode is primarily inspirational, imaginative, creative, intuitive. Feelings rather than facts predominate. “Art” when it is opposed to “Science” is often romantic.  The classic mode, by contrast, proceeds by reason and by laws—which are themselves underlying forms of thought and behavior. [ibid: 73-4]

There is a second general, pre-philosophical theme. The narrator’s alter-ego, Phaedrus, teaches English composition. He has a chance conversation with a Greek teacher which runs as follows.

She came trotting by with her watering pot between those two doors, going from the corridor to her office, and she said, “I hope you are teaching Quality to your students.” This in a la-de-da, singsong voice of a lady in her final year before retirement about to water her plants. That was the moment it all started. That was the seed crystal. [ibid: 180]

This leads him to set as an essay for his class the title: What is a 350-word essay answering the question, What is quality in thought and statement? There follows a description of a kind of teaching experiment in which he argues that the students know what quality is even though none can define it. As part of the experiment, he withholds marks (though not comments) and refuses to deploy principles of rhetoric until after the students have grasped an inchoate understanding of quality for which the principles are useful guides rather than constitutive of it.

The principles expounded in them were no longer rules to rebel against, not ultimates in themselves, but just techniques, gimmicks, for producing what really counted and stood independently of the techniques—Quality. [ibid: 208]

This leads to a manifesto:

“(1) Every instructor of English composition knows what quality is. (Any instructor who does not should keep this fact carefully concealed, for this would certainly constitute proof of incompetence.) (2) Any instructor who thinks quality of writing can and should be defined before teaching it can and should go ahead and define it. (3) All those who feel that quality of writing does exist but cannot be defined, but that quality should be taught anyway, can benefit by the following method of teaching pure quality in writing without defining it.” [ibid: 213]

That seems to me the main setup for the metaphysical exposition of quality which takes about 30 pages. I am not sure that the descriptions of Hume and Kant and of the scientific method adds a great deal to this. So plunging ahead, the narrator reports that Phaedrus was challenged by colleagues:

[T]he second wave of crystallization, the metaphysical one… was brought about in response to Phaedrus’ wild meanderings about Quality when the English faculty at Bozeman, informed of their squareness, presented him with a reasonable question: “Does this undefined ‘quality’ of yours exist in the things we observe?” they asked. “Or is it subjective, existing only in the observer?” It was a simple, normal enough question, and there was no hurry for an answer. Hah. There was no need for hurry. It was a finisher-offer, a knockdown question, a haymaker, a Saturday-night special—the kind you don’t recover from. Because if Quality exists in the object, then you must explain just why scientific instruments are unable to detect it. You must suggest instruments that will detect it, or live with the explanation that instruments don’t detect it because your whole Quality concept, to put it politely, is a large pile of nonsense. On the other hand, if Quality is subjective, existing only in the observer, then this Quality that you make so much of is just a fancy name for whatever you like. [ibid: 228]

The narrator then describes Phaedrus’ response to the dilemma. First, unlike contemporary philosophers such as John McDowell, he rejects any attempt to locate quality in the world as an observer-dependent property like colour. So the bulk of the response is to the second, subjective, horn.

Here a first diagnostic move is to realise that there is something illicit in the way it is characterised: “Or is it subjective, existing only in the observer?”.

Why should Quality be just what you like? Why should “what you like” be “just”? What did “just” mean in this case? When separated out like this for independent examination it became apparent that “just” in this case really didn’t mean a damn thing. It was a purely pejorative term, whose logical contribution to the sentence was nil. Now, with that word removed, the sentence became “Quality is what you like,” and its meaning was entirely changed. It had become an innocuous truism. [ibid: 232]

Despite this, however, he does not manage to dismiss this either. There are two sub-moves concerning the implicit perjorative characterisation. One might think that the subjective was just what one likes because of a contrast with a view of objectivity supplied by either a scientific materialism or a classic formalism. Against the former, Phaedrus argues that aspects of its world view depends on subjective elements. (the examples given are the number zero and the status of laws of nature.) Against the latter, Phaedrus gives way realising that at best he will have to subdivide quality into two.

What the classical formalists meant by the objection “Quality is just what you like” was that this subjective, undefined “quality” he was teaching was just romantic surface appeal. Classroom popularity contests could determine whether a composition had immediate appeal, all right, but was this Quality? Was Quality something that you “just see” or might it be something more subtle than that, so that you wouldn’t see it at all immediately, but only after a long period of time?...

Instead of one single, uniform Quality now there appeared to be two qualities; a romantic one, just seeing, which the students had; and a classic one, overall understanding, which the teachers had. A hip one and a square one. Squareness was not the absence of Quality; it was classic Quality. Hipness was not just presence of Quality; it was mere romantic Quality. The hip-square cleavage he’d discovered was still there, but Quality didn’t now seem to fall entirely on one side of the cleavage, as he’d previously supposed. Instead, Quality itself cleaved into two kinds, one on each side of the cleavage line. His simple, neat, beautiful, undefined Quality was starting to get complex. [ibid: 235-6]

In fact, a little later, just such a distinction returns in Pirsig’s account as the first subdivision after the primal quality. Still a failure to respond by neutralising one or other horn forces the narrator to describe Phaedrus’ conclusions as follows:

And so: he rejected the left horn. Quality is not objective, he said. It doesn’t reside in the material world. Then: he rejected the right horn. Quality is not subjective, he said. It doesn’t reside merely in the mind. And finally: Phaedrus, following a path that to his knowledge had never been taken before in the history of Western thought, went straight between the horns of the subjectivity-objectivity dilemma and said Quality is neither a part of mind, nor is it a part of matter. It is a third entity which is independent of the two…
Quality is not a thing. It is an event. Warmer. It is the event at which the subject becomes aware of the object. And because without objects there can be no subject—because the objects create the subject’s awareness of himself—Quality is the event at which awareness of both subjects and objects is made possible. Hot. Now he knew it was coming. This means Quality is not just the result of a collision between subject and object. The very existence of subject and object themselves is deduced from the Quality event. The Quality event is the cause of the subjects and objects, which are then mistakenly presumed to be the cause of the Quality! [ibid: 234-9]

So that seems to be the heart of the metaphysics of quality. The philosophy backstory continues with Phaedrus going in search of the inversion which made quality as a whole, or as such, not an undefinable pre-rational origin of the relation of subject and object but a mere element within a larger rational structure. His aim is to make sure ‘Aristotle got his’ [ibid: 345].

I am struck now that there is something in all this a little reminiscent of my very basic understanding of Kant’s problem of the schematism. What guides the application of concepts to the world if one cannot simply presuppose the choice of the appropriate concept? The Critique of Judgment can be read as attempting to answer this general question. In its solution, reflective judgment plays a central role and is defined by contrast to determinate judgment as follows:

If the universal (the rule, principle, law) is given, then judgment, which subsumes the particular under it, is determinate... But if only the particular is given and judgment has to find the universal for it, then this power is merely reflective. [Kant 1987: 18]

The task which reflective judgment has to undertake is to ascend from the particular in nature to the universal. A necessary presupposition of this activity is that nature can be brought under concepts. This principle, which is not constitutive of nature but is a subjective principle governing judgment, is that we think of nature as purposive: we think of it, roughly, as art. The claim, roughly that we must think of the world as teleological, is one part of the solution. The other is that aesthetic judgment sheds light on how judgment generally is possible. The key element of aesthetic judgment, Kant suggests, is the ‘ability to judge an object in reference to the free lawfulness of the imagination’ in which there is ‘a subjective harmony of the imagination with the understanding without an objective harmony’ [ibid: 91-92]. It is the harmony of the faculties of imagination and understanding in judgment which is both the source of pleasure that grounds aesthetic judgment and which solves the problem.

Given that Pirsig/the narrator describes classical understanding of the world as involving the analysis of phenomena into parts and sub-parts - he calls this ‘classical rational analysis’ [Pirsig 2009: 76] – a similar question can be asked in the context of Zen and the Art of Motorcycle Maintenance. How is it that such a form of analysis can be brought to bear on the world? The answer is that it stems from a pre-rational encounter: the quality event which makes the relation of subject and object possible. Pirsig’s quality plays a role akin to Kant’s aesthetic understanding in being a half way house to conceptual judgement. As the narrator stresses, Phaedrus’ English teaching relied on the idea that quality could be recognised and identified and known even if it could not be formally analysed.

Still, it doesn’t seem very satisfactory. One problem is very familiar: trying to balance an ineffability claim with the identification of something. Pirsig/the narrator/Phaedrus tells us that the ‘Quality event’ causes the division of subject and object but makes it entirely unclear how he earns the right to say this since it – I assume – requires a prior division of quality, on the one hand, and the emergence of a subject-object split, on the other. But such a meta-division presupposes classical understanding.

‘Event’ is also tricky as that usually presupposes a series of distinguishable worldly happenings which again presupposes a subject-object split.

The metaphysical account is partly motivated by the prephilosophical distinction between romantic and classical quality judgements but such judgements don’t seem to characterise the ineffable quality he wants. Classical quality is downstream of the primal event as it is articulable. Romantic quality is an instantaneous judgement of the appearance of things. But that idea now looks to fall prey to the dilemma of being ‘just what one likes’. If it is, then it lies on the subject side of the subject-object split and thus presupposes just that division. If it isn’t, if, say, pictorial aesthetics are susceptible to some sort of placing in the space of reasons, then romantic quality will end up a variant of classical understanding in somewhat different terms. But again that presupposes the subject-object split behind which primal quality was supposed to lie as its cause. (Phaedrus’ reintroduction of rhetorical principles suggests a view in which English composition aesthetics cannot be given context-independent general rules. But that does not rule out context-dependent articulations, or reasons, of what is good and bad in an essay.) In neither case will it be the origin of the subject-object split.

Despite this, the main problem is much more recognisable than I would have expected. My hunch is that it could have been addressed more plausibly by rejecting the idea that rationality is codifiable in context-independent, general terms than by rejecting rationality as such. Quality isn’t outside the space of reasons.

Kant, I. (1987) Critique of judgment Indianapolis: Hackett

Pirsig, R. (2009) Zen and the Art of Motorcycle Maintenance: an inquiry into values, Harper Collins e-book

Campbell on the meaning-rationality link in delusions

Aline, Gloria and I met together to discuss John Campbell’s 2001 paper ‘Rationality, meaning and the analysis of delusion’. As a result I think I have a clearer picture of why I disagree with it than before. The following are thus not my own thoughts (though neither do I want to saddle - my expression of - them onto either of my colleagues).

Campbell’s paper divides between two phases of argument. In the first, he deploys a Davidsonian link between meaning and rationality to press problems with the interpretation of characteristic expressions of the Capgras delusion. The characteristic type of utterance – “That woman is not my wife!” - is insufficient to specify an interpretation since that type of utterance, freed of context, might be used to flag a mere discovery of illegality in the wedding ceremony. (I worried that by the end of the paper, Campbell had lost the right to this refutation but Aline pointed out that the proof of the pudding was in the lack of acceptance by the Capgras subject of this interpretation.) But the most plausible interpretation – “This [demonstrated] woman is not that [remembered] woman” - fails because the subject fails to deploy paradigmatic or canonical forms of checking. They do not do what they ought to do to check such a thought. Given the meaning-rationality link, this apparent failure of rationality undermines such an interpretation.

The positive phase aims to respond with a suggestion about the shape, at least, of the thought-content involved. The very fact of the failure to adopt paradigmatic checking strategies would be rational if the delusion had the status of a (third period) Wittgensteinian hinge proposition. So the form of the thought can be identified even though not the content (in G’s helpful terminological analogy though it will conflict with my philosophy of content use of ‘content’, sorry).

It thus seems as though the negative phase presses a failure of rationality and hence a failure of interpretation in accord with the meaning-rationality link. The positive phase suggests a ‘sort of’ rationality and hence a ‘sort of’ interpretation that reaches only as far as the form, not the content, of the thought.

I think this summary of what is going on enables me to state my earlier worry in slightly different terms. If one takes the negative phase seriously, the positive phase is unavailable. It, the positive phase, says of we-know-not-what content that it has the form of a hinge proposition. But surely the form-content distinction is an abstraction from the motley of thoughts subjects have rather than something independently understandable. (To be so would require prior commitment to something like the representational theory of mind in a strong sense of it being independently characterisable and understandable as the a priori engineering of minds rather than merely a post facto explanation of how they could be possible.) Given the meaning-rationality link (ie the constitutive ideal of rationality underpinning interpretation through the principle of charity) and given a plausible additional claim that rationality is not codifiable, drawing a distinction of form and content would require first articulating thoughts as a piece of radical interpretation and then abstracting forms and contents (from thought-contents, I want to say, with a danger of ambiguity). So if that could be done, one would then be in a position to say that delusions have the form of hinge propositions. But the first phase of Campbell’s paper is an argument against the possibility of that necessary preliminary work.

To assume access to the form of delusions without their contents is to assume something about the shape of their intentional content (in the usual philosophy of content sense of that word). Aside from abstraction from the output of radical interpretation, the only other route I can see to that would be to start with a picture of the internal vehicles of content and describe their functional roles. This approach faces a dilemma. If the functional roles presuppose the structure of rationality then the approach cannot sidestep the meaning-rationality link since rationality governs thought-contents. But if they are just any dispositional causal connections between inner vehicles of content (whatever the content turns out to be) then this threatens the connection between what is being described and our ways of making sense of one another since only some connections would be (so much as, as they say in Oxford) intelligible. There would need to be some reason to think that both structures kept in step. In the absence of that, such an approach seems a non-starter and hence the assumption that delusions are some sort of shaping of thought-content in the form of a hinge proposition despite being inaccessible to rational interpretation looks illicit.

Campbell, J. (2001) ‘Rationality, meaning, and the analysis of delusion’ in Philosophy Psychiatry and Psychology 8: 89-100

If a lion could talk...

I am delighted to see this issue of Existential Comics doesn’t assume, as so often by others, that Wittgenstein’s quip about the lion suggests that we would not be able to interpret the lion’s speech.  

This line complements the last line in the Tractatus as the quotations all the participants on that fine 1980-90s radio 4 show Stop the Week knew. (And it really was an excellent programme, an excellent use of 30 minutes of the radio. I recall – dimly albeit – a good 15 minute discussion of the worth of fish knives, the vague recollection of which sometimes makes me wonder now whether I ought to buy some. My partner’s family deployed them with due solemnity for fish fingers and I think that they were right so to do.) But typically the assumption is made that it is a kind of exception to a broadly Davidsonian view. The lion really is speaking, is in the space of reasons, but is somehow inaccessible to interpretation.  

It seems, from the context, that Wittgenstein’s comment is more subtle and helps to flag some of the range of meaning that attaches to ‘understand’. It is worth noting what comes before the famous line. We can fail to understand, not because we cannot grasp their meanings, (whether or not for Mulhallian reasons one wants to rejects the word ‘interpretation’ for this), but because we cannot find our feet with them.

We also say of some people that they are transparent to us. It is, however, important as regards this observation that one human being can be a complete enigma to another. We learn this when we come into a strange country with entirely strange traditions; and, what is more, even given a mastery of the country's language. We do not understand the people. (And not because of not knowing what they are saying to themselves.) We cannot find our feet with them. 

“I cannot know what is going on in him” is above all a picture. It is the convincing expression of a conviction. It does not give the reasons for the conviction. They are riot readily accessible.  

If a lion could talk, we could not understand him. [Wittgenstein 1953: 223]

Well I hope that this is what the comic strip is flagging rather than the fact that the lion is actually Frege.

((I have no doubts, given the immediately preceding comment by Wittgenstein. There is a nice, heavy Travisian atmosphere to the scene.))