text:
tag:blogger.com,1999:blog-66584329963742519072015-10-07T18:59:13.569+01:00In the Space of ReasonsTim Thorntonhttp://firstname.lastname@example.com:blogger.com,1999:blog-6658432996374251907.post-3368964758659198602015-08-15T18:02:00.000+01:002015-09-03T09:48:55.871+01:00Twitter and authority

I have some vague recollections of an INPP (International Network of Philosophy and Psychiatry conference) in Lisbon a few years ago: the surprising defences of lobotomy by a disproportionate number of local psychiatrists (perhaps Portuguese psychiatry was having a moment); a paper by Rom Harre which lacked his customary zing; my own part in a panel presentation, in a big echoing hall of rather fascist-architecture, on Recovery when, after I'd spoken (sceptically? thoughtfully?) and was returning to the panel's seats on the podium, both Larry Davidson and Bill Fulford had their heads in their hands and wouldn't meet my eye. But at some point in the conference I was accosted by a stranger who said: "This is dull, let's go and get something to eat". A half hour taxi ride into town and the indecisions of people who don't know one another, and I had an iffy steak but the most enjoyable company. But I've not seen much of Dariusz since.

Cropping up – briskly, abruptly as is the nature of the medium - on twitter today, he expressed a common (and my) view from within academia: twitter and its visibility may be necessary for academic work and the stress on dissemination and impact but it is difficult: "I find it exhibitionist. Who cares what I do, did or think?" I don't think his point is that people will not care what an academic thinks per se (though that may also be true, sadly) but rather what an academic writing via twitter thinks. It strikes me that this highlights a feature of twitter which may be why I don't like it: it depends on authority. It embodies an appeal to extra-textual authority.

Some tweets won't. Those which most encourage the label 'meme' (a dreadful concept), perhaps. So, for example, tweeted pictures of ducklings cuddling up to cats make an appeal (if they do) which has no need for an author. Perhaps the famous one word proof of Pythogoras' Theorem: "ecce!" augmented by a suitable diagram. But invoking tweeted images seems to be cheating. Pure text cannot do very much in a 140 characters. Crucially, it cannot offer a case for a claim or display its reasons, the kind of thing for which academics aim. That can be done in the standard media for academic dissemination: the books and papers of tradition. It can also be done in blog posts where, again, there is enough space to make a case.

I realise I risk being naïve about the authority of a text that's longer than a tweet. David Foster Wallace wrote a fine positive review ('Authority and American Usage') of a 700 page work of prescriptive grammar. Such a case raises the difficulty of assuming authority in spades: why on earth should one follow some fellow's hunches about how English ought to be written? Descriptive grammar seems to be the only intellectually honest approach. But in this case, the author – Foster Wallace tells us – cajoles us into following him through a series of choices. Surely if you want to be clear, you can see how it would be better to write this than that? And hence the authority of the text rests on the display of technical mastery available to the neutral reader. And for any reader who does not see that appeal, no matter. (As the public information film against swimming in dark swampy building sites ended: "Sensible children: I have no power over them")

But a tweet seems to have to trade on the authority of its author in one of two ways. Either by accord with the principle: Stephen Fry says X (in a 140 characters) so X must be true. Or, worse I think, Stephen Fry's saying X makes X interesting for that reason alone. This is an instance of the power of celebrity. Stephen Fry eats eggs for breakfast / thinks coffee passé / wears tweed again and thus so should we. It's not because we think him likely to right about the objective aesthetics of eggs, coffee or tweed as an expert. Rather he is an expert in being Stephen Fry. That's enough reason for us to do those things. That is, I think, how twitter works and why academics, aside perhaps from celebrity academics (or perhaps even more so for them), should shun it. Tim Thorntonhttp://email@example.com:blogger.com,1999:blog-6658432996374251907.post-14202140361079658152015-08-07T12:59:00.001+01:002015-08-07T16:24:45.375+01:00Avner Baz on the final section of Avner Baz' 'On when words are called for'

"Dear Tim,

I just read your post about the paper. Thank you so much for reading it and commenting on it.

I wrote the paper almost 15 years ago, but the basic argument is simple and still seems to me to be sound (McDowell has since retracted the idea, which was the target of my paper, that our experience contains claims, or has propositional content):

The content of a judgment (what Travis later came to call 'auto-representation') of perception, and similarly the content of an utterance describing what someone else is seeing, or saw, just like the content of any utterance, is context-dependent. So of course I could, given a suitable context, say what you see, and you could say what you see, and it could also be said that what you said was the same as what I said—so we could be said to be attributing the same content to your visual experience. But the content of any of those utterances is context-dependent—the words by themselves, apart from some suitable context, (would) leave it indeterminate. And the problem with McDowell (of Mind and World and 'Having the World in View') is that he wants to say—he SAYS—that the very same content that such utterances would have, was somehow already in the experience—independently from being articulated in one way or another, in a context suitable for such articulation (Travis would say independently of being auto-represented)—just by virtue of your being a competent speaker and awake, and facing the cube, or the tree. And THAT idea, I argue, cannot be made sense of. In attempting to make sense of it, McDowell relies on the words that could, given a suitable context, be used to say what someone (or oneself) sees, or saw. And that reliance betrays a misunderstanding—which I suspect McDowell himself would have disavowed if it were presented to him explicitly—of how language functions.

Best,

Avner"
Tim Thorntonhttp://email@example.com:blogger.com,1999:blog-6658432996374251907.post-28483048113205514682015-08-05T17:41:00.004+01:002015-08-07T12:59:53.616+01:00The final section of Avner Baz' 'On when words are called for'

I have been reading Avner Baz's paper, slightly confusingly called 'On when words are called for'. It is an interesting Travis-like attack on McDowell's representationalist account of experience. But I am not sure I follow the argument because it doesn't seem as forceful as I expected it would.

The final section requires the defence, in an earlier section, of Stanley Cavell's Wittgensteinian thought that the meaning of utterances cannot be read off the words alone but turns on their point or interest. Their point is not accidental to meaning but partly constitutes it. The final section applies this to McDowell's account of experience in Mind and World which, like Sellars' Myth of Jones, suggests that the content of experiences can be modelled on that of judgements.

Baz reports that:

We are invited by McDowell to think of the content of our experience as the very same content that judgments or claims might have… I think it would be more precise, and more to McDowell's point, to say that to judge is to make up our mind what we are going to call something, what we are going to count something as (an object in front of us as a red cube; a surface as smooth; a government as stable). [485]

The first objection now runs as follows:

Already at this point we might begin to feel uncomfortable with the idea that 'a judgment of experience simply endorses the conceptual content, or some of it, that is already possessed by the experience on which it is grounded' (MW, p. 49, my emphases). For it is not clear what room this formulation leaves for faithfulness or unfaithfulness to our experience – and I mean this not primarily in the sense of telling or hiding the truth about it, or being right or wrong about it, but rather in the sense of being true to it, or failing to. [486]

I don't follow this. I'm not sure I understand the difference between, on the one hand, being right or wrong about an experience and, on the other, being true to it or not. If that difference is vital then it undermines what I initially thought that this was: a worry that judgement can fail to fit experience so a model in which the former inherits the latter's content cannot be correct because it cannot account for such failure. Had that been the worry then there are responses in the McDowellian account. To mention one: although a judgement may inherit the very same content as an experience it may also have a different content made as a recognition grounded in the experience. (Particular kinds of birds for example.) Such recognition could misfire.

But this seems not to matter as Baz warns us that this isn't the way he will proceed.

If we press this worry too soon, however, we run the risk of remaining within the grip of the picture that underlies such formulations. And then we might end up still thinking (that we know what 'judgment' means, what judgment is, what faithfulness to the world requires) instead of looking (at what goes into our use of the word 'judgment', at what we, in actual cases, call 'judgment', at what faithfulness to the world requires). [486]

So what follows will respect the Wittgensteinian injunction to look rather than to think and hence to look at how ascriptions of what is seen are made.

The next objection presses the point set out in the previous section from Stanley Cavell that the meaning of utterances is partly determined by the point of making them, by the particular cares or concerns they express. This is then – I think – directed at the idea that a judgement might share the content of an experience. The question is: what is the content of the judgement?

[I]n judgments… what we decide to call the thing, and what we mean in calling it this or that, is inseparable from the nature of our interest in that thing – from that which leads us to ask ourselves what we want to count it as. Whether or not we decide, for example, to call a surface 'smooth' would depend on the nature of our specific interest in that surface. If you came to me and asked me, out of the blue, whether my desk, or face, was smooth, I would not know what to say. I would need for you to tell me what you meant; unless I could see, or was somehow able to guess, why you were asking me that – what the nature of the interest you were expressing with your words was. Similarly, if you asked me, under whatever circumstances, whether there was, whether I would say (judge) that there was, a red cube in front of me, I would not know what you were asking, unless I were able to see the point of your question. [486]

This passage suggests that the questions that might evoke the judgement that the table is smooth or that there is a red cube in front of one are varied depending on the matter of interest and, hence, that the content of the judgement to be made in response varies. In paradigmatic cases such as Sellars' example of the red cube, it may seem that there isn't this variability.

[I]t is extremely tempting to think that we can and do know what is being asked by 'Is there a red cube in front of you?', even in cases in which we cannot see the point of any such question. [486]

But even the meaning of utterance 'There is a red cube in front of me' is underdetermined by the words alone. To show this, Baz constructs a Travis-like example.

For suppose you say 'There is a red cube in front of me'; I look, and see what for all the world is a green cube. Do I know what you said? Have you, for example, said something false? Will forming for myself an image of a red cube, or staring hard at the cube in front of you, or both, help me find out? The next thing you do is to scratch the green paint to show me that underneath the green paint there is red paint. Do I now understand what you said? Has it turned out that what you originally said was true? But then, shouldn't you simply have said that underneath the green paint there was red paint? I'm still puzzled: What judgment (or claim), if any, did you express with your words? But suppose you now add: 'Those idiots thought they could fool me and get away with it. Everybody knows that their green cubes are far superior to their red cubes. But I could tell (judge) immediately, just by holding it in my hand, that that wasn't a green cube'. Now I finally understand you and know what judgment or claim you made: you weren't just trying to be clever; and it wasn't really the color of the cube you were concerned about, but its quality. [487]

This example presses the general claim to follow:

A judgment (or claim), I argue, requires a particular context in which it is called for. Without such a context, it would not be a judgment (or claim), nor have any determinate content. [487]

The paper doesn't pause here. But I take it that a consequence of this is that there is a tension between two thoughts: that the content of a judgement answers to a context of inquiry but also that the content of some judgements is supposed, by McDowell, to be inherited from experience. The passage continues, directly, though with a possible contrast between judgements and experiences.

Now what about an experience? Isn't it clearly different in that respect? It would appear that unlike a judgment or claim an experience does not need to be called for; or anyway not in the same way. It just happens to us, as we saw McDowell saying, whether we want it to or not. Whereas a judgment requires a reason if it is to be a judgment, with an intelligible content, it would seem absurd to say that you need a reason in order for you to see this or that that lies in front of your eyes – wouldn't it? [487]

So one possible line of argument would stress a prima facie difference between the properties of judgements and experiences in order to undermine the connection – via shared contents – that McDowell suggests. But it seems not to work like that. Baz approaches the nature of experiences by looking at how we ascribe seeing something (rather than judging something) to someone. In this case too, he also wants to suggest, against his interlocutor's intuition, the ascription depends on a context of interests or concerns.

What my interlocutor really wants to say is that the fact that there is a red cube in front of me, and that I'm looking right at it, and perhaps also that I can tell colors and shapes, justifies him in saying that I'm seeing a red cube in front of me and ensures not only the sense, but also the truth, of his words. But is that true? Is this what we call 'seeing that this or that is such and such'? Is this what we normally mean when we say of someone that he sees this or that (to be the case)? What does determine – how do we tell– what someone sees? [498]

Again, Baz deploys a Travisian example of the possibility of different meanings dependent on context.

Here is a tree and there is Jones walking in its direction. And let us even assume that the color of the tree is of some significance to Jones, or ought to be; let us assume that we told him to wait for us by the tree whose leaves have turned red. Does Jones see that the tree is green? It is easy enough to imagine a case in which it would make perfect sense for me to say that he does. However, if I choose to say of Jones that he sees that the tree is green, my reason for saying the words would determine their – that is, my – exact meaning. [489]

That last phrase is key. Just as in the case of a judgement, so in the case of the ascription of seeing something, the claim, the ascription, about what is seen depends on context. The same Cavellian message is pressed.

I've been urging, following Cavell, that crucial to the conditions of someone's saying that Jones sees this or that particular fact is that there be reason for that person to say that Jones sees this or that particular fact. [490]

However…

It might be said, 'But aren't you confusing the issue of your reason for saying that Jones sees this or that with the question of whether or not he sees it? Granted that you need to make some specific point if you are to say something intelligible about what Jones sees; but this has nothing to do with his seeing what he sees…But we already saw that what you've just said of Jones ('He sees that the tree is green') can have more than one sense, depending on the specific point of saying it, and is not even obviously a 'saying that he sees that the tree is green'. [490]

And…

And different questions would make for different contexts and therefore for different things for him to be able to say on the basis of what faces him. [490]

For even in the case of the store manager facing the cube, or in the case of Jones facing the tree, different occasions for saying what they see at any given moment would make for different (correct) determinations of the content of what they then see.30 Even the perceiver himself can find himself offering different specifications of what he sees, or saw, given different possible occasions, or reasons, for him to attend to that matter. And so, given that most of what encounters us never actually gets articulated – even if it is something that we clearly do need in one way or another to attend to (say, where we step, or where we place something, or how someone has responded to something that we did or said); and given that different contexts of articulation will make for different specifications of the content of what we see, or saw;31 what might it mean to insist, as McDowell does, that what we take in in experience has the very same content that a judgment or claim might have? [492]

So I infer from this that the problem is not that seeing is a state with an interests-independent content whilst explicit judgement is interests-dependent and hence they cannot share the same content. Rather, the problem is that both are context-dependent in such a way that one cannot say, absolutely, what either content is.

If this is the right interpretation – and thus I think it cannot be – I'm not sure how decisive it is. Couldn't one hold the McDowellian-Sellarsian-Myth-of-Jones idea of the judgement 'containing' the same content as the experience with both fixed by words used in a particular context? It is hard to assess such a thought because McDowell himself has moved on. But if one were sufficiently relaxed, could one not refuse to be embarrassed by the question of which concepts and simply grant that the content of the experience depends on what interests the subject? (My assumption is that the McDowell of 'Avoiding the Myth of the Given' could not take this line because that paper hints at a priori limits on the conceptual articulation of experience such that [bird] cannot be an element but [perching animal] might.)

There is a further and distinct objection.

[W]e may be tempted to pursue another understanding of the idea that our experience of the world is to be understood on the model of speech – the idea that our experience contains claims ('contains' 'claims')… Suppose we want to be able to say something about what must be happening in or to us when we see this or that. Suppose we want to insist, in response to philosophical pressures of the kind expressed in the previous paragraph, that what a competent speaker sees when she opens her eyes has the very same content as what she might say; that our experience presents us with content, in virtue of our being competent speakers whose senses are functioning, and that all that is then left for us to do is to endorse that very same content in judgment, or to express it in an utterance. Then, I'm afraid, we may find ourselves having to rely on words, those things ordinarily used for saying things, to be drawn into operation and capture – by themselves, as it were – the content of our experience, apart from some specific context in which there would be something in particular for them to mean. And then we will be proposing that what we experience is somehow already articulated (by us? for us?), and that all that is left for our judgments to do is simply to 'select from among a rich supply of already conceptual content' (MW, p. 49, fn. 6). [493]

But I don't think that this would counter the contextualist response above.

PS: Avner Baz generously emailed me about this post thus.Tim Thorntonhttp://firstname.lastname@example.com:blogger.com,1999:blog-6658432996374251907.post-63144731235645059522015-08-03T16:00:00.001+01:002015-08-03T16:03:18.779+01:00The Collaborating Centre for Values-based Practice in Health and Social Care Website

The Collaborating Centre for Values-based Practice in Health and Social Care Website is now live. It's here.

"Dear All
We are delighted to announce the launch of our website - it is now live and open to all!
If you have any contributions for our news and Notes section please do not hesitate to get in contact and if you know of any new partners who might be interested in becoming an individual or organizational partner please ask them to contact us via the website.
Kind Regards
Jenette Sefton (On Behalf of the Management Team)"Tim Thorntonhttp://firstname.lastname@example.com:blogger.com,1999:blog-6658432996374251907.post-17047556993939802242015-07-31T10:47:00.000+01:002015-07-31T15:24:50.593+01:00Reasons for buying a house

I was talking to a friend over pizza in Kendal last night who is beginning to think of buying a house, possibly here. Asking about the factors that would influence a selection she suggested a variety. I have not tidied them up to be properties or qualities of a house but rather reasons of any sort. They included:

Proximity to either Kendal station

A view of greenery

An appropriate price

Avoidance of a split level garden

Fear of icy pavements

Walking access to civic facilities

Location outside three less salubrious areas of town

Other factors that sometimes affect such decisions were not important including house age or style or having particular a priori room configurations.

In the UK, there is a widespread fascination, which I share, with house buying that goes beyond our eccentric habit of treating houses as primary financial investments. And so I began to wonder where in Kendal the ideal house would be and had to resist getting out my phone and searching the web there and then.

The nature of the decision has, however, a couple of interesting general features in seeming tension.

First, even given a list of factors, their combination is not transferable to someone else. The list I've just written down isn't necessarily a ranking order. And some of the reasons are, as it were, enthymemes. It turns out that the desirability of avoiding a split level garden (the most left field feature on the list) was not so much aesthetic as I initially assumed (who can stand the sight of them?!) but a concern with trip hazards: a reason more familiar in those over 70 with the fear of 'having a fall' than younger than 40. But context and personal history is all for a reason like this (visiting relatives?). Hence perhaps a graded split level garden with grab handles on non-slip illuminated steps would be fine. And so on. But given the general Wittgensteinian idea of a symmetry of understanding explanations between speaker and audience, that suggests that the way the reasons operate for my interlocutor also awaits a context. Their valence will depend on their holistic combination in particular cases. The list doesn't actually codify the right decision for speaker or audience.

Second, despite the uncodifiability of the reasons operating in complex decisions like this, it is still tempting – well for me at least – to think that there is a kind of unique correct outcome (in this case, relative to the houses actually for sale). (In truth, I think my wiser colleague immune to my foolish assumption.) Such a mythology also seems implicit in the presentation of house buying TV programmes – of which there are many – in the UK. Buyers are guided in a teleological quest for their ideal house, waiting somewhere out there for them. This contrasts with, say, buying a bunch of bananas where, providing they are the right degree of ripeness/unripeness, number, size and fair-trade status, any bunch satisfying those criteria will do. Ditto cars, I think. So that suggests an interesting tension between the very complexity of the case and still the thought that it is not so much aimed at satisfying criteria but rather at a correctness for which the criteria are mere epistemic guides rather than constituting a standard of correctness.

(Lurking in this area is the interesting combination in McDowell's moral anti-anti-realism. The notion of correctness of moral judgement doesn't rule out the possibility of difficult cases which tolerate a kind of ambiguity. The reality at which moral judgement is aimed is, if I read him right, gappy.) Tim Thorntonhttp://email@example.com:blogger.com,1999:blog-6658432996374251907.post-55512915090968083672015-07-22T09:42:00.001+01:002015-07-23T18:27:58.392+01:00Tâtonnement and failing to 'find' a paper

I spent yesterday trying to start a paper on John Campbell's noughties papers [Campbell 2007, 2008, 2009] on causation in psychiatry and psychology but failed to get anywhere. Having recently read Peter Goldie's book The Mess Inside, I wonder whether the word for the day's activities is 'tâtonnement', which he suggests is a kind of feeling one's way to a narrative: 'a tentative, groping procedure: one might begin with an idea of how the narrative should be shaped, and, once one has developed it somewhat, one might be able to see saliences that one could not see before, and then find it appropriate to go back and reshape the narrative in this new light.' [Goldie 2012: 11]

The basic plot idea I was struggling with has the following vague elements.

1) Campbell argues that the idea of levels of explanation is the result of a pre-Humean assumption about that causation that the world must have an intelligible causal structure. (He suggests that this is a standard philosophical synthetic a priori claim.) But Hume teaches us that it need not. Causation is brute and Campbell suggests that the best approach to causation is interventionism. Whilst such ideas are sometimes fruitful we should neither assume that physical causation must be mediated by mechanisms nor that mental causation must be mediated by rational connections. It may be, for example, that all that can be said to explain a particular delusion is that intervening on whether someone is seen by the subject to be scratching his beard changes whether the subject forms and holds the delusion. There may be neither rational nor mechanical intermediaries.

2) Campbell's illustration of how the facts about causation may eschew mechanisms resembles some unpopular remarks by Wittgenstein in Zettel. They include: 'Why should there not be a natural law connecting a starting and a finishing state of a system, but not covering the intermediary state? (Only one must not think of causal efficacy.)' [Wittgenstein 1981: §613] Of the underlying thought of these comments, Wittgenstein says: 'If this upsets our concepts of causality then it is high time they were upset.' [§610]

3) Wittgenstein's remarks seem, however, to be aimed at removing the tension of reconciling a connection made at the mental level in mental and, according to him, non-causal terms with assumptions about underlying causal mechanisms at a physiological level. Campbell's, by contrast, suggest that the top level is causal. This suggests that there is still a motivation (available to us, untouched by Campbell's argument and distinct from the one Hume criticises) for adopting a particular synthetic a priori (rendering unto Caesar in accord with a distinct obligation). The claim that something is a delusion itself requires some synthetic a prioris. Campbell himself acknowledges this in a quite different seeming paper on the interpretation of Capgras [Campbell 2001]. To grasp the content of the expression of a delusion requires fitting it into a rational pattern of canonical testing.

4) So the explanation of delusions does require something more than brute interventionism. It requires the prior recognition of the effect of whatever putative causes as an instance of a delusion. That requires the kind of mental-level normative patterns that Wittgenstein stresses.

Well, as can be seen from the summary, this doesn't really hang together. That I think it ought suggests something like the paradox of analysis for the activity of tâtonnement. The confidence that there is a narrative structure to be reached for suggests no need for tricky reaching activity. But where there is such activity, there's no obvious goal for the reaching so how does one know where in conceptual space to look?

Whilst I can take in my stride the kind of fallible glad start of thinking one knows how to continue a series or launch a spoken sentence, it seems an odder piece of phenomenology that one can think one is not persuaded by a paper but only dimly grasp why not.

This paper may thus fall off my list of activities unless something changes on a run round Kentmere later.

Campbell, J. (2001) 'Rationality, meaning, and the analysis of delusion' in Philosophy Psychiatry and Psychology 8
Campbell, J. (2007) 'An interventionist approach to causation in psychology' in Gopnik, A. and Schulz, L. Causal learning: psychology, philosophy, and computation, Oxford: Oxford University Press
Campbell, J. (2008) 'Causation in psychiatry' in Kendler, K.S. and Parnas, J. (eds) Philosophical Issues in Psychiatry, Baltimore: Johns Hopkins University Press
Campbell, J. (2009) 'What does rationality have to do with psychological causation? Propositional attitudes as mechanisms and as control variables' in Bortolotti, L. and Broome, M. (eds) Psychiatry as Cognitive Neuroscience, Oxford: Oxford University Press
Goldie, P. (2012) The Mess Inside: narrative, emotion, and the mind, Oxford: Oxford University Press
Wittgenstein, L. (1981) Zettel, Oxford: Blackwells

For own housekeeping convenience, my other ongoing writing activities are as follows.

Papers / chapters under review

'Bootstrapping conceptual normativity?' Foundations of Science

'Nursing knowledge: its nature and generation' for Chambers, M. (ed) Psychiatric & Mental Health Nursing: the craft of caring, Abingdon: CRC Press

'Transcultural psychiatry' for White, R., Read, U., Jain, S. and Orr, D. (eds) The Palgrave Handbook of Global Mental Health: Sociocultural Perspectives, London: Palgrave

'Naturalism and dysfunction' for Forest, D. and Faucher, L. (eds) Defining Mental Disorders: Jerome Wakefield and his Critics, MIT Press

 'Psychiatric classification, tacit knowledge and criteria' for Keil, G., Kutschenko, L., Hauswald, R. (eds) Gradualist Approaches to Mental Health and Disease, Oxford: OUP

'Recovery, paternalism and narrative understanding in mental healthcare' Maria Francesca Freda, M.F. and De Luca Picione, R. (eds) Cultural Construction of Social Roles in Medicine, Information Age Publishing: Charlotte, N.C.

Papers / chapters in preparation

'Phenomenological implication as transcendental argument' for van Staden, W. and Pickering, N. (eds) Wittgenstein and mental health, Oxford: OUP

'The normativity of meaning and the constitutive ideal of rationality' for Verheggen, C. (ed) Wittgenstein and Davidson on Thought, Language, and Action, Cambridge: Cambridge University Press

'Philosophical understandings of mental health' for Wright, K. and McKeown, M. (eds) Essentials of Mental Health Nursing, London: Sage

Book in preparation

John McDowell (second edition), Abingdon: RoutledgeTim Thorntonhttp://firstname.lastname@example.com:blogger.com,1999:blog-6658432996374251907.post-91300655420188190712015-07-15T09:28:00.001+01:002015-07-15T09:28:52.722+01:00Psychiatric diagnosis, tacit knowledge and criteria
I realise that these draft papers are rather a dull use of a blog but it is why I started it originally.

Abstract<o:p></o:p>

The two main psychiatric taxonomies set out codifications of psychiatric diagnoses via lists of symptoms with the aim of maximising the reliability of diagnostic judgements. This approach has been criticised, however, for failing to capture the precise connection between diagnostic judgements and symptoms as detected by skilled clinicians. Assuming that this criticism is correct, this chapter offers related two accounts of why this might be so. First, skilled diagnostic judgement may be an exercise of tacit knowledge: a practical skill the exercise of which requires the presence of the patient or client. Second, the conception of criteria implicit in DSM and ICD is based on a mistaken view of how what people say and do connects to their mental states. On an alternative account, in an overall gestalt diagnostic judgement the various criteria are abstractions from a whole which directly expresses the underlying psychopathological state of patients or clients.<o:p></o:p>

Introduction<o:p></o:p>

For the last 50 years, both of the major psychiatric diagnostic systems – DSM and ICD – have aimed at reliability at the potential cost of validity. They have done this by codifying diagnosis in the form of criteria, influenced by operationalism from the philosophy of physics and down playing aetiological theory. It is an empirical question whether DSM-III, -IV and now -5 and the parallel ICD classifications have achieved this aim overall.<o:p></o:p>

There have been criticisms, however, that the explicit criteria under-determine the diagnoses made by skilled clinicians. That is, the criteria themselves have a vagueness or indeterminacy for which experienced psychiatrists have to compensate in diagnostic judgements in response to particular patients expressing particular signs and symptoms. The overall top-down or gestalt judgement is more precise than the component criteria on which it is supposed to be based.<o:p></o:p>

The aim of this chapter is not to address whether this is so but rather how it could be so. In doing so, I will make two suggestions. First, diagnosis may involve an important tacit element. As a recognitional judgement, it may share characteristics of an uncodifiable form of know-how. Second, the postulation of criteriological intermediaries between the skilled clinician and their patients' or clients' actual conditions may distort the recognitional process. Judgement of the underlying mental states of patients and clients may be more secure than the operationalised criteria. <o:p></o:p>

The first section outlines the reasons for the emphasis, since the second half of the twentieth century, on operationalism in both the main psychiatric taxonomies. The second section sets out three similar clinically based criticisms of the resulting criteriological model of diagnosis. <o:p></o:p>

The final two sections set out to shed light on how this might possible first by suggesting that diagnositic judgements are an instance of a broader class of tacit knowledge and then by suggesting that the criteriological view distorts the way that clinical signs and symptoms bespeak, to a skilled clinical, underlying pathologies directly.<o:p></o:p>

Background: the rise of criteriological diagnosis<o:p></o:p>

Over the last half century, there has been a concerted effort to improve the reliability of psychiatric diagnosis by pruning the two main diagnostic systems of possibly over hasty aetiological theory and stressing instead more directly observational features of presenting subjects. Two main factors explain this. (For a fuller account, see [Fulford et al 2005].)<o:p></o:p>

First, on its foundation in 1945, the World Health Organisation set about establishing an International Classification of Diseases (ICD). The chapters of the classification dealing with physical illnesses were well received but the psychiatric section was not widely adopted. The British psychiatrist Erwin Stengel was asked to propose a basis for a more acceptable classification. Stengel chaired a session at an American Psychological Association conference of 1959 at which the philosopher Carl Hempel spoke. As a result of Hempel's paper (and an intervention by the psychiatrist Sir Aubrey Lewis) Stengel proposed that attempts at a classification based on theories of the causes of mental disorder should be given up (because such theories were premature), and suggested that it should instead rely on what could be directly observed, that is, symptoms. <o:p></o:p>

In fact, Hempel's paper provided only partial support for the moral that was actually drawn for psychiatry. He argued that:<o:p></o:p>

Broadly speaking, the vocabulary of science has two basic functions: first, to permit an adequate description of the things and events that are the objects of scientific investigation; second, to permit the establishment of general laws or theories by means of which particular events may be explained and predicted and thus scientifically understood; for to understand a phenomenon scientifically is to show that it occurs in accordance with general laws or theoretical principles. [Hempel 1994: 317]<o:p></o:p>

These two requirements – that terms employed in classifications should have clear, public criteria of application and should lend themselves to the formulation of general laws – correspond to the aims of reliability and validity respectively. Clear public criteria promote both test-retest and inter-rater reliability whilst general laws are a step, at least, towards construct validity. But it was the former that was adopted by psychiatry as the key aim at the time. With respect to it, Hempel claims that<o:p></o:p>

Science aims at knowledge that is objective in the sense of being intersubjectively certifiable, independently of individual opinion or preference, on the basis of data obtainable by suitable experiments or observations. This requires that the terms used in formulating scientific statements have clearly specified meanings and be understood in the same sense by all those who use them. [ibid: 318]<o:p></o:p>

He commends the use of operational definitions (following Bridgman's book The Logic of Modern Physics [Bridgman 1927]), although he emphasises that in psychiatry the kind of measurement operations in terms of which concepts would be defined would have to be construed loosely. This view has been influential up to the present WHO psychiatric taxonomy in ICD-10.<o:p></o:p>

The second reason for the emphasis on reliability and hence operationalism was a parallel influence within American psychiatry on drafting DSM-III. Whilst DSM-I and DSM-II had drawn heavily on psychoanalytic theoretical terms, the committee charged with drawing up DSM-III drew on the work of a group of psychiatrists from Washington University of St Louis. Responding in part to research that had revealed significant differences in diagnostic practices between different psychiatrists, the 'St Louis group', led by John Feighner, published operationalised criteria for psychiatric diagnosis. The DSM-III task force replaced reference to Freudian aetiological theory with more observational criteria. <o:p></o:p>

This stress on operationalism has had an effect on the way that criteriological diagnosis is codified in DSM and ICD manuals. Syndromes are described and characterised in terms of disjunctions and conjunctions of symptoms. The symptoms are described in ways influenced by operationalism and with as little aetiological theory as possible. (That they are neither strictly operationally defined nor strictly aetiologically theory free is not relevant here.) Thus one can think of such a manual as providing guidance for, or a justification of, a diagnosis of a specific syndrome. Presented with an individual, the diagnosis of a specific syndrome is justified because he or she has enough of the relevant symptoms, which can be, as closely as possible, 'read off' from their presentation. The underlying syndrome is connected to more accessible, epistemologically basic signs and symptoms.<o:p></o:p>

An objection to criteriological approaches<o:p></o:p>

Although the rationale for a criteriological, or bottom up, approach to diagnosis seems clear, it has not escaped criticism. The charge outlined in this section is that combining individual signs and symptoms understood initially in isolation from context and only assembled in the conjunctions that add to diagnosis is makes the signs and symptoms imprecise.<o:p></o:p>

In a paper called 'Phenomenological and criteriological diagnosis: different or complementary?' Alfred Kraus, professor of psychiatry at Heidelberg, argues that diagnostic systems such as DSM and ICD miss out an important element of psychiatric diagnosis [Kraus 1994]. Because they assume that diagnoses are built up from a number of individual and conceptually independent symptoms they cannot capture top-down and holistic elements of diagnosis. <o:p></o:p>

One key criticism that Kraus makes of what he calls this criteriological approach to diagnosis, is that rather than providing a reliable foundation, the connection between individual symptoms and conditions lacks specificity. <o:p></o:p>

[S]ymptomatological/criteriological diagnosis not only makes the reality of the patient accessible in a very reduced way but also portrays the pathological phenomena in a very imprecise and broad manner…The reduction of phenomena to symptoms and criteria has as its consequence a loss of specificity. [ibid: 153-4]<o:p></o:p>

Taking delusions as an example of a symptom, on the criteriological model, for schizophrenia, Kraus argues that there is not a reliable connection between delusions in general and schizophrenia. 'Delusion' is a vague term picking out a variety of psychological states. The reliable connection is between particular kinds of delusional structure and schizophrenia. But the identification of delusions with a specific schizophrenic colouring presupposes, Kraus argues, a top down holistic model rather than a bottom up description. The assumption on the criteriological approach that symptoms can be recognised and described independently of the psychopathological diagnostic categories of which they are a part introduces vagueness to their descriptions and hence undermines the specificity of their connection to diagnostic judgements.<o:p></o:p>

Kraus also argues that in the bottom-up model, symptoms can only be added together through conjunction. But no mere conjunction of individual symptoms—a 'Chinese restaurant menu' approach—can capture the psychological integrity up to which the individual parts add. For that, one again needs a top down holistic approach. This is not to say, however, that particular elements cannot be identified in a holistic diagnosis. It is just that the individual elements have a different logic. <o:p></o:p>

One way of marking this distinction (although not Kraus' own) is to contrast parts that are independent pieces and parts that are essential aspects. The pieces of a jigsaw add up to a whole, but each piece can exist independently of the others. By contrast a musical note has both a tone and a pitch, but neither aspect can exist independently of the other. Thus, according to a holistic approach, psychological symptoms are not independent building blocks towards diagnostic judgements but are interdependent aspects of a psychological unity. <o:p></o:p>

Kraus combines with these two comments on the limits of a criteriological model of diagnosis with a further philosophical explanation of the difference in approach. This is why he contrasts the criteriological with a phenomenological rather than merely a holistic model. This concentrates not on psychiatric diseases but on the mode of being of whole persons, the 'whole of the being in the world of schizophrenics or manics'. Thus the phenomenologically based diagnosis of schizophrenia turns on an overall assessment of the patient—a 'praecox feeling'—as having a very different form of 'being-in-the-world'. Whether or not that more general view is correct, Kraus' criticism suggests that the operational structure of psychiatric manuals introduces a vagueness into the description of symptoms and hence undermines the specificity of the link between symptom, when properly understood, and diagnostic judgement.<o:p></o:p>

Mario Maj makes a similar criticism. Again taking the example of schizophrenia, he argues that:<o:p></o:p>

One could argue that we have come to a critical point in which it is difficult to discern whether the operational approach is disclosing the intrinsic weakness of the concept of schizophrenia (showing that the schizophrenic syndrome does not have a character and can be defined only by exclusion) or whether the case of schizophrenia is bringing to light the intrinsic limitations of the operational approach (showing that this approach is unable to convey the clinical flavour of such a complex syndrome). In other terms, there may be, beyond the individual phenomena, a 'psychological whole' (Jaspers, 1963) in schizophrenia, that the operational approach fails to grasp, or such a psychological whole may simply be an illusion, that the operational approach unveils. [Maj 1998: 459-60]<o:p></o:p>

In fact, Maj argues that this shows the weakness of the operational approach. He argues that the DSM criteria fail to account for aspects of a proper grasp of schizophrenia: for example, the intuitive ranking of symptoms (which have equal footing in the DSM account). He suggests that there is, nevertheless, no particular danger in the use of DSM criteria by skilled, expert clinicians for whom it serves merely as a reminder of a more complex prior understanding. But there is a problem in its use to encode the diagnosis for those without such an additional underlying understanding:<o:p></o:p>

If the few words composing the DSM-IV definition will probably evoke, in the mind of expert clinicians, the complex picture that they have learnt to recognise along the years, the same cannot be expected for students and residents. [ibid: 460]<o:p></o:p>

Maj's criticism that the DSM criteria do not capture a proper, expert understanding of the diagnosis of schizophrenia raises the question of how or why that could be the case. If the criticism is right, is it that the wrong criteria have been used: either the wrong symptoms and / or the wrong rules of combination? Or is there something more fundamentally wrong with the criteriological approach as applied to psychiatry? <o:p></o:p>

Josef Parnas suggests the latter. In a paper describing pre-operational approaches to taxonomy and diagnosis as a 'disappearing heritage' he comments on an underlying difference in attitude towards signs and symptoms of schizophrenia.<o:p></o:p>

When the pre-DSM-III psychopathologists emphasized this or that feature as being very characteristic of schizophrenia, they did not use the concept of a symptom/sign as it is being used today in the operational approach. This latter approach envisages the symptoms and signs as being (ideally) third person data, namely as reified (thing-like), mutually independent (atomic) entities, devoid of meaning and therefore appropriate for context-independent definitions and unproblematic assessments. It is as if the symptom/sign and its causal substrate were assumed to exhibit the same descriptive nature: both are spatio-temporally delimited objects, ie, things. In this paradigm, the symptoms and signs have no intrinsic sense or meaning. They are almost entirely referring, ie, pointing to the underlying abnormalities of anatomo-physiological substrate. This scheme of 'symptoms = causal referents' is automatically activated in the mind of a physician confronting a medical somatic illness. Yet the psychiatrist, who confronts his 'psychiatric object', finds himself in a situation without analogue in the somatic medicine. The psychiatrist does not confront a leg, an abdomen, not a thing, but a person, ie, broadly speaking, another embodied consciousness. What the patient manifests is not isolated symptoms/ signs with referring functions but rather certain wholes of mutually implicative, interpenetrating experiences, feelings, beliefs, expressions, and actions, all permeated by biographical detail. [Parnas 2011: 1126]<o:p></o:p>

The claim here is that the criteriological approach has the wrong model of psychiatric symptoms and signs in two respects. Just as smoke can indicate fire or tree rings the age of a tree, the criteriological approach takes signs and symptoms to be free standing items which merely causally indicate underlying states. Furthermore, these relations are independent of one another: they are atomic. By contrast, Parnas suggests, psychiatric signs and symptoms are both essentially meaning-laden rather than brutely causal and also mutually interdependent wholes. It is the latter claim, which plays the more important role in his criticism.<o:p></o:p>

One argument for their interdependence is that it is only in particular contexts that symptoms are reliable. Thus, for example, mumbling speech is comparatively widespread (Parnas estimates 5% of the population) but in – and only in – the context of other features such as 'mannerist allure, inappropriate affect, and vagueness of thought, it acquires a psychopathological significance' [ibid: 1126]. So the effectiveness of the sign is context-dependent. In some contexts it is indicative and in others not. Excluded from context – as it is in the criteriological context – it is vague. But it is precise in context. Parnas goes further by suggesting a more than merely additive view. Grasp of psychiatric symptoms is likened to seeing the figure of the duck-rabbit first as a rabbit and then suddenly as a duck: seeing the signs and symptoms under an overall aspect or gestalt.<o:p></o:p>

A Gestalt is a salient unity or organization of phenomenal aspects. This unity emerges from the relations between component features (part-whole relations) but cannot be reduced to their simple aggregate (whole is more than the sum of its parts)... A Gestalt instantiates a certain generality of type (eg, this patient is typical of a category X), but this typicality is always modified, because it is necessarily embodied in a particular, concrete individual, thus deforming the ideal clarity of type (universal and particular). [ibid: 1126]<o:p></o:p>

So the model of diagnosis is one in which the skilled clinician grasps the right diagnosis as an integrated whole in which different aspects can be seen as abstractions from that whole rather than as its basic building blocks. Such a view would accommodate Kraus' rejection of a 'Chinese restaurant menu' approach and Maj's suggestion that criteriological elements serve as reminders for already skilled clinicians. They do – on this view – in the sense that, after the fact, such articulations of the overall picture are possible, as a musical note may be divided into its pitch, tone and duration whilst it cannot be built up from those as independent building blocks. But that does not imply that the expert judgement of the whole could be built up from the individual criteria understood in isolation. <o:p></o:p>

There is a further possibility hinted at in the criticism of Kraus, Maj and Parnas. On a criteriological view symptoms are not merely independent of each other (as Kraus points out) they are conceptually independent of the underlying psychopathological state that they indicate. But in the case of Kraus and Parnas, at least, there is a suggestion that the connection between symptoms (when correctly understood) and psychopathological state is more direct: the state is expressed directly in the signs and symptoms to those, at least, with the skill to see it.<o:p></o:p>

Diagnosis and tacit knowledge<o:p></o:p>

The criticisms of the criteriological approach set out in the preceding section prompt two further questions. The bottom up codification of diagnosis through simpler, more basic signs and symptoms suggests an explanation of how complex diagnostic judgement is possible. It is possible because it is based on simpler more epistemically accessible building blocks. The first question concerns the nature of an overall 'gestalt' judgement if that explanation is rejected. On what is top-down judgement based and what is its relationship to the criteriological approach? In this section, I will suggest an analogy with context-dependent tacit knowledge to try to make the rejection of the above explanation seem a less puzzling possibility [for a more detailed discussion see Thornton 2013]. But it will also help highlight how the move from context-dependent recognition to explicit criteria introduces vagueness into the description of psychiatric symptoms.<o:p></o:p>

Second, if diagnostic judgement is not based on more observational features of a clinical encounter, how can it yield knowledge of underlying mental states? In the final section, I will suggest an analogy with the more general 'problem of other minds' and outline what may initially seem a counter-intuitive view outlined by the philosopher John McDowell which inverts the epistemic priority of judgements about behavioural signs and symptoms and judgements of underlying mental states. Again it will suggest that reliance on basic criteria comes at the cost of introducing vagueness into description of psychiatric symptoms which undermines the potential directness of psychiatric diagnosis as described by Kraus, Maj and Parnas.<o:p></o:p>

I suggested at the start that the development of the theoretically minimal criteriological approach to diagnosis in psychiatry was partly influenced by operationalism in the philosophy of science in the first part of the twentieth century. The aim was to minimise uncodified elements in psychiatric diagnosis so as to maximise reliability. But there was, in the second half of the century, a contrasting view about the nature of scientific knowledge: the chemist turned philosopher Michael Polanyi's arguments for the importance of tacit knowledge. (Polanyi himself talks of tacit knowing rather than knowledge. I will, nevertheless, use 'knowledge' whilst talking about his views but will return to emphasise the practical dimension to what is tacit.) Top-down or gestalt judgement in psychiatry can be thought of as an instance of tacit knowledge. I will use Polanyi to introduce this notion but will deviate from his account shortly.<o:p></o:p>

Polanyi gives the following example:<o:p></o:p>

We know a person's face, and can recognize it among a thousand, indeed among a million. Yet we usually cannot tell how we recognize a face we know. So most of this knowledge cannot be put into words. [Polanyi 1967b: 4]<o:p></o:p>

This is an instance of what he takes to be a general phenomenon. Indeed, he begins his book The Tacit Dimensionwith the following bold claim:<o:p></o:p>

I shall reconsider human knowledge by starting from the fact that we can know more than we can tell. [Polanyi 1967b: 4]<o:p></o:p>

The broad suggestion is that knowledge can be tacit when it is, on some understanding, 'untellable'. 'Tellable' knowledge is a subset of all knowledge and excludes tacit knowledge. But the slogan is gnomic. Does it carry, for example, a sotto voce qualification 'at any one particular time'? Or does it mean: ever? <o:p></o:p>

The very idea of tacit knowledge presents a challenge: it has to be tacit and it has to be knowledge. But it is not easy to meet both conditions. Emphasising the tacit status, threatens the idea that there is something known. Articulating a knowable content, that which is known by the possessor of tacit knowledge, risks making it explicit. There is a second strand through Polanyi's work which helps address this problem. At the start of his book Personal Knowledge in which he says:<o:p></o:p>

I regard knowing as an active comprehension of things known, an action that requires skill. [Polanyi 1958: vii]<o:p></o:p>

These two features suggest a way to understand tacit knowledge: it is not, or perhaps cannot be made, explicit and it is connected to action, the practical knowledge of a skilled agent. The latter connection suggests a way in which tacit knowledge can have a content: as practical knowledge of how to do something. Taking tacit knowledge to be practical suggests one way in which it is untellable. It cannot be made explicit except in context-dependent practical demonstrations. It is not that it is mysteriously ineffable but that it cannot be put into words alone.<o:p></o:p>

Psychiatric diagnostic judgement can be thought of as an example of such a skill: the ability to recognise, in a particular context, the manifestation of psychiatric illness. Polanyi also compares recognition to a practical skill, likening it to bicycle riding:<o:p></o:p>

I may ride a bicycle and say nothing, or pick out my macintosh among twenty others and say nothing. Though I cannot say clearly how I ride a bicycle nor how I recognise my macintosh (for I don't know it clearly), yet this will not prevent me from saying that I know how to ride a bicycle and how to recognise my macintosh. For I know that I know how to do such things, though I know the particulars of what I know only in an instrumental manner and am focally quite ignorant of them. [ibid: 88]<o:p></o:p>

In both cases, the 'knowledge-how' depends on something which is not explicit: the details of the act of bike riding or raincoat recognition. Whilst one can recognise one's own macintosh one is, according to Polanyi, ignorant, in some sense, of how. Thus how one recognises it is tacit. Polanyi suggests here that explicit recognition of something as an instance of a type is based on the implicit recognition of subsidiary properties of which one is focally ignorant. He explains the distinction of focal and subsidiary awareness using the example of focusing attention on what a pointing finger points to. In looking from the finger to the object, the object is the focus of attention whilst the finger, though seen, is not attended to. It is not invisible, however, and could itself become the object of focal attention. <o:p></o:p>

Polanyi seems to assume that the question of how one recognises something always has an informative answer and then to cover cases where it is not obvious what this is he suggests it can be tacit. But, firstly, whilst it sometimes may have an informative answer, there is no reason to think that it always has (cf recognising that a wall is red). Secondly, even in cases where one recognises a particular as an instance of a general kind in virtue of some further properties and cannot give an independent account of those properties, it is not clear that one need be focally ignorant of them. It may be, instead, that the awareness one has of the 'subsidiary' properties is simply manifested in the act of recognition. I might say, I recognise that this is a, or perhaps my, macintosh because of how it looks here with the interplay of sleeve, shoulder and colour even if I could not recognise a separated sleeve, shoulder or paint colour sample as of the same type. Whilst it seems plausible that one might not be able to say in context-independent terms just what it is about the sleeve that distinguishes a or my macintosh from any other kind of raincoat (one may, for example, lack the vocabulary of fashion or tailoring) that need not imply that one is focally ignorant of, or not attending to, just those features that make a difference. Recognition may depend on context-dependent or demonstrative elements, such as recognising shapes or colours for which one has no prior name. But if anything, that suggests one has to be focally aware, not focally ignorant, of them.<o:p></o:p>

Thus Polanyi's own account of the tacit nature of recognition faces objections. But such criticism suggests the possibility of a more minimal account of tacit knowledge. Recognition is tacit because it is a skill – for example, developed through repetition and critical practice and demonstrated in applications – and because it can thus be articulated only in context-dependent terms such as 'like this!'. It cannot be explicated in words alone independently of additional practical demonstrations in context.<o:p></o:p>

If the skilled diagnostic judgement described in the previous section by Kraus, Maj and Parnas is thought of as tacit knowledge as just explicated then it can be contrasted with criteriological diagnosis in the following way. The criteria set out in ICD and DSM are an attempt to make psychiatric diagnosis explicit, to put it into words alone. They attempt to set out context-independent descriptions of psychiatric syndromes. <o:p></o:p>

Such an attempt is akin to attempting to model an ability to recognise colours and shades on general knowledge of the names for colours that ordinary people have. For most people, the ability to recognise, think about and recall (at least for some period) particular shades of colour goes beyond what they can make explicit linguistically. The ability can instead be manifested by pointing to particular instances of colour themselves. By contrast with the fine discriminations that can be made in the presence of actual colours and shades, colour vocabulary is generally vague. <o:p></o:p>

Similarly, by contrast with the context depending discriminations of skilled clinicians made in the presence of their patients and clients, the criteria set out in diagnostic manuals are vague. Because they are fully linguistic, the criteria in DSM and ICD are portable. There is an advantage in communication of a linguistic codification of diagnosis that floats free of particular inter-personal relations. But it is bought at the cost of precision. By contrast, the features that play a role in the top-down diagnoses of skilled clinicians are identified in the presence of a particular patient's or client's psychological whole. Such recognition cannot be captured in words alone.<o:p></o:p>

The analogy suggested in this section has been between clinical judgement made possible by the presence of a patient or client and recognition of a macintosh, either as an instance of a kind or as a particular one, or recognition of a colour or shade in its presence. The analogy suggests that the patient herself is passive and plays no active role. Since clinical judgement depends a great deal on what patients say and do, the general picture of tacit knowledge needs augmenting with a specific account of the recognition of mental states. That is the subject of the next section.<o:p></o:p>

Criteria and other minds<o:p></o:p>

In the previous section, I suggested that tacit knowledge can be used to shed light on the idea that an overall top down or gestalt diagnostic judgement could be more specific than a diagnosis based on general but vague criteria. A skilled clinician has a recognitional skill which can only be exemplified in context-dependent judgements in the presence of patients or clients. That is to approach the problem from an epistemological perspective: what it is to have knowledge in this way. In this section, I will complement that by taking an ontological view. What could the relation be between the underlying mental states and conditions amounting to mental illness or disease syndromes and the more apparently epistemically accessible criteria set out in DSM and ICD? Addressing this question will also address the active role of patients and clients raised just now.<o:p></o:p>

To sketch an answer to this question I will consider a debate from the philosophy of mind about whether our knowledge of other minds in general is based on behavioural criteria. Although the argument against that view that I will outline does not directly carry over to the case of psychiatric diagnosis, it does suggest why criteriological diagnosis is vague compared to top-down or gestalt judgement.<o:p></o:p>

The concept of a criterion was introduced into the philosophy of mind as a solution to the problem of other minds by followers of the philosopher Ludwig Wittgenstein. The influential Wittgenstein exegete PMS Hacker, writing in the Oxford Companion to Philosophy, defines a criterion thus:<o:p></o:p>

A standard by which to judge something; a feature of a thing by which it can be judged to be thus and so. In the writings of the later Wittgenstein it is used as a quasi-technical term. Typically, something counts as a criterion for another thing if it is necessarily good evidence for it. Unlike inductive evidence, criterial support is determined by convention and is partly constitutive of the meaning of the expression for whose application it is a criterion. Unlike entailment, criterial support is characteristically defeasible. Wittgenstein argued that behavioural expressions of the 'inner', e.g. groaning or crying out in pain, are neither inductive evidence for the mental (Cartesianism), nor do they entail the instantiation of the relevant mental term (behaviourism), but are defeasible criteria for its application. [<s>Honderich 1995</s>]<o:p></o:p>

Key features of this definition are that the criteria of, for example, an 'inner' state like pain are fixed by convention and are partly constitutive of what we mean by the word 'pain'. Thus groaning and crying out are not mere symptoms but rather part of what we understand by 'pain', connected by definition not induction. At the same time, however, the criteria of pain are defeasible.<o:p></o:p>

The reason for this qualification is the following intuition. Whilst, in general, pain behaviour is the expression of underlying pain, on occasion behaviour which resembles pain behaviour in every detail is not the expression of pain. It may be the result of acting or pretence. (And equally, genuine underlying pain may sometimes be stoically kept from expression.) As a result, the criterial support that apparent pain behaviour gives for a judgement that someone is in pain is taken to be defeasible. It can, on occasion, be overturned.<o:p></o:p>

The idea that criteria give only defeasible support for a claim is combined with a further assumption which the philosopher John McDowell, in his criticism of this very notion, describes thus: 'if a condition is ever a criterion for a claim, then any condition of that type constitutes a criterion for that claim, or one suitably related to it' [McDowell 1982: 462-3]. In other words, criteria are types. Whilst on most occasions, when instances of some general type of criterion are satisfied the underlying fact for which those instances are criteria also obtains, on some occasions the type of criterion is satisfied (by some particular circumstances) but the fact does not obtain. In such cases, the criterion is satisfied but is nevertheless also defeated.<o:p></o:p>

This suggests that there is an essential underdeterminination in the support that criteria, so understood, provide for judgements about mental states. In any particular case, on this picture, some expression, some sign or symptom of pain for example, may or may not actually mean that the person expressing it is actually in pain. Hence the behavioural expression is vague. Its meaning is imprecise.<o:p></o:p>

This worry provides the basis for McDowell's criticism of the use of criteria, understood in this way, to explain how knowledge of other minds is possible. On the assumption that it is sometimes, at least, possible to know someone else's mental state, McDowell asks how such knowledge is supposed to be based 'on an experiential intake that falls short of the fact known... in the sense [of]... being compatible with there being no such fact' [McDowell 1982: 459].<o:p></o:p>

The worry is this. If one knows something, then it cannot be the case that - 'for all one knows' - things may be otherwise. That possibility is ruled out precisely because one knows what is the case. But if criteria fall short of implying the fact that they are supposed to enable one to know, then they cannot themselves rule out the possibility that the fact does not obtain. So if our everyday concept of knowledge does rule this out then such knowledge cannot be based on perception that the criteria for some mental state are satisfied. A possible alternative view in which the perceived the criteria is supposed merely to be enough to satisfy linguistic conventions for the ascription of knowledge would also not address this objection, either.<o:p></o:p>

If experiencing the satisfaction of 'criteria' does legitimise ('criterially') a claim to know that things are thus and so, it cannot also be legitimate to admit that the position is one in which, for all one knows, things may be otherwise. But the difficulty is to see how the fact that "criteria" are defeasible can be prevented from compelling that admission; in which case we can conclude, by contraposition, that experiencing the satisfaction of 'criteria' cannot legitimize a claim of knowledge. How can appeal to "convention" somehow drive a wedge between accepting that everything that one has is compatible with things not being so, on the one hand, and admitting that one does not know that things are so, on the other? [McDowell 1982: 458]<o:p></o:p>

Imagine that there are two observers who both see that the behavioural criteria, so construed, for two other people being in pain are satisfied but that only one of them really is in pain: the other is pretending. If the observers' experiences are the only grounds for them knowing the mental state of their respective subject and if their perceptions are the same in both cases (seeing that the criteria for pain are met) then how can one observer know their subject's mental state and the other observer not? Surely, neither has knowledgeeven if one has, by chance, a true belief. It seems merely a matter of luck that one observers' experience is of undefeated criteria whilst the other's is of defeated criteria, that in one case the observed subject really is in pain and in the other merely pretending. The luckier observer has done nothing extra to earn the right to knowledge. Construing criteria as defeasible to try to accommodate the fact that we are fallible at knowing other people's minds cannot work because it rules out that we ever have knowledge.<o:p></o:p>

There is, however, an alternative view of criteria and of knowledge of other minds based on them. Rather than assuming that, in the case of pretence, the criteria for mental states are satisfied but are also defeated - by the fact that it is a case of pretence - one can instead construe it as a case of the criteria only appearing to be satisfied. This is a rejection of the idea that criteria are defeasible typesof situation. Instead, McDowell presses the idea that, when criteria are satisfied, one's experience does not fall short of the facts. So there cannot be cases where the criteria are satisfied without the fact for which they give criterial support also holding.<o:p></o:p>

McDowell supports this interpretative possibility by considering a passage in which Wittgenstein discusses criteria in a non-mental context.<o:p></o:p>

The fluctuation in grammar between criteria and symptoms makes it look as if there were nothing at all but symptoms. We say, for example: "Experience teaches that there is rain when the barometer falls, but it also teaches that there is rain when we have certain sensations of wet and cold, or such-and-such visual impressions." In defence of this one says that these sense-impressions can deceive us. But here one fails to reflect that the fact that the false appearance is precisely one of rain is founded on a definition. [Wittgenstein 1953 §354]<o:p></o:p>

Wittgenstein rejects the temptation to say that both the fall of a barometer and also sensations of wet and cold (or visual impressions) are mere symptoms of rain. Instead, and by contrast with the barometer fall, the connection between the sensations (or the visual impressions) and rain is definitional or criterial. They are used in an explanation of what 'rain' means. This thought can, however, be interpreted in two ways.<o:p></o:p>

Commentators often take this to imply that when our senses deceive us, criteria for rain are satisfied, although no rain is falling. But what the passage says is surely just this: for things, say, to look a certain way to us is, as a matter of 'definition' (or 'convention'... ), for it to look to us as though it is raining; it would be a mistake to suppose that the 'sense-impressions' yield the judgement that it is raining merely symptomatically - that arriving at the judgement is mediated by an empirical theory. That is quite compatible with this thought... when our "sense-impressions" deceive us, the fact is not that criteria for rain are satisfied but that they appear to be satisfied. [McDowell 1982:466]<o:p></o:p>

Someone who steps outside their house when the lawn sprinklers are switched on may think that by having experiences of wet and cold they have experienced the criteria for rain, albeit on this occasion defeated. After all, when being taught about rain they may have been taught it through practical definitions involving experiences that felt similar. But the experiences used in the practical definition were not just any experiences of wet and cold but wet and cold experiences of rain falling. Similarly in the case of criteria for mental states, pretence can make it seemthat the criteria for pain, for example, are satisfied when, in fact, they are not.<o:p></o:p>

Taking the criteria to be merely any experience of wet and cold (for rain) or any experience of high pitched cries (for pain) makes them too vague to sustain knowledge. Correcting this requires rethinking the generality and the descriptive nature of criteria. If the criteria for pain are given in general and behavioural terms, they are too vague to underpin knowledge. Such 'criteria' do not only mean pain. So one might think of them as particular though still behavioural. If so, only particular instances of behavioural criteria (particular instances of crying out and rubbing knees etc) are valid guides to underlying pain. Such a suggestion maintains the behavioural character of criteria for mental states but denies their generality. But this threatens the idea that one can learn how to recognise pain. The alternative is to maintain (something of) their generality but deny the restriction to merely behavioural signs and symptoms. On such an account, the criteria for pain do not have in common anything that could be given in mind-free behavioural terms. Rather they share the essentially mind-involving generality of being expressions of pain.<o:p></o:p>

McDowell offers a philosophical diagnosis of why such a view of criteria seems to go unnoticed which goes back to the influence of Cartesian dualism. If one starts from that basic picture then it invites a contrast between the behavioural states of other people to which one can have direct perceptual access, and mental states, which are, in some sense, hidden behind them. According to Descartes, they even exist in different kinds of space (res cogitans and res extensa). Cartesian dualism suggests an alienated picture of human behaviour in which all that anyone else can ever see is bodily movement which is only contingently associated with minds. Because perception of, and judgements about, such 'behaviour' is taken to be unproblematic whilst access to other people's mentalstates is taken to be problematic, a route is needed from one to the other. Thus it seems plausible to think that judgements about mental states have to be grounded in independent judgements about behaviour. The alienated picture of human behaviour survives in approaches to the philosophy of mind which have long since rejected Descartes' conception of the mind as res cogitans (or thinking stuff) existing in a different dimension to matter (res extensa).<o:p></o:p>

This picture of the relation of mind and body is neither obligatory nor natural, however. One can instead think of mind and body as more closely linked. What one says and does expresses what one thinks and feels. Whilst one person's mental states do not themselves fall within the direct experience of another their expression of their mental state does. Such expression is notone that is consistent with the absence of the inner state. So McDowell replaces an account in which all that is visible to an observer is another person's intrinsically brute or meaningless behaviour, standing in need of further interpretation and hypothesis, with one in which that behaviour is charged with expression.<o:p></o:p>

This claim addresses the worry raised at the end of the previous section that an analogy with a tacit recognitional judgement of a macintosh or a shade of colour suggests that patients and clients are passive in the face of a clinical gaze. If the analogy held closely then one person's mental state would have to fall directly within the experience of another just as a colour can. The nuanced view is that this is not so. Patients and clients have to reveal their mental states through speech and action. But, to continue to describe the nuanced view, what they say and do makes their mental lives available to others in a way that requires no inference. This accounts adds to the more general picture of tacit knowledge in the previous section the further idea that recognitional judgement of others' mental states requires that the other people actively express them.<o:p></o:p>

By denying that our 'access' to the minds of others must proceed through a neutrally described behavioural intermediary (their behaviour), McDowell can offer a much less technically charged account of criteria which he summarises thus:<o:p></o:p>

I think we should understand criteria to be, in the first instance, ways of telling how things are, of the sort specified by "On the basis of what he says and does" or "By how things look"; and we should take it that knowledge that a criterion for a claim is actually satisfied - if we allow ourselves to speak in those terms as well - would be an exercise of the very capacity we speak of when we say that one can tell, on the basis of such-and-such criteria, whether things are as the claim would represent them as being. [McDowell 1982: 470-1]<o:p></o:p>

Knowledge of other minds depends on what people say and do. It does not require a kind of direct mind reading. The judgement is based on, emerges from, what they say and do. But the conceptualisation of what they say and do need not be couched in mind-independent neutral terms. As Dowell comments:<o:p></o:p>

This flouts an idea we are prone to find natural, that a basis for a judgement must be something on which we have firmer cognitive purchase than we do on the judgement itself; but although the idea can seem natural, it is an illusion to suppose it is compulsory. [McDowell 1982: 471]<o:p></o:p>

It may be easier to see patterns and generalities in behaviour construed as essentially expressive of minds than in neutrally described bodily movement. So even though judgements about others' minds may be based on their behaviour, the description of the behaviour may be less secure than the description of what it expresses. <o:p></o:p>

I have set out two contrasting accounts of criteria from the philosophical discussion of the problem of other minds to shed light on the more specific issue of mental illness diagnosis. There are, however, two related important differences between the two cases which need mention.<o:p></o:p>

First, the application of the idea of criteria in the more general problem of other minds and in the case of psychiatric diagnosis differ in one clear respect. It is merely a theoretical idea in the former case but set out in practical detail in recent editions of the DSM and ICD in the latter case. Second, and related to this, is an important difference in the dialectical context of criticism of behavioural criteria in the two cases. The argument above assumes that it is possible to have knowledge of other minds. Since the standard model of criteria (as defeasible behavioural types) makes knowledge impossible, it cannot be the basis of our knowledge of other minds. <o:p></o:p>

But one might object that psychiatry does not aspire to knowledge when it comes to diagnosis but some weaker state such as a belief with a particular degree of probability. And hence an argument which shows that knowledge cannot be based on criteria, so understood, need not undermine that project. Such an objection carries risk, however. Since psychiatry is a practical discipline, diagnoses form the basis for action (concerning treatment and management). Thus clinicians need more than merely having beliefs with a particular (suitably high) probability of being true, they need to know that they do.<o:p></o:p>

Nevertheless, even if psychiatric diagnosis need not aspire to knowledge itself but merely to some known probability of being correct, it could be based on criteria understood as behavioural types (ie the target of the criticism of this section). Providing that there are other methods of arriving at diagnoses, such as the considered judgement of skilled clinicians or longitudinal studies, it would be possible to make an assessment of the sensitivity and specificity – in probabilistic terms – of types of behavioural criteria. The dialectical context differs for defenders of defeasible criteria for knowledge of other minds because they assume that there is no more fundamental way of having such knowledge and hence no independent test of the construct validity of the criteria.<o:p></o:p>

Despite these differences, McDowell's discussion of the two accounts of criteria and the role, in the account he defends, of the idea that behaviour can be more than mere behaviour but rather expressive mental states sheds light on the possibility, at least, of the relative vagueness of criteriological diagnosis compared to the specificity of gestalt judgement. Both the DSM and ICD stress operationalised descriptions as opposed to more essentially psychiatric descriptions couched in aetiological terms. They do this in an attempt to provide secure foundations for diagnosis. But that very strategy makes the criteria mere approximations of the underlying psychopathological states they aim to capture. As Kraus, Maj and Parnas suggest, precision requires thinking of psychiatric symptoms as abstractions from a diagnostic whole rather than built up from neutral – or more neutral – criteria whose obtaining does not strictly imply the presence of the psychiatric syndrome for which they are supposed to be signs.<o:p></o:p>

An alternative view of diagnostic criteria, drawing on McDowell's account and influenced by the empirical claims of Kraus, Maj and Parnas would stress the specific schizophrenic colouring of particular delusions, for example. It may seem that this carries the risk that identifying that a patient or client is experiencing such a delusion is riskier than the vaguer claim that they are experiencing some sort of delusion or other. But this may not be so in context. In particular cases, the justification for thinking that the delusion carries a specific schizophrenic colouring may be what warrants the more general claim that they are thus experiencing some more general category of delusion.<o:p></o:p>

This view also helps address a suggestion in Kraus' and Parnas' description mentioned earlier: that the connection between symptoms and psychopathological state is more direct than a mere evidential or causally indicating relation. The state is expressed directly in signs and symptoms to those, at least, with the skill to see it. On the view developed above, skilled clinicians do not merely infer the diagnostic state of their patients and clients from signs and symptoms that are independent of or distinct from them. Rather, they see (or hear) in what their patients say and do the expression of a diagnostic condition. <o:p></o:p>

It is natural to object to such a view (as the editors of this book did) that clinicians are fallible beings, too and so the shortcoming of the criteriological approach cannot be that criteria do not strictly imply the presence of what they are criteria for. But on the view sketched, this objection presupposes the wrong account of the fallibility of such judgements. If criteria for mental illnesses were both general and defeasible, that would explain how knowledge claims could fail but it would also fail to explain how knowledge is ever possible. On the alternative view sketched above, when all goes well a skilled clinician is able to respond to the expressions of, say, schizophrenia which do indeed necessitate that the patient has schizophrenia. Fallibilism is explained by the fact that some apparent criteria for schizophrenia are not in fact such criteria. But it is a mistake to assume that the best that even a skilled clinician can rely on is a description of the signs and symptoms that merely indicates that it is likely that someone has that syndrome. Skilled judgement is more precise than the vague descriptions of symptoms found in the DSM.<o:p></o:p>

Conclusions<o:p></o:p>

I have considered the charge made against criteriological models of diagnosis that, compared with the gestalt judgement of a skilled clinician, criteriological descriptions of symptoms are essentially vague. I have argued that two independently plausible considerations help explain how this could be so. Epistemologically, diagnosis based on gestalt judgement could be akin to the kind of context-dependent practical skill that underpins one model of tacit knowledge. Such skill resists codification in general context-independent terms akin to the DSM and ICD's diagnostic criteria but is nevertheless a form of conceptually structured knowledge. Ontologically, the diagnostic criteria of the DSM and ICD may be merely more or less behavioural abstractions from underlying psychological reality. Skilled clinicians need not rely on neutral criteria but on the direct expression of complex psychological wholes.<o:p></o:p>

Acknowledgement<o:p></o:p>

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.<o:p></o:p>

References<o:p></o:p>

Bayer, R. and Spitzer, R.L. (1985) 'Neurosis, psychodynamics and DSM-III' Archives of General Psychiatry42: 187-96<o:p></o:p>

Bridgman, P.W. (1927) The Logic of Modern Physics, New York: Macmillan<o:p></o:p>

Fulford, K.W.M., Thornton, T. and Graham, G. (2006) The Oxford Textbook of Philosophy and PsychiatryOxford: Oxford University Press <o:p></o:p>

Hacker, P.M.S. (1995) 'Criterion' in Honderich, T. (ed) Oxford companion to philosophy, Oxford: Oxford University Press: 171<o:p></o:p>

Hempel, C.G. (1994) 'Fundamentals of taxonomy' in Sadler, J.S. Wiggins, O.P. and Schwartz, M.A. (eds) Philosophical Perspectives on Psychiatric Diagnostic Classification, Baltimore: Johns Hopkins: 315-331<o:p></o:p>

Kraus, A. (1994) 'Phenomenological and criteriological diagnosis: different or complementary?' In Philosophical Perspectives on Psychiatric Diagnostic Classification (ed. J.S. Sadler, O.P.Wiggins, and M.A. Schwartz) Baltimore, MD: Johns Hopkins University Press, pp. 148–162.<o:p></o:p>

McDowell, J. (1982) 'Criteria, defeasibility and knowledge' Proceedings of the British Academy 68: 455-79<o:p></o:p>

Maj, M. (1998) 'Critique of the DSM-IV operational diagnostic criteria for schizophrenia' The British Journal of Psychiatry 172: 458-460<o:p></o:p>

Parnas, J. (2011) 'A Disappearing Heritage: The Clinical Core of Schizophrenia' Schizophrenia Bulletin37: 1121–1130<o:p></o:p>

Polanyi, M. (1962) Personal Knowledge, Chicago: University of Chicago Press<o:p></o:p>

Polanyi, M. (1967a) 'Sense-giving and sense-reading' Philosophy 42: 301-325<o:p></o:p>

Polanyi, M. (1967b) The Tacit Dimension, Chicago: University of Chicago Press<o:p></o:p>

Ryle, G. (1949) The Concept of Mind, London: Hutchinson.<o:p></o:p>

Ryle, G. (1945) 'Knowing How and Knowing That' Proceedings of the Aristotelian Society, 46: 1-16<o:p></o:p>

Shorter, E. (1997) A History of Psychiatry, New York: John Wiley and Sons <o:p></o:p>

Thornton, T. (2013) 'Clinical judgement and tacit knowledge' for Fulford, KWM (Bill) et al (ed) Oxford Handbook of Philosophy and Psychiatry, Oxford: Oxford University Press <o:p></o:p>
Wittgenstein, L. (1953) Philosophical Investigations, Oxford: Blackwell.

<o:p></o:p>
Tim Thorntonhttp://email@example.com:blogger.com,1999:blog-6658432996374251907.post-52018374962851483432015-07-10T13:42:00.000+01:002015-07-16T16:44:27.689+01:00Recovery, paternalism and narrative understanding in mental healthcare

I have cheated and replaced the first version with a second version a week later.

Recovery, paternalism and narrative understanding in mental healthcare<o:p></o:p>

Abstract<o:p></o:p>

There has been a growing emphasis on the idea that recovery in mental healthcare should not be seen as a matter of getting better but instead of successfully living a flourishing life as conceived by the subject herself. Theorists of recovery also stress the importance of narrative understanding for articulating the sort of life that would count as recovery. But surely one of the threats of mental illness is that it can undermine a subject's autonomy and hence capacity to author a suitable narrative for recovery? Addressing this worry raises the threat of paternalism. Having sketched an abstract model of recovery and compared it to the capabilities model of Sen and Nussbaum, this chapter outlines a minimal account of narrative understanding drawn from Peter Goldie's book The Mess Inside can address the worry of paternalism.<o:p></o:p>

Introduction: Recovery as the goal of mental healthcare.<o:p></o:p>

In this first section, I introduce recovery as the goal of mental healthcare and sketch an abstract model for it. Recovery aims at a value-laden and person specific conception of flourishing. In the second section, I show how the capabilities approach of Amartya Sen and Martha Nussbaum fits this abstract model but that the difference between Nussbaum's and Sen's versions reflects a corresponding difference between substantive and procedural accounts of personal autonomy. This difference is also present in Davidson and Hopper's more specific claims about the possibilities for recovery from mental illness and leads to a challenge to the recovery model. If mental illness can compromise autonomy and calls for sensitive clinical intervention to recover it, does this not risk the paternalist imposition of others' values? In the final two sections I argue that a narrative view of a sense of self can address this on either opposed broad view of recovery and autonomy.<o:p></o:p>

Recovery has come to be promoted as a novel and desirable target for mental healthcare. It has become a proud boast that mental healthcare is recovery orientated. Nevertheless, whilst there is agreement that in this context, it does not mean merely getting better or returning to a previous state of health, there remains disagreement as to what recovery is. <o:p></o:p>

There is an increasing global commitment to recovery as theexpectation for people with mental illness. There remains, however, little consensus on what recovery means in relation to mental illness. [Davidson and Roe 2007: 450]<o:p></o:p>

The term 'recovery' appears to have a simple and self-evident meaning, but within the recovery literature it has been variously used to mean an approach, a model, a philosophy, a paradigm, a movement, a vision and, sceptically, a myth. [Roberts and Wolfson 2004: 38]<o:p></o:p>

In the UK, a policy paper published by the Sainsbury Centre for Mental Health, titled 'Making recovery a reality', begins by summarising some key points of emphasis which, it is suggested, characterise any broadly conceived recovery-based approach. These points include:<o:p></o:p>

Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems.
Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness.
Hope is central to recovery and can be enhanced by each person seeing how they can have more active control over their lives ('agency') and by seeing how others have found a way forward.
Self-management is encouraged and facilitated. The processes of self-management are similar, but what works may be very different for each individual. No 'one size fits all'.
The helping relationship between clinicians and patients moves away from being expert / patient to being 'coaches' or 'partners' on a journey of discovery. Clinicians are there to be "on tap, not on top".
People do not recover in isolation. Recovery is closely associated with social inclusion and being able to take on meaningful and satisfying social roles within local communities, rather than in segregated services.
Recovery is about discovering – or re-discovering – a sense of personal identity, separate from illness or disability. [Shepherd, Boardman and Slade 2008: 0]<o:p></o:p>

The Scottish Recovery Network summarises its views of recovery in similar terms:<o:p></o:p>

Recovery is about living a satisfying and fulfilling life.
Recovery is about more than the absence of the symptoms of illness. Some people describe themselves as being in recovery whilst still experiencing symptoms.
There can be lots of ups and downs during the recovery process – some people describe it as a journey.
For this reason people often talk about being in recovery rather than recovered.
Some people consider recovery as being 'back to the way things were' or back to 'normal' but for others recovery is more about discovering a new life or a new way of being. [Brown and Kandirikirira 2007: 3]<o:p></o:p>

These lists provide a starting point for setting out a theoretical model of recovery. But there is a further structural constraint. To articulate a recovery model which is distinct from or contrasts with, for example, a bio-medical model of mental healthcare, it is not enough to say that recovery (construed in some broad way) is a desirable aim of mental health care. One could hold that whilst holding a broadly bio-medical view of health and illness: for example, as pertaining to biological function versus dysfunction. To count as a distinct model of healthcare, it must offer more than just a broad aim but rather a theoretical conception of what illness, or health, or something like health is. (In the UK, the rise of the recovery movement coincided with both greater optimism within biological psychiatry of the efficacy of medicines but also the kind of theoretical articulation of a novel view of recovery with which I am here concerned. Both elements played a role, complicating the historical story.)<o:p></o:p>

The characterisations of recovery above suggest the importance of two distinctions. First, there is a distinction of focus between pathology and whatever is its relevant contrast, perhaps health. Second, there is the distinction between what is evaluative or normative and what is merely plainly factual. Together these can be used to sketch a distinct although abstract conception of recovery. I will take each in turn.<o:p></o:p>

The philosophy of psychiatry, and more generally the philosophy of medicine, has tended to focus on the illness end of a spectrum between health and illness. The key concern has been with the notion of illness (or disease or disorder). One reason for that has been the origin of the debate, at least within the philosophy of psychiatry, in the response to Thomas Szasz' argument that mental illness is a myth [Szasz 1972]. Szasz' claim that mental illness is an oxymoron prompted responses by biologically minded psychiatrists and researchers who attempted to devise models of illness (or disease or disorder) which accommodated not only physical but also mental illness [Kendell 1975, Boorse 1975]. That in turn has led to an ongoing debate focusing squarely on ill health [Fulford 1989, Pickering 2006, Wakefield 1999]. There was no equivalent Szaszian argument for the mythic status of mental health and hence no incentive for a philosophical defence of that notion.<o:p></o:p>

Against a background focus on the nature of illness, recovery can seem to be simply a return from, or a removal of, that status. Whatever illness or disease is, recovery is its negation. By contrast, concentration first on the health end of the spectrum is at the heart of the recovery approach. This accords with the claim quoted from the document 'Making recovery a reality' above that 'Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness'. A recovery model has to do more than just take the aim of healthcare to be the removal of illness.<o:p></o:p>

The second distinction is between views of mental illness in particular, or illness more generally, as necessarily evaluative or merely descriptive. Does the analysis of mental illness contain reference to values or not? Some philosophers and psychiatrists argue that at the heart of the idea of illness is something that is either bad or wrong for a sufferer or is a deviation from a social or moral norm. Both of these are evaluative or normative notions and hence both are views of illness as value-laden. <o:p></o:p>

Others argue that illness is a plainly factual matter. Typically, they argue that illness involves a failure of a biological function and that function – and hence deviation from, or failure of, function – is a plainly factual, biological (and/or psychological) term couched in evolutionary theory. <o:p></o:p>

Having sketched the two distinctions, I suggest that a clue to articulating a recovery model which genuinely contrasts with a medical model is to locate it on the health-focused rather than pathology-focused side of the first distinction and on the values-laden or normative side of the second. <o:p></o:p>

That remains just a clue: more conceptual work has to be done. But it might be objected that the first of these two distinctions is unnecessary; we can articulate a genuine contrast to a bio-medical model simply by using the second distinction.<o:p></o:p>

The idea is that a bio-medical model construes mental illness as value-free, as reducible to plain facts about biological (and/or psychological) function. Adopting the opposite view – that illness is a necessarily evaluative notion – stands in genuine contrast. And a conception of recovery in relation to illness, so construed, might be enough to count as a recovery model because of that genuine, substantive contrast.<o:p></o:p>

Whilst such a position is a genuine contrast to a plausible candidate for a bio-medical model of illness, it does not seem to capture an important element of the recovery approach: a particular goal or aim of therapy which is not defined merely as the absence of illness. It is instead captured in specific terms such as a hope, autonomy and social inclusion.<o:p></o:p>

One specific problem is that even if one thinks of illness as a necessarily evaluative notion, this is not a sufficient reason to think that health is. It might be the mere absence of an evaluatively identified illness state. Health might be conceptualized in merely statistically normal (rather than normative or evaluative) terms, perhaps as the state of most people, or, alternatively, the state one was previously in. If so, whilst the states that individuals have an interest in recovering from are those with particular normative or evaluative properties (whatever those are), recovery itself might be characterized in non-normative non-evaluative terms. And that does not seem to fit the way the recovery approach is characterized by its supporters.<o:p></o:p>

What of the other distinction? Could a recovery model be defined simply as one which focuses on a positive conception of health, or something like it, rather than merely the absence of pathology, however construed? Again, no. As the authors of 'Making recovery a reality' make plain, they have a very particular conception of the aim of recovery tied to a conception of hoped for and autonomous life connected to social inclusion. That specific content is not captured merely by a focus on health which, as I have just argued, might be thought of in statistical normal terms.<o:p></o:p>

To capture what is characteristic of a recovery approach in order to frame a recovery model, it seems that both aspects are needed: a) a focus on a conception of health, or something like it, and b) in normative or evaluative terms. A recovery model is thus one which construes the positive aim of mental healthcare to be a state of health or something like it, necessarily characterised in normative or evaluative terms.<o:p></o:p>

The capabilities approach to recovery<o:p></o:p>

The model sketched above abstracts from typical comments made about the nature of recovery in mental healthcare in practical policy documents. The idea that recovery aims at a value-laden conception of a flourishing life, which is tailored to the individual concerned, fits such documents. But that is not to say that that is the most that might be offered by way of theoretical articulation of recovery. More can, and has been, said which is, nevertheless, consistent with the abstract model just sketched. In this section, I will outline an influential theoretical framework for thinking about recovery: the capabilities approach. I will use this to extract a potential tension in thinking about the value-ladenness and person-centeredness of recovery and thus flag the role, in the next section for narrative.<o:p></o:p>

The capabilities approach to recovery in mental healthcare is based on Amartya Sen's model for welfare economics developed in the 1980s. Rather than focusing on the fair distribution of resources or primary goods, Sen proposes that the focus of welfare economics should be on a fair distribution of the capacity to lead a flourishing life. In this context, capability is a measure of the ability to do the things and to be the ways that amount to a flourishing form of life. Sen uses the word 'functionings' for this latter idea.<o:p></o:p>

The expression ['capability'] was picked to represent the alternative combinations of things a person is able to do or be-the various 'functionings' he or she can achieve. The capability approach to a person's advantage is concerned with evaluating it in terms of his or her actual ability to achieve various valuable functionings as a part of living… Functionings represent parts of the state of a person-in particular the various things that he or she manages to do or be in leading a life. The capability of a person reflects the alternative combinations of functionings the person can achieve, and from which he or she can choose one collection… Some functionings are very elementary, such as being adequately nourished, being in good health, etc., and these may be strongly valued by all, for obvious reasons. Others may be more complex, but still widely valued, such as achieving self-respect or being socially integrated. Individuals may, however, differ a good deal from each other in the weights they attach to these different functionings-valuable though they may all be-and the assessment of individual and social advantages must be alive to these variations. [Sen 1993 :31]<o:p></o:p>

Applied to welfare economics, the approach takes account of the fact that people can differ in the resources they need to achieve valuable ways of being and acting. Hence it delivers different results from simply advocating equal distributions of resources or primary goods.<o:p></o:p>

In characterising capability, Sen stresses the role of freedom. The freedom to live different kinds of life is reflected in a person's set of capabilities. Freedom itself adds value to a life. Even the existence of possibilities not adopted or embraced add, via a sense of freedom, to the value of a life. But the relevant sense of freedom does not range over just any possible life. Having the option to live kinds of life that an individual would never consider is not freedom in Sen's sense. Genuine freedom has to be assessed relative to what a subject values. Further, what is valued changes what counts as 'functioning'. Fasting and starving both involve the deprivation of food but because the former is chosen it counts as functioning. <o:p></o:p>

This sensitivity of what counts as capability fits the value-ladenness and person-centredness of the abstract model of recovery outlined in the previous section of this chapter. It also fits the focus not on pathology but on health or flourishing. The aim of recovery, on such an understanding, is to maximise the capability of a person to achieve various valuable functionings as a part of their life. It thus connects the abstract requirements on a recovery model to some pre-existing philosophical and economic thinking. But this connection also highlights a tension in, or challenge for, the recovery model which, in the next two sections, will be connected to the role of narrative.<o:p></o:p>

Despite the importance of freedom there is an important tension in thinking about capability because of a second influence on its initial articulation: the Aristotelian philosopher Martha Nussbaum. Nussbaum draws on Aristotle's account of flourishing to argue that there is a list of basic human functions that applies to all human beings [Nussbaum 1988: 176]. Not just anything could count as human functioning. Thus drawing on Aristotle, Nussbaum argues for universal standards for assessing human capability. This contrasts with Sen's liberal or relativist view that with freedom comes proper diversity of choice. This forms the basis in the The Tanner Lectures on Human Values of one of his criticisms of traditional welfare economics based on the fair distribution of resources or primary goods [Sen 1980].<o:p></o:p>

In the co-authored introduction to a collection of papers on the capabilities approach, Nussbaum and Sen jointly set out the difficulties that apply to the choice between pressing a universal or a culturally relative view of human capabilities. It is worth quoting this passage at length.<o:p></o:p>

Should we, for example, look to the local traditions of the country or region with which we are concerned, asking what these traditions have regarded as most essential to thriving, or should we, instead, seek some more universal account of good human living, assessing the various local traditions against it? This question needs to be approached with considerable sensitivity, and there appear to be serious problems whichever route we take. If we stick to local traditions, this seems to have the advantage of giving us something definite to point to and a clear way of knowing what we want to know... It seems, as well, to promise the advantage of respect for difference: instead of telling people in distant parts of the world what they ought to do and to be, the choice is left to them. On the other hand, most traditions contain elements of injustice and oppression, often deeply rooted; and it is frequently hard to find a basis for criticism of these inequities without thinking about human functioning in a more critical and universal way…The search for a universally applicable account of the quality of human life has, on its side, the promise of a greater power to stand up for the lives of those whom tradition has oppressed or marginalized. But it faces the epistemological difficulty of grounding such an account in an adequate way, saying where the norms come from and how they can be known to be the best. It faces, too, the ethical danger of paternalism, for it is obvious that all too often such accounts have been insensitive to much that is of worth and value in the lives of people in other parts of the world and have served as an excuse for not looking very deeply into these lives. [Nussbaum and Sen 1993: 4]<o:p></o:p>

Uncritical relativism versus paternalism is an apparent rather than actual dilemma, however. Each is the criticism that someone taking the corresponding opposed view might make. Universalists fear uncritical relativism but are in turn accused of paternalism by their opponents who emphasise diversity. To see this it is worth flagging corresponding opposed views of autonomy since paternalism is the trumping of another's autonomy.<o:p></o:p>

The idea that universal standards of human flourishing necessarily threatens paternalism presupposes that autonomy really is autonomous of external standards. One such view is proceduralism equates base autonomy with the capacity of a subject to reflect on and endorse, at a second order level, their first order actions and values [eg Frankfurt 1971]. But it remains neutral as to what those first order actions and values are. Substantive approaches, by contrast, argue that the notion of autonomy involves an ability to be guided by the good and the true. And hence a specification of what it is to be autonomous cannot avoid substantive claims about human flourishing [eg Wolf 1990]. <o:p></o:p>

Clearly if the very idea of autonomy presupposes tracking some universal standards, then the mere existence of such standards cannot threaten the ethical danger of paternalism, the unwarranted undermining of autonomy. If, on the other hand, one thinks that autonomy is merely a matter of reflective coherence, then the absence of universal standards is not a threat of uncritical relativism, it is just that criticism is a matter of local coherence.<o:p></o:p>

This opposition within accounts of autonomy and versions of a capabilities approach to welfare economics also has an echo in its application to the recovery model in mental healthcare. In their paper 'A Capabilities Approach to Mental Health Transformation: A Conceptual Framework for the Recovery Era', Larry Davidson and colleagues follow Sen in stressing the connection between a capabilities approach to recovery and the proper diversity of choices that will be made:<o:p></o:p>

It is in the very nature of choice to result in variability, otherwise choice would not really be free but would refer only to changes in the quantity of some basic universal. While smoked salmon and french fries are, in fact, both foods, to say that a person who prefers smoked salmon to french fries has no real preference because they are both foods is to miss the point of having preferences to begin with. It is to gloss over the issue of choice, but this is precisely where our primary interest lies. Without choice there is no freedom, and therefore no justice; with choice there inevitably will be differences and diversity. [Davidson et al 2009: 42]<o:p></o:p>

The view could be described as 'liberal' or 'procedural'. It stresses the role of freedom and the proper diversity of responses to its exercise. By contrast, Kim Hopper argues in his paper 'Rethinking social recovery in schizophrenia: what a capabilities approach might offer' that:<o:p></o:p>

Any application of capabilities must therefore first define/defend a (full or partial) list of valued functionings... [Hopper 2007: 876]<o:p></o:p>

Hopper follows Nussbaum following Aristotle in assuming some objective and universally applicable limits to the proper exercise of choice and freedom. An objective and substantive list of valued functionings would be an objective standard independent of individual choices and that might, in principle at least serves as standards of correctness for them. That is, it makes sense on Hopper's view to think that someone might be in error about the nature of their own flourishing. They might be able to follow the correct procedures of second order reflection on first order values but be in error about objective values at both levels. That possibility is ruled out on a liberal or procedural view.<o:p></o:p>

A similar contrast is also evident concerning the authenticity of choice. Davidson et al claim that mental illness does not affect the status as an agent of individuals.<o:p></o:p>

There can be no recovery without self-determination… Mental illness may pose an obstacle to the person's achievement of the kind of life he or she wishes to have, may make it more difficult to live that life, and, at its most extreme, may even deprive the person of life altogether. In none of these cases, though, does mental illness fundamentally alter the basic nature of human beings, which is that of being self-determined agents, free to choose and pursue the kind of life they as individuals value. Mental illness does not rob people of their agency, nor does it deprive them of their fundamental civil rights. [Davidson 2009: 4-1 italics added]<o:p></o:p>

By contrast Hopper warns that the choices made people with mental illnesses may lack authenticity. Their choices may be affected or distorted as a consequence of illness itself or their treatment as a result of that illness.<o:p></o:p>

Deprivation and disgrace can so corrode one's self worth that aspiration can be distorted, initiative undercut and preferences deformed. Sensitive work will be needed to recover that suppressed sense of injustice and reclaim lost possibility. [Hopper 2007: 877]<o:p></o:p>

Whichever view one takes of the local and diverse or universal view of capabilities and the corresponding opposition between procedural versus substantive view of autonomy, Hopper's point is surely empirically correct. The stigma of carrying a mental illness diagnosis is often reported to be as disabling as the mental itself [Corrigan and Watson 2002]. That raises the possibility of an indirect connection – mediated by medical and broader societal treatment – between illness and aspiration. But there are also direct connections. In his study of the phenomenology of depression, Matthew Ratcliffe reports that in severe depression not only is motivation undermined but awareness of the very possibilities for action diminish. Objects are no longer imbued with the possibilities for action. So it is not just that there are possible actions which the sufferer feels incapable of taking up. Rather, the sense of such possibilities also vanishes. In extreme cases, this undermines an understanding of other people's purposive actions.<o:p></o:p>

[M]ore profound losses involve an inability to comprehend the possibility of anything being practically significant for anyone:
But in among the bad and worse times, there were also moments when I felt, if not hope, then at least the glimmerings of possibility… It was like starting from the beginning. It took me a long time, for example, to understand, or to re-understand, why people do things. Why, in fact, they do anything at all. What is it that occupies their time? What is the point of doing? During my long morning walks, I watched people hurrying along in suits and trainers. Where was it they were going, and why were they in such haste? I simply couldn't imagine feeling such urgency. I watched others throwing a ball for a dog, picking it up, and throwing it again. Why? Where was the sense in such pointless repetition? [Brampton, 2008, p.249]
This description of the 'return of possibility' serves to make salient what was previously diminished or lost: a sense of what it is for someone to act purposively, to find things significant and respond to them accordingly. Activities such as playing with a ball or hurrying to a destination had become strange, unfamiliar, bereft of meaning. The depressed person therefore experiences her situation as something she cannot act upon. [Ratcliffe 2015: 167]<o:p></o:p>

The examples Ratcliffe describes suggest that Davidson et al are wrong to deny that mental illnesses can rob people of their agency. Such a connection to agency seems, to the contrary, to be a key element in the way that mental illnesses cause harm. This may not be so obvious in in schizophrenia, for example, but it is still plausible to think that delusions disrupt the formation of intentions for action [Fulford 1989]. Perhaps the reason Davidson makes that claim is a confusion with, or assimilation to, the claim that follows: 'nor does it deprive them of their fundamental civil rights'. This claim might express the following warning. One should not assume that just because someone has a mental illness that they therefore forfeit fundamental civil rights premised on the idea of being an autonomous human agents. But even this claim has to accommodate the complication of legal detention and compulsory treatment under mental health legislation. Such a widely held legal principle suggests that mental illness can, in a limited and nuanced way, even alter fundamental civic rights.<o:p></o:p>

Hopper's comment that reclaiming a lost sense of possibility will require 'sensitive work' suggests, however, the danger that Nussbaum and Sen flag concerning an objective view of human flourishing: the danger of paternalism. If the central aim of the recovery model is to articulate a conception of a life worth living which fits the values of the person concerned, but if mental illness can corrode their sense of possibility and undermine their agency, how can the right endpoint for healthcare for them be selected without external imposition? Although highlighted within conceptions of recovery drawn from a capabilities approach, this general problem seems also to affect the more abstract account of recovery developed in the previous section. If recovery is aimed at a conception of flourishing articulated by the mentally ill patient or client him or herself, and if mental illness can affect his or her ability authentically to choose, what should guide the right conception of recovery?<o:p></o:p>

In the final two sections of this chapter, I will suggest a role for narrative in addressing this problem. In the next section I will highlight the connection between recovery and narrative and draw on one particular view of narrative for a narrative sense of self. In the final section I will argue that this helps address the risk of paternalism whichever view of capabilities and whichever view of autonomy is adopted.<o:p></o:p>

The link to narrative<o:p></o:p>

To begin the section, I will first motivate the idea that narrative is a helpful place to address the tension between two different versions of the capabilities-based approach to recovery. There have been a number of claims that there is a close direct connection between recovery and narrative understanding. One indication of this is the proliferation of 'recovery stories' as part of the promotion of the recovery approach. These explore:<o:p></o:p>

the personal and existential dimensions of recovery, taking the form of subjective and self-evaluated accounts of how an individual has learned to accommodate to an illness. These accounts have become the founding stories of the recovery movement [e.g. Chamberlin, 1978; Lovejoy, 1984; Deegan, 1988, 1996; Leete, 1989; Unzicker, 1989; Clay, 1994; Coleman, 1999; Ridgeway, 2000], and anthologies of these personal stories have been used by governments and professions as a means of combating stigma and reasserting a focus on personal perspectives [Leibrich, 1999; Lapsley et al, 2002; Ramsay et al, 2002]. [Roberts and Wolfson 2004: 38-9]<o:p></o:p>

More generally it is claimed that people who have suffered mental illness can be helped towards recovery through a narrative based theory. Pat Bracken and Phil Thomas, for example, cite both Larry Davidson and Glen Roberts.<o:p></o:p>

In their work on recovery, both Davidson and Roberts choose not to use an approach grounded in traditional descriptive psychopathology, but turn instead to narrative theory and methods, seeing this as providing a rigorous empirical and clinical methodology in helping people suffering from chronic psychosis to move to recovery. [Bracken and Thomas 2009: 245]<o:p></o:p>

On Bracken and Thomas' view, clinical work is informed by narrative theory which is distinct from traditional Jasperian descriptive psychopathology. Roberts himself makes the connection between recovery and narrative even closer (or at least even more explicit). By contrast with Bracken and Thomas, he sees a narrative view as consistent with Jaspers' view of understanding (by contrast with explanation).<o:p></o:p>

A narrative view values content, and in seeking to understand delusions and hallucinations, as opposed to explaining them [Jaspers 1974], one is engaged in re-contextualising the illness in the life experience of the individual. This in turn may inform the rehabilitation process and give insight into the complexities of recovery, which for some will include the loss of the compensations of delusional beliefs and re-engagement with the implications of having a severe mental illness and what preceded it [Roberts 1999]. [Roberts 2000: 436]<o:p></o:p>

But he goes on to suggest (or at least to make explicit the idea) that subjects or patients – rather than only clinicians – possess a narrative understanding and it is this which can help or hinder them in recovery.<o:p></o:p>

Patients with self-sufficient, unelaborated, dismissive narratives need to be encouraged to break open their defensive stories and consider other possibilities. Conversely, those who seem unable to find a narrative thread and to be drowning in the chaos of their experience need help to find a shape and pattern that enables them to fit things into place [Holmes, 1999]. In therapy, patients learn to build up their storytelling capacity, their "autobiographical competence" [Holmes, 1993]. [Roberts 2000: 436]<o:p></o:p>

Across the literature there is evidence of an idea that narratives structure subjects' lives in such a way that partially determines what seems possible to them. Therapists can propose new life 'plots' and help map out new possibilities in the face of mental illness and hence new possibilities for recovery. To take a non-mental health example, therapists can propose new plotlines to spinal cord injured patients for whom there is, sadly, no going back to their past able-bodied plots. They have suffered a kind of 'narrative wreckage' from which they need rescuing in a dialogue with therapists [Frank 1997: 53-56].<o:p></o:p>

Whilst that direct connection between narrative understanding and recovery is potentially an important clinical one, it is not a necessary connection. Exploring the options for a flourishing life through the idea of stories may in itself be directly therapeutic for many people, but it is possible that such an approach might fail because, for example, it may remind people of what they cannot do anymore. <o:p></o:p>

What is the conceptual or logical connection between a recovery model and narrative understanding? Narrative theorists who apply the idea of narrative to social phenomena face a strategic choice. Either, they offer a specific detailed account of narrative in which case it narrows the range of application of narrative theory since few social phenomena will fit all the characteristics of narrative so defined. Or, they stress the universal application of narrative theory and hence are forced to offer a more general, thinner characterisation of narrative.<o:p></o:p>

In the former approach, they may, for example, divide narratives into: abstract, orientation, complicating action, evaluation, resolution and coda [Labov and Waletsky, 1967]. Or, alternatively: temporality, people, action, certainty (or not) and context [Clandinin and Connelly 2000]. In practice there is a great deal of overlap between the accounts. Nevertheless, there is no obvious necessary connection between a recovery model and narrative understood in this detailed concrete way. Whilst narratives may often have the elements narrative theorists favour, and whilst this may contingently be true of the kind of 'recovery stories' often published in support of the recovery approach, there is no need to link the very idea of recovery in mental healthcare to the provision of a narrative with all of the parts of a favoured detailed theory of narrative.<o:p></o:p>

But if not, what is the role of narrative understanding and recovery? A more plausible approach to answer this question is to take a more modest view of the necessary and sufficient elements of narrative understanding. The philosopher Peter Goldie articulates just such a minimal account in his last book The Mess Inside [Goldie 2012]. His account of narrative starts with the general claim that:<o:p></o:p>

A narrative is a representation of events which is shaped, organized, and coloured, presenting those events, and the people involved in them, from a certain perspective or perspectives, and thereby giving narrative structure – coherence, meaningfulness, and evaluative and emotional import – to what is narrated. [Goldie 2012: 8]<o:p></o:p>

This definition emphasises that a narrative is a representation. It is constructed from the perspective of a narrator even when the narrative is not actually written or told and is merely an exercise of thought by a subject. Thus the narrative is fundamentally distinct from what it represents: the events or, for example, the life of a subject being narrated. The three characteristics of the structure of the narrative thus pertain to the narrative and not to what is narrated. <o:p></o:p>

The first characteristic feature of a narrative is that it has coherence, in the sense that it reveals, through the process of emplotment, connections between the related events, and it does so in a way that a mere list, or annal, or chronicle, does not. [ibid: 14]<o:p></o:p>

In fact, Goldie does not attempt to say very much about the nature of narrative coherence. Surprisingly, given that narrative structure might be thought to be distinct from the nomological or lawlike structure of the physical sciences, he uses a comparison with causal explanation. Such explanations cite factors that are typically neither necessary nor sufficient for the explanans [Mackie 1993]. But they are selected from the total set of causal factors for an event on the basis of the interests of the author and audience of the account. Although he denies that there is a simple relation between causal explanation and narrative understanding, Goldie suggests that this is common with narrative accounts.<o:p></o:p>

A further clue to the nature of narrative coherence comes from a remark on the epistemological of narrative construction. Borrowing and modifying Paul Ricoeur's notion of 'emplotment' itself based on Aristotle's Poetics, Goldie suggests that it involves shaping, organizing, and colouring events, the raw material of the narrative, itself always already described in significant ways. Arriving at this is a matter of tâtonnementor trial and error, feeling one's way to the real significance of what is narrated.<o:p></o:p>

The process of emplotment is often a tâtonnement, a tentative, groping procedure: one might begin with an idea of how the narrative should be shaped, and, once one has developed it somewhat, one might be able to see saliences that one could not see before, and then find it appropriate to go back and reshape the narrative in this new light. More than that, the tâtonnement typically involves a groping search for the appropriate evaluative and emotional import of what is narrated. [ibid: 11]<o:p></o:p>

The second general characteristic set out is meaningfulness. Goldie suggests that there are two aspects to the meaning of narratives.<o:p></o:p>

First, a narrative can be meaningful by revealing how the thoughts, feelings, and actions of those people who are internal to the narrative could have made sense of them from their perspective at the time—that is, from their internal perspective. And, secondly, a narrative can be meaningful by revealing the narrator's external perspective: his or her thoughts and feelings that throw light on why the narrative was related (or just thought through) in that particular way. Bound up with these two kinds of meaningfulness are the two ways in which a narrative can have evaluative and emotional import. [ibid: 17]<o:p></o:p>

This connects to the third key element: the evaluative and emotional import of narratives. In a nutshell.<o:p></o:p>

Things matter to people, and a narrative involving people can capture the way things matter to them. [ibid: 23]<o:p></o:p>

These characteristics are supposed to apply across the board to narratives. Goldie has, however, a particular focus: autobiographical narrative thinking. In particular, he discusses in depth autobiographical thinking about one's past and one's future. Both illustrate the claim that an autobiographical narrative sense of self is an essential aspect of human subjectivity. <o:p></o:p>

In the case of narrative thinking about the past, the difference between internal and external perspective on both meaning and evaluative and emotional import plays a role. In thinking, now, about one's past, an autobiographical narrative presents a view of the meaning and significance of past events and actions through the emotional lens of the present. A mismatch between past and present perspectives can take the form of regret in cases where one realises that had one not acted in such and such a way, such an effect would not have occurred.<o:p></o:p>

In narrative thinking about the future, imagination plays a role analogous to memory in thinking about the past. Goldie suggests that it plays a key role in thinking through the 'branching possibilities' of different ways in which events may come to pass. In future directed thinking, there is again a difference between internal and external perspective on both meaning and evaluative and emotional import. One can imagine not only different future actions but also their emotional effects. The emotion imagined for the future can have an emotional effect in the present. Goldie suggests that narrative thinking is also involved in developing virtues. One connection is through fictional narratives. An emotional response to the lives and actions of fictional characters enables an understanding goes had in hand with an imagined response to other possibilities. But the same applies to future planning for one's own life based on responses of shame and guilt to mistakes made in the past and hence the adoption of counter-factual and causal thinking about how to act in the future.<o:p></o:p>

Narrative, paternalism and Hopper's 'sensitive wok'<o:p></o:p>

Kim Hopper's mention (above) of the 'sensitive work' needed to recover a suppressed sense of injustice and reclaim lost possibility reflects the dual dilemma for a clinician of either paternalistically imposing an entirely external view of what someone in recovery from mental illness ought to want or failing to challenge a view which may be impoverished by mental illness, stigma and even, in some cases, experience of psychiatric treatment. If the central aim of the recovery model is to articulate a conception of a life worth living which fits the values of the person concerned, but if mental illness can corrode their sense of possibility and undermine their agency, how can the right endpoint for healthcare for them be selected?<o:p></o:p>

Although it does not offer a way out of the fundamental tension articulated by Nussbaum and Sen, a narrative sense of self offers some practical help. Narrative, understood along the lines that Goldie suggests, has a balance of subjectivity and objectivity. The objectivity lies in the need for narrative coherence and structure and in the implicit contrast between internal and external perspectives in narratives. The subjectivity lies in the essentially perspectival nature of the narratives. Autobiographical narratives are both narrated from a particular perspective but also concern the life of the very same person as the narrator. These come together in the tâtonnement, the tentative, reaching for the right narrative structure of events.<o:p></o:p>

On a broadly procedural view of autonomy, any intervention to impose values on a subject who already enjoys a reflective balance between first and second order values and policies is a form of paternalism. But there may still be a need for what Hopper calls 'sensitive work' is a subject's self narrative is incoherent. For example, is there is a lack of coherence between past regret and suitable future directed policies to avoid similar errors in the future. Clinical narrative-based intervention could take the form of working with a client to enable their understanding of their past and plans for the future to fit their current conception of themselves. Narrative self-understanding introduces a temporal dimension and the explicit possibility of divergence of value between what one valued in the past, values now and may come to value in the future. Narrative coherence provides a standard by which present values and habits can be subject to criticism by the subject her or himself. In the initial apparent dilemma, an extreme of relativism is avoided insofar as a conception of flourishing and hence recovery will have to have a form of narrative coherence for the subject. Whilst the notion of objectivity within narrative understanding is not one of external <o:p></o:p>

On a substantive view of autonomy, answering to external, universal standards for human flourishing need not involve paternalism. Hence a clinician's 'sensitive work' may involve persuasion that some forms of life are more valuable than others and their neglect by a subject is the result of his or her illness. Whilst external standards need not seem to a substantivist to threaten paternalism they could. Given the connection, to which both sides of the debate about capabilities agree, between flourishing and freedom a brute imposition of an external view of flourishing could be paternalistic. But if externally proffered conceptions of the good life are suggested and adopted as part of a narratively structured set of policies and plans for future life reconciled with the subject's narrative account of their past and present too then that is not a brute imposition. Even if a clinician has to work to introduce neglected values, if they are adopted they will have to made to cohere by the subject him or herself with a narrative account. This avoids the charge of crude paternalism.<o:p></o:p>

Emphasising the normative standards implicit in the idea of narrative coherence is not a quick fix for a balanced conception of recovery. The severely depressed person quoted by Ratcliffe (above) was, at the time of the experiences described, incapable of the kind of narrative understanding just outlined. In such cases, a recovery model can neither be adopted nor can it coherently be imposed. But a narrative sense of self suggests a rationale for a middle way between paternalism and uncritical relativism whichever broad view of recovery and of autonomy is adopted.<o:p></o:p>

Conclusion<o:p></o:p>

In this chapter I have attempted to shed light on three related issues. First, in the light of its recent popularity and promotion as the goal of mental healthcare, what is meant by 'recovery'? Second, how can the harm that mental illness can do to people's autonomy be reconciled with a recovery approach which is based on patient or client choice? Third, does the existing connection between recovery and narrative shed light on the first two issues?<o:p></o:p>

Drawing on typical statements of the aims of the recovery movement in mental healthcare, I have articulated an abstract specification for a recovery model. It is health rather than illness based and it is essentially value laden. Recovery aims towards the goal of a conception of flourishing tailor-made to individual patients and clients. This is consistent with one elaboration of a theory of recovery based on Sen's capabilities approach to welfare economics. On that model, the valued 'functionings' that underpin capability are person-specific. But as two of the key architects of that policy suggest, there is a tension between two rival versions of it. On one (Nussbaum's), there are universal standards for human flourishing. On the other (Sen's), the emphasis on freedom as a key aspect of capability implies diversity. These two views give rise to two opposing perceived dangers: uncritical relativism versus paternalism.<o:p></o:p>

Paternalism is a threat to human autonomy and the two approaches to capabilities correspond to two broad approaches to it. On a proceduralist account, autonomy is a form of internal coherence of beliefs and values. On a substantivist account, the idea of autonomy presupposes successfully tracking some particular conception of the good and the true.<o:p></o:p>

The two view find expression within recovery on a stress on human diversity (Davidson) versus the idea of some universal standards coupled with the idea that mental illness may cloud people's judgements of flourishing so understood or otherwise undermine their agency (Hopper). This raises a threat, however, that in responding to this clinicians will inevitably be paternalist.<o:p></o:p>

On the assumption that mental illness can indeed distort people's views of their own flourishing, the final section has suggested that a narrative sense of self can play a role in undermining the threat of paternalism. On a proceduralist view of autonomy, and Sen's version of capabilities, a clouding of judgement is a lack of coherence in a narrative sense of self and hence the sensitive work to correct this involves helping the patient or client to repair their own narrative. On a substantive view of autonomy, which corresponds to Nussbaum's view of capabilities, a clouding of judgement may also involve failing to observe universal forms of human flourishing. And hence the sensitive work to correct this involves enabling a patient to see the rightness of these universal forms. But the role of narrative ensures that this is not a brute imposition from without. Only if the subject can integrate the universal values into his or her own narrative will the work have been successful.<o:p></o:p>

Bibliography<o:p></o:p>

Boorse, C. (1975) 'On the distinction between disease and illness' Philosophy and Public Affairs 5: 49-68<o:p></o:p>

Bracken, P. and Thomas, P. (2009) 'Authors' response. Invited commentary on… Beyond consultation' Psychiatric Bulletin 33: 245-246<o:p></o:p>

Brampton, S. (2008) Shoot the Damn Dog: A Memoir of Depression. London: Bloomsbury<o:p></o:p>

Brown, W. and Kandirikirira, N (2007). Recovering mental health in Scotland. Report on narrative investigation of mental health recovery. Glasgow, Scottish Recovery Network <o:p></o:p>

Chamberlin, J. (1978) On Our Own: Patient Controlled Alternatives to the Mental Health System, New York: McGraw-Hill<o:p></o:p>

Clandinin DJ & Connelly FM (2000) Narrative Inquiry: Experience and Story in Qualitative Research. Jossey-Bass, San Francisco, CA.<o:p></o:p>

Clay, S. (1994) The wounded prophet. In Recovery: The New Force in Mental Health, Columbus, OH: Ohio Department of Mental Health<o:p></o:p>

Coleman, R. (1999) Recovery: An Alien Concept, Gloucester: Hansell Publishing<o:p></o:p>

Corrigan, P.W. and Watson, A.C. (2002) 'The Paradox of Self-Stigma and Mental Illness' Clinical Psychology: Science and Practice 9: 35–53<o:p></o:p>

Davidson, L. and Roe, D. (2007) 'Recovery from recovery in serious mental illness: one strategy for lessening confusion plaguing recovery' Journal of Mental Health 16: 459-470.<o:p></o:p>

Davidson, L., Ridgway, P., Wieland, M., & O'Connell, M. (2009). A capabilities approach to mental health transformation: a conceptual framework for the recovery era. Canadian Journal of Community Mental Health (Revue canadienne de santé mentale communautaire), 28(2), 35-46<o:p></o:p>

Deegan, P. E. (1988) 'Recovery: the lived experience of rehabilitation' Psychosocial Rehabilitation Journal, 11: 11-19<o:p></o:p>

Deegan, P. (1996) 'Recovery as a journey of the heart' Psychiatric Rehabilitation Journal 19: 91-97<o:p></o:p>

Frank, A.W. (1997) The Wounded Storyteller, Chicago: University of Chicago Press<o:p></o:p>

Frankfurt, H. (1971) 'Freedom of the Will and the Concept of the Person' Journal of Philosophy

68:5-20<o:p></o:p>

Fulford, K.W.M. (1989) Moral Theory and Medical Practice, Cambridge: Cambridge University Press<o:p></o:p>

Goldie, P. (2012) The Mess Inside: narrative, emotion, and the mind, Oxford: Oxford University Press<o:p></o:p>

Holmes, J. (1993) John Bowlby and Attachment Theory. London: Routledge<o:p></o:p>

Holmes, J. (1999) 'Defensive and creative uses of narrative in psychotherapy' In Healing Stories: Narrative in Psychiatry and Psychotherapy (eds G. Roberts & J. Holmes) pp. 152–180. Oxford: Oxford University Press.<o:p></o:p>

Hopper, K. (2007) Rethinking social recovery in schizophrenia: what a capabilities approach might offer. Social Science & Medicine 65: 868-879<o:p></o:p>

Jaspers, K. ([1913] 1974) 'Causal and "Meaningful" Connections between Life History and Psychosis', trans. by J.Hoenig, in S.R.Hirsch and M.Shepherd. in Hirsch, S.R., and M. Shepherd, Themes and Variations in European Psychiatry, Bristol: Wright: 80-93<o:p></o:p>

Kendell, R.E. (1975) 'The concept of disease and its implications for psychiatry' British Journal of Psychiatry 127: 305-315<o:p></o:p>

Labov, W. and Waletsky, J. (1967) Narrative analysis, in J. Helm (ed) Essays on the Verbal and Visual Arts.Seattle: University of Washington Press.<o:p></o:p>

Lapsley, H., Waimarie, L. N. & Black, R. (2002) Kia Mauri Tau! Narratives of Recovery from Disabling Mental Health Problems, Wellington: Mental Health Commission<o:p></o:p>

Leete, E. (1989) 'How I perceive and manage my illness' Schizophrenia Bulletin, 8: 605-609<o:p></o:p>

Leibrich, J. (1999) A Gift of Stories: Discovering How to Deal with Mental Illness, Dunedin: University of Otago Press<o:p></o:p>

Lovejoy, M. (1984) 'Recovery from schizophrenia: a personal Odyssey' Hospital and Community Psychiatry, 35: 809-812<o:p></o:p>

Mackie, J.L. (1993) 'Causes and conditionals' in Sosa, E. and Tooley, M. (eds) Causation,Oxford: Oxford University Press: 33-50<o:p></o:p>

Nussbaum, M. (1988). 'Nature, Function, and Capability: Aristotle on Political Distribution', Oxford Studies in Ancient Philosophy, suppl. vol.<o:p></o:p>

Nussbaum, M. and Sen, A. (eds) (1993) The Quality of Life, Oxford: Clarendon<o:p></o:p>

Ramsay, R., Page, A., Goodman, T., et al (2002) Changing Minds: Our Lives and Mental Illness, London: Gaskell<o:p></o:p>

Ratcliffe, M.R. (2015) Experiences of Depression: a study in phenomenology, Oxford: Oxford University Press<o:p></o:p>

Ridgeway, P. A. (2000) 'Re-storying psychiatric disability: learning from first person narrative accounts of recovery' Psychiatric Rehabilitation Journal 24: 335-343<o:p></o:p>

Roberts, G. (1999) 'The rehabilitation of rehabilitation: a narrative approach to psychosis' In Healing Stories: Narrative in Psychiatry and Psychotherapy (eds G .Roberts & J. Holmes), pp. 152-180. Oxford: Oxford University Press.<o:p></o:p>

Roberts, G. (2000) 'Narrative and severe mental illness: what place do stories have in an evidence-based world?' Advances in Psychiatric Treatment 6: 432-441<o:p></o:p>

Roberts, G. and Wolfson, P. (2004) 'The rediscovery of recovery: open to all' Advances in Psychiatric Treatment 10: 37-49<o:p></o:p>

Sen, A., 1980, 'Equality of What?' in McMurrin (ed.), Tanner Lectures on Human Values, Cambridge: Cambridge University Press.<o:p></o:p>

Sen, A. (1993) 'Capability and Well-Being' in Nussbaum, M. and Sen, A. (eds.) The Quality of Life, New York: Oxford Clarendon Press<o:p></o:p>

Shepherd, G., Boardman, J. & Slade, M. (2008) Making Recovery a RealityLondon: Sainsbury Centre for Mental Health<o:p></o:p>

Szasz, T. (1972) The Myth of Mental Illness, London: Paladin <o:p></o:p>

Unzicker, R. (1989) 'On my own: a personal journey through madness and re-emergence' Psychosocial Rehabilitation Journal 13: 70-77<o:p></o:p>

Wolf, S. (1990) Freedom within Reason Oxford: Oxford University Press
Tim Thorntonhttp://email@example.com:blogger.com,1999:blog-6658432996374251907.post-52982681152005876812015-07-07T08:37:00.001+01:002015-07-07T08:38:02.817+01:00Cross-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.<o:p></o:p>

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.<o:p></o:p>

Cultural factors in DSM-5<o:p></o:p>

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].<o:p></o:p>

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. <o:p></o:p>

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:<o:p></o:p>

· The boundaries between normality and pathology for different types of behaviour. <o:p></o:p>

· Vulnerability and suffering (for example, by amplifying fears that maintain panic disorder). <o:p></o:p>

· The stigma of, or the support for, mental illness. <o:p></o:p>

· The availability of coping strategies. <o:p></o:p>

· The acceptance or rejection of a diagnosis and treatments, affecting the course of illness and recovery. <o:p></o:p>

· The conduct of the clinical encounter itself and how this affects the accuracy of diagnosis, acceptance of treatment, prognosis and clinical outcomes.<o:p></o:p>

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:<o:p></o:p>

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]<o:p></o:p>

Although the authors distinguish between these different ideas, they concede that the same elements may play a role in all three categories. For example, depressionis 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. <o:p></o:p>

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.<o:p></o:p>

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].<o:p></o:p>

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]<o:p></o:p>

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. <o:p></o:p>

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?<o:p></o:p>

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.<o:p></o:p>

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]<o:p></o:p>

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.<o:p></o:p>

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]<o:p></o:p>

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. <o:p></o:p>

Three models of cultural concepts of distress<o:p></o:p>

A two-factor pathogenic-pathoplastic model<o:p></o:p>

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.<o:p></o:p>

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]<o:p></o:p>

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.<o:p></o:p>

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.<o:p></o:p>

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.<o:p></o:p>

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 'myideas'). 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. <o:p></o:p>

[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]<o:p></o:p>

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:<o:p></o:p>

[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]<o:p></o:p>

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.<o:p></o:p>

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'. <o:p></o:p>

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. <o:p></o:p>

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.<o:p></o:p>

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 distinctillnesses 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. <o:p></o:p>

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.<o:p></o:p>

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:<o:p></o:p>

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]<o:p></o:p>

and<o:p></o:p>

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]<o:p></o:p>

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:<o:p></o:p>

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]<o:p></o:p>

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.<o:p></o:p>

Two single factor models of cultural variation: pathoplastic-only and pathogenic-only<o:p></o:p>

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. <o:p></o:p>

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. <o:p></o:p>

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 mentalprocess: a failure of a mentalfunction. 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.<o:p></o:p>

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. <o:p></o:p>

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.<o:p></o:p>

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.<o:p></o:p>

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].<o:p></o:p>

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. <o:p></o:p>

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.<o:p></o:p>

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.)<o:p></o:p>

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.<o:p></o:p>

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. <o:p></o:p>

The status of khyal cap<o:p></o:p>

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. <o:p></o:p>

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]. Khyalcap 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.<o:p></o:p>

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. <o:p></o:p>

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. <o:p></o:p>

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.<o:p></o:p>

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.<o:p></o:p>

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]. <o:p></o:p>

[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]<o:p></o:p>

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].<o:p></o:p>

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.<o:p></o:p>

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.<o:p></o:p>

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.<o:p></o:p>

Conclusion<o:p></o:p>

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.<o:p></o:p>

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. <o:p></o:p>

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.<o:p></o:p>

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. <o:p></o:p>

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.<o:p></o:p>

Acknowledgement<o:p></o:p>

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.<o:p></o:p>

Bibliography<o:p></o:p>

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV), Washington, D.C.: American Psychiatric Association<o:p></o:p>

American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR), Washington, D.C.: American Psychiatric Association<o:p></o:p>

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), Washington, D.C.: American Psychiatric Association<o:p></o:p>

Birnbaum, K. ([1923] 1974) 'The Making of a Psychosis' Translated by H. Marshall, in S. R. Hirsch & M Shepherd (eds) Themes and Variations in European Psychiatry, Bristol: John Wright. 197–238<o:p></o:p>

Bolton D. (2008). What is mental disorder? An essay in philosophy, science and values, Oxford: Oxford University Press<o:p></o:p>

Boorse, C. (1975) 'On the distinction between disease and illness' Philosophy and Public Affairs5: 49-68<o:p></o:p>

Cummins, R. (1975) 'Functional Analysis' Journal of Philosophy 72: 741–65<o:p></o:p>

Fulford, K.W.M. (1989) Moral Theory and Medical Practice, Cambridge: Cambridge University Press <o:p></o:p>

Guarnaccia, P.J. and Rogler, L.H. (1999) 'Research on Culture-Bound Syndromes: New Directions' Am J Psychiatry 156: 1322–1327<o:p></o:p>

Hinton, D.E., Pich, V., Marques, L., Nickerson, A. and Pollack, M.H. (2010) 'Khyal Attacks: A Key Idiom of Distress Among Traumatized Cambodia Refugees' Cult Med Psychiatry 34: 244–278<o:p></o:p>

Kleinman, A. M. (1977). Depression, somatization and the 'new cross-cultural psychiatry'. Social Science and Medicine, 11, 3–10.<o:p></o:p>

Kupfer, D. J., First, M. B. and Regier, D. A. (eds) (2002) A Research Agenda for DSM–V, Washington, DC.: American Psychiatric Association <o:p></o:p>

Littlewood, R. (1985) 'The migration of culture-bound syndromes' In E. Pichot (ed) Psychiatry The State of the Art Volume 8 History of Psychiatry, National Schools, Education, and Transcultural Psychiatry, London: Springer: 703-707<o:p></o:p>

Littlewood, R. (1986) Russian dolls and Chinese boxes: an anthropological approach to the implicit models of comparative psychiatry', in J. L. Cox (ed.) Transcultural Psychiatry, Beckenham: Croom Helm: 37-58<o:p></o:p>

Littlewood, R. (2002) Pathologies of the West, London: Continuum<o:p></o:p>

Littlewood, R. and Lipsedge, M. (1986) 'The culture-bound syndromes' of the dominant culture: culture, psychopathology and biomedicine'. In J. L. Cox (ed.) Transcultural Psychiatry, Beckenham: Croom Helm: 253-273<o:p></o:p>

Mackie, J.L. (1993) 'Causes and conditionals' in Sosa, E. and Tooley, M. (eds) Causation, <st1:place w:st="on">Oxford</st1:place>: Oxford University Press: 33-50<o:p></o:p>

Mezzich J.E., Kirmayer L.J., Kleinman A., et al (1999) 'The place of culture in DSM-IV' J Nerv Ment Dis187: 457–464<o:p></o:p>

Mezzich, J.E., Caracci, G., Fabrega Jr., H. and Kirmayer, L.J. (2009) 'Cultural formulation guidelines' Transcultural Psychiatry 46: 383-405<o:p></o:p>

Sass, L.A. (1994) The Paradoxes of Delusion, New York: Cornell<o:p></o:p>

Sass, L.A. (1992) Madness and modernism, New York: Cornell<o:p></o:p>

Wakefield, J.C. (1999) 'Mental disorder as a black box essentialist concept' Journal of Abnormal Psychology108: 465-472<o:p></o:p>
Wright, L. (1973) 'Functions' Philosophical Review 82: 139–68

<o:p></o:p>
Tim Thorntonhttp://email@example.com:blogger.com,1999:blog-6658432996374251907.post-88207340754885503692015-06-26T11:03:00.000+01:002015-06-26T11:03:13.740+01:00Dialogues in Philosophy, Mental and Neuro SciencesI see that there is a new issue of this online journal.

Here.Tim Thorntonhttp://email@example.com:blogger.com,1999:blog-6658432996374251907.post-64647158390695731792015-06-24T18:00:00.000+01:002015-06-25T15:02:28.500+01:00Delivering 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.
Tim Thorntonhttp://email@example.com:blogger.com,1999:blog-6658432996374251907.post-33454720223331532552015-06-16T13:18:00.001+01:002015-06-16T18:09:40.497+01:00Motivational speaking as instant enlightenmentEvery 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.Tim Thorntonhttp://firstname.lastname@example.com:blogger.com,1999:blog-6658432996374251907.post-83184492253422433582015-05-20T22:24:00.002+01:002015-05-21T15:52:14.715+01:00Rereading 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 Maintenancein 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.<o:p></o:p>

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.<o:p></o:p>

So ignoring all the present tense adventure on a motorbike, the following themes struck me on a quick review.<o:p></o:p>

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:<o:p></o:p>

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]<o:p></o:p>

This leads to the following key early distinction between romantic and classical.<o:p></o:p>

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]<o:p></o:p>

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.<o:p></o:p>

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]<o:p></o:p>

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. <o:p></o:p>

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]<o:p></o:p>

This leads to a manifesto:<o:p></o:p>

"(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]<o:p></o:p>

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:<o:p></o:p>

[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]<o:p></o:p>

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.<o:p></o:p>

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?". <o:p></o:p>

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]<o:p></o:p>

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.<o:p></o:p>

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?...<o:p></o:p>

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]<o:p></o:p>

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:<o:p></o:p>

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]<o:p></o:p>

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].<o:p></o:p>

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:<o:p></o:p>

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]<o:p></o:p>

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.<o:p></o:p>

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.<o:p></o:p>

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.<o:p></o:p>

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.<o:p></o:p>

Kant, <st1:place w:st="on">I.</st1:place> (1987) Critique of judgment Indianapolis: Hackett <o:p></o:p>

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

Tim Thorntonhttp://firstname.lastname@example.com:blogger.com,1999:blog-6658432996374251907.post-23273473718141718882015-05-13T16:06:00.000+01:002015-05-14T16:20:50.789+01:00Campbell 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 <a href="https://2fdfafd9-a-62cb3a1a-s-sites.googlegroups.com/site/drtimthornton/publications/chapters/uploads/Whytheideaofframeworkpropositions.pdf?attachauth=ANoY7cq9jjR_4SZtx1kHLRAkqxi7edk4ZzMeh8eVyW6nNMB8IxN1gn1HaYBbEVEN_M24P4AR0ZDJ87QgABPBDP7HHYXFKSg3wNd4ubQFs_nNn6rRFRKhgifOVUWQQd50MbmlEns3uEHeEc-44Xxxft5Sx3i5kZ0hg5IkxtyjazL2CWdFEEvqcw4iOXMHv_ABggjcboXJd5Dw6Yk1BJm0uH-zHXU65MwQabLjIljF-yY_50hZ9v2co7JhtYZN7UNmpIMoMWdXVnT0ODipXEh68wchYgQIZsF7PVJcPkpNxIK16mDtrIpeaBQ%3D&attredirects=0" target="_blank">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).<o:p></o:p>

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.<o:p></o:p>

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).<o:p></o:p>

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.<o:p></o:p>

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.<o:p></o:p>

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.<o:p></o:p>

Campbell, J. (2001) 'Rationality, meaning, and the analysis of delusion' in Philosophy Psychiatry and Psychology 8: 89-100<o:p></o:p>
Tim Thorntonhttp://email@example.com:blogger.com,1999:blog-6658432996374251907.post-44022774320529616502015-05-12T15:27:00.002+01:002015-05-14T16:21:08.484+01:00If a lion could talk...

I am delighted to see this issue of Existential Comicsdoesn'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.))
Tim Thorntonhttp://email@example.com:blogger.com,1999:blog-6658432996374251907.post-46713259800721868042015-05-08T15:27:00.002+01:002015-05-08T15:28:11.653+01:00Democracy and Jubilee the elephant

For some reason today I am reminded of the first occasion I wondered whether it was conceptually possible that democracy could deliver, not just a result I didn't like but rather, something that surely no one with a proper view of the facts could think the best.

In 1977 a baby elephant was born in Chester Zoo and the BBC children's television programme Blue Peter was given the task of polling popular opinion for the choice of name. It being 1977, a particular year long royal event was much in the news. As a Cub Scout, I was issued with a huge badge to be worn all that year and there was much predictable and eventually quite tedious hoo-hah even as far I, as an impressionable 12 year old, was concerned. So it was no surprise at all when the utterly witless suggestion 'Jubilee' topped the poll for the elephant's name with about 90% of the votes and some random people were awarded prizes for having had just the same idea as everyone else.

I seem to recall that the third name was completely left-field. Perhaps 'Gary'. Quite why half a dozen people thought of that I've no idea.

But in second place, with perhaps 10% of the vote, came the rather more imaginative 'Jumbilee', a nice compromise of royalist atmosphere with something at least a little elephant specific. Also an idea that required even just a bit of imagination. Surely, I thought, this is obviously better than the actual winner? And what shame must the idiots collecting their prizes for not having thought at all be feeling? Crucially, if they were in possession of the full facts, surely no-one who voted 'Jubilee' would really defend it in the face of 'Jumbilee', the objectively better name? Such were my 12 year old's thoughts and doubts. But it seemed, and it still seems, difficult baldly and boldly to think that most people are just idiots and democracy isn't all it's cracked up to be.Tim Thorntonhttp://email@example.com:blogger.com,1999:blog-6658432996374251907.post-45361918911587461742015-05-07T14:57:00.001+01:002015-05-15T17:44:15.170+01:00Suzanne Stern-Gillet on 'Is philosophy a set of footnotes to Plato?'

I went to an interesting polemical talk by Professor Suzanne Stern-Gillet yesterday called 'Is philosophy a set of footnotes to Plato?'.<o:p></o:p>

The abstract ran as follows.<o:p></o:p>

A unique particularity of philosophy as an academic discipline is to include, as an integral part of itself, a reflection on its own past. This is a 'fact' insofar as anyone embarking on the study of philosophy today can expect frequent encounters with Plato, Aristotle, Descartes, Kant and countless other figures from the past. Why should this be so? And, if it is so, why did a well-known Princeton philosopher, in the heyday of analytic philosophy, advise his students to 'say "no" to the history of philosophy'? An outline of the two positions will be followed by a discussion of a few case studies chosen to highlight the pitfalls (unless they be benefits) of creative appropriation and the challenge involved in casting one's mind back to the distant philosophical past.<o:p></o:p>

The structure of the talk involved first assembling some characteristic quotations from analytic philosophy expressing ahistorical views of the nature of the subject and then pointing out some vices to which this left them hostage. (Whilst continental philosophers were not charged with equal crimes neither did they escape entirely on the grounds of obfuscation.)<o:p></o:p>

Some characteristic analytical comments included:<o:p></o:p>

Bernard Williams: 'The legacy of Greece to Western philosophy is Western philosophy.' (1981, reprinted in The Sense of the Past: Essays on the Philosophy of History, 2006)

Quine (allegedly): 'There are two sorts of people interested in philosophy, those interested in philosophy and those interested in the history of philosophy.'

John Searle (allegedly): 'I am an analytical philosopher. I think for myself'

Gilbert Harman (allegedly): Just 'say "no" to the history of philosophy' (inspired by Nancy Reagan's 'Just say "no" to drugs.'). N.B.: he denied having said it.

I jotted down some of the problems that an ahistorical approach fell victim to. They included. <o:p></o:p>

Assuming that philosophical problems are trans historical, remain the same unaffected by contingencies. (This is indicated by book titles such as Problems of Philosophy).

Presenting historically separated philosophers as conversational partners. (eg Jonathan Bennett in the preface to A Study of Spinoza's Ethics (1984, p. 1): The book was written in the hope of convincing philosophers that Spinoza can be treated as 'an energetic collaborator or antagonist' (p. 1), mindful no doubt of Ryle's warning to Wittgenstein and his acolytes that past philosophers 'should be treated more like colleagues than like pupils.' ('Autobiographical', 1971, p.10 sqq.)).

Adopting what Ian Hacking calls this a pen friend approach but it is also akin to a ghostly dinner party in which the shade of dead philosophers are present together. But this assumes, falsely, that they would be able to engage with each other's views.

Paying minimal attention to dialectical context. They do not ask why texts were written, in response to which problems and why the problems were problems.

Paying minimal attention to the overall coherence of an argument with the rest of a dead philosopher's work.

Although I certainly agree with the virtues of a rounded historically-informed approach to philosophy (even though I lamentably fail to adopt one myself never happy delving further back than 1953), it seemed to me that the talk did not actually engage the philosophers it criticised. The vices Suzanne warned of and the virtues she praised all presupposed that the idea that getting the history of the subject right mattered. But that is just what ahistorical analytic philosophers do not care about. For example, they do not make the historical error of assuming that their problems are the same as those of the real though dead Plato. They don't give a damn about his problems only their own. Because of this they do not assume historical continuity, rather they deny history. Philosophy is restricted to the present tense. Given that, then none of the vices will seem to be vices to those to whom the argunents are addressed. (The likely fact that the actual dead philosophers would not have understood one another again misses the point. 'Their' views are compared and contrasted from the contemporary perspective so they are not really their views at all.)<o:p></o:p>

<o:p></o:p>

One of the vices that Suzanne ascribed to ahistorical philosophers was not being sensitive to other philosopher's genuinely different perspectives. But in assuming that ahistorical analytic philosophers assume the continuity of their problems with the past (by contrast with making no such assumption and at most projecting contemporary problems back onto a fictionalised past) she seemed to fall prey to that very vice. If one presupposes the value of the history of philosophy then what ahistorical philosophers do will seem epistemically risky or simply blind to important facts. But that presupposition is not shared by them: they are doing something genuinely different.<o:p></o:p>

If I heard correctly there was a further interesting brief suggestion: the history of philosophy need not be interested in the whole of the context of philosophical authors and texts: not social context, for example. That would be mere history of ideas. Having rubbed shoulders with social historians of science this seemed to me to be an interestingly arbitrary view of what was essential for understanding the history of the subject.
Tim Thorntonhttp://firstname.lastname@example.com:blogger.com,1999:blog-6658432996374251907.post-92120194879118657702015-05-05T14:21:00.002+01:002015-05-05T14:21:46.224+01:00Essex Autonomy Project Summer School 7th July 2015
"This year the Essex Autonomy Project will be joining forces with the Human Rights Centre at Essex to contribute to the Summer School on Human Rights Research Methods. Don't be put off if you are not a researcher (!), as the EAP has planned a practical and discussion-based day around the challenges of applying the UN Convention on the Rights of Persons with Disabilities, taught by the leading members of the Autonomy Project research team.

The day will cover:

An introduction to the CRPD, led by Wayne Martin

We will consider the difference between the Convention itself and its Optional Protocol, the standing and responsibilities of the convention's treaty body, and some of the contested issues regarding the requirements of compliance. As a test case for examining the issues around compliance, we will introduce three pieces of UK legislation that are relevant to the challenge of achieving CRPD-compliance: The Mental Health Act of England and Wales (1983, rev 2007); The Mental Capacity Act of England and Wales (2005); the Adults with Incapacity (Scotland) Act (2000).

Discrimination against persons with disabilities, led by Timo Jütten

One of the central aims of the CRPD is to end discrimination on the basis of disability. We examine the definition of "discrimination" within the convention, consider the distinction between direct and indirect discrimination, and survey the controversy over whether the convention sanctions any kind of defence against charges of discrimination. We then break into groups to consider whether two specific provisions of UK law stand in violation of the anti-discrimination provisions of the CRPD: the use of "mental disorder" as an element in the justification for detention under the Mental Health Act, and the use of the so-called "Diagnostic Threshold" in the definition of "mental incapacity" in the Mental Capacity Act.

Conflicts of Rights, led by Sabine Michalowski

The CRPD, like other international human rights instruments, calls for the respect and protection of a range of different rights, including the right to legal capacity, to equal standing before the law, to life, to the highest attainable standard of health care, to protection against neglect and abuse, etc. But what happens when two or more distinct rights come into conflict? How should the conflict be resolved? We contrast two approaches that have been taken to this challenge — one that has developed in the case history of the European Convention on Human Rights, and the other that is implicit in the recent General Comments of the UN Committee on the Rights of Persons with Disabilities.

Substituted decision-making under the Best-Interests paradigm, led by Wayne Martin

The UN Committee on the Rights of Persons with Disabilities has claimed that compliance with the CRPD requires states parties to abolish substitute decision-making and the best-interest paradigm. What is the meaning of this claim? What is its basis in the Convention? And what is its legal authority? Are the Committee correct in this claim about the requirements on CRPD-compliance? What would be the consequences for UK mental health law? Does current UK law provide sufficient safeguards to ensure respect for the rights, will and preferences of disabled persons? If not, how might those safeguards best be strengthened?

The day is suitable for anyone with an interest in the UNCRPD and will introduce the Autonomy Project's latest research on the issues surrounding this human rights convention. The fee for the day is £225 – if you book before the 30th April a 10% early booking discount is available.

To book your place please go to the Human Rights Centre website: https://www.essex.ac.uk/hrc/summerschool/

Best wishes,

Becky

_______________________

Becky Parsons

Project Officer

The Essex Autonomy Project

http://autonomy.essex.ac.uk/"
Tim Thorntonhttp://email@example.com:blogger.com,1999:blog-6658432996374251907.post-56048072000415364302015-05-01T11:27:00.001+01:002015-05-01T11:27:19.478+01:00Philosophy as creative writing?

I had an interesting misunderstanding with a friend, Jo, this week about the creativity involved in writing philosophy. I think it may have begun with some confusion on my part stemming from momentarily forgetting that 'creative writing' is a proper name for a genre as well as being an adjectival qualification of an activity. It might also have been influenced by Jo's background in advertising, a business that seems to me to mythologise creativity in its absolute distinction between 'creatives' and everyone else.

We were discussing - at a funeral - the common intuition that a flourishing life requires, as one component, some exercises of creativity and I mentioned writing philosophy. Jo was surprised, suggesting that it surely wasn't creative.

Of course, philosophy isn't Creative Writing: the activity taught in masters courses at some UK universities. One might stipulate that forms of short story, novel and poetry writing just are what one means by that name and also any homophonic phrase. But there is surely no general intuition that flourishing requires Creative Writing in that sense.

Jo's reasonable objection to my assumption that philosophy is, or at least can be, creative was that it is descriptive. It's guided by the norm of truth in a way that fiction isn't, whether or not there is a kind of truth in fiction. But even if descriptive accuracy is the goal, little philosophical writing looks like a description. To win through to a description involves the usual philosophical methods of argument, of deriving consequneces of views, of thinking up counter-examples, perhaps even occasional thought experiments. There seems something right in Wittgenstein's poetic suggestion that 'philosophy is a battle against the bewitchment of our intelligence by means of our language' [1953 §109] which points to the difficulty in achieving a clear description even if that is the aim. It simply hadn't occurred to me to think such an activity anything other than creative.

Having said that, as a aide memoire for me rather than anything else, here's a bit of housekeeping with respect to my own rather pedestrian efforts. The following are now forthcoming (I think).

Thornton, T. (forthcoming) 'Bootstrapping conceptual normativity?' for Foundations of Science

Thornton, T. (forthcoming) 'John McDowell' for Pritchard, D. (ed) Oxford Bibliographies in Philosophy New York: Oxford University Press

Under review

'Psychiatric classification, vagueness and tacit knowledge' for Keil, G., Kutschenko, L., Hauswald, R. (eds) Gradualist Approaches to Mental Health and Disease Oxford: Oxford University Press

'Naturalism and dysfunction' for Forest, D. and Faucher, L. (eds) Defining Mental Disorders: Jerome Wakefield and his Critics Cambridge, MA: MIT Press

'Nursing knowledge: its nature and generation' for Chambers, M. (ed) Psychiatric & Mental Health Nursing: the craft of caring Abingdon: CRC Press (I have some doubts about this one actually making it through. If anyone else wants a fine 6-10,000 word chapter on knowledge underpinning nursing practice, let me know.)<o:p></o:p>

'Transcultural psychiatry' for White, R. (ed) The Palgrave Handbook of Global Mental Health: Sociocultural Perspectives London: Palgrave<o:p></o:p>

In preparation

'Phenomenological implication as transcendental argument' for van Staden, W. and Pickering, N. (eds) Wittgenstein and mental health, Oxford: Oxford University Press<o:p></o:p>

'The normativity of meaning and the constitutive ideal of rationality' for Verheggen, C. (ed) Wittgenstein and Davidson on Thought, Language, and Action, Cambridge: Cambridge University Press<o:p></o:p>

'Philosophical understandings of mental health' for Wright, K. and McKeown, M. (eds) Essentials of Mental Health Nursing, London: Sage
Tim Thorntonhttp://email@example.com:blogger.com,1999:blog-6658432996374251907.post-55942286209806001192015-04-29T16:39:00.004+01:002015-04-29T16:49:44.829+01:00Another draft nursing textbook chapter

Abstract<o:p></o:p>

By its very nature, mental healthcare raises a number of key conceptual questions calling for philosophical, rather than empirical, inquiry. This chapter outlines some of the answers that have been proposed to, perhaps, the most central question: what is a mental illness? We then discuss links between answers to this question and concerns about the justification of coercion in mental healthcare, shared decisions about recovery, and the objectivity, or otherwise, of psychiatric taxonomy.<o:p></o:p>

Introduction<o:p></o:p>

Mental illness and mental healthcare raise a number of difficult and deep questions. Here are just a few.<o:p></o:p>

· What is the difference between just being different and having a mental illness?<o:p></o:p>

· What, if anything, is the justification for detaining people merely because they have a particular kind of illness?<o:p></o:p>

· Should someone with a mental illness have less say over the nature of their recovery than someone with a physical illness?<o:p></o:p>

· Can a classification or taxonomy of mental illness, such as the recently published DSM-5, aspire to be as objective as the Periodic Table in chemistry. Or is it more like the Top 40?<o:p></o:p>

Questions such as these seem to arise not just from quirky or accidental features of healthcare in this particular country at this particular time but from something deeper and more general: the very idea of mental health and illness. If that is so, they cannot be answered by empirical means - experiments, questionnaires etc - because such means presuppose that we already know what we mean by 'mental health' and 'mental illness'. Thus trying to answer questions like these calls for a method based on examining our concepts. That method is philosophy. So in thinking about questions such as these, we are researching the philosophy of mental healthcare.<o:p></o:p>

In this chapter, we will examine some recent attempts to answer the first question, starting with Thomas Szasz' suggestion that the answer is 'nothing' because there is no such thing as mental illness. We will then trace some connections between accounts of mental illness and answers to the other questions set out above.<o:p></o:p>

Szasz and the myth of mental illness<o:p></o:p>

Thomas Szasz' attack on the very idea of mental illness is often thought of as belonging to a wider movement, called 'Anti-Psychiatry', which began in the 1960s, questioning the legitimacy of psychiatry. Other thinkers grouped under the same label include the French philosophical historian Michel Foucault, who argued that mental healthcare was a form of social control developed to support capitalism, and the radical British psychiatrist RD Laing. In fact, Szasz rejected the label 'anti-psychiatry' as firmly as he rejected the idea of mental illness. <o:p></o:p>

The centrepiece of Szasz' critique is an article and then a book called 'The Myth of Mental Illness'. A key argument is expressed in this passage:<o:p></o:p>

The concept of illness, whether bodily or mental, implies deviation from some clearly defined norm. In the case of physical illness, the norm is the structural and functional integrity of the human body. Thus, although the desirability of physical health, as such, is an ethical value, what health is can be stated in anatomical and physiological terms. What is the norm, deviation from which is regarded as mental illness? This question cannot be easily answered. But whatever this norm may be, we can be certain of only one thing: namely, that it must be stated in terms of psychological, ethical, and legal concepts…
[W]hen one speaks of mental illness, the norm from which deviation is measured is a psychosocial and ethical standard. Yet the remedy is sought in terms of medical measures that – it is hoped and assumed – are free from wide differences of ethical value. The definition of the disorder and the terms in which its remedy are sought are therefore at serious odds with one another… [Szasz 1972: 15]<o:p></o:p>

The argument here starts from the assumption that mental and physical illness involve deviations from different norms. Medical intervention, however, is capable of addressing only one sort of deviation – that of physical illness – and thus it cannot address the kind of deviation from a norm implicit in mental illness. Since the conception of mental illness involves the idea that it can be so treated, there is something incoherent about the very idea.<o:p></o:p>

Since medical interventions are designed to remedy only medical problems, it is logically absurd to expect that they will help solve problems whose very existence have been defined and established on non-medical grounds. [ibid: 17]<o:p></o:p>

Szasz also develops a shorter argument. If mental illness is a deviation from a psychosocial norm then this leads by itself to an objection of circularity:<o:p></o:p>

Clearly, this is faulty reasoning, for it makes the abstraction 'mental illness' into a cause of, even though this abstraction was originally created to serve only as a shorthand expression for, certain types of human behaviour. [ibid: 15]<o:p></o:p>

Critical thinking stop point: think about both these arguments. Are they successful in implying that mental illness could not exist? It might help to summarise them on the back of an envelope. How might one challenge them?<o:p></o:p>

Neither of Szasz' arguments is compelling. Consider the argument of circularity. We can set it out in logical steps as follows:<o:p></o:p>

1. Mental illness is an abstraction from a description of deviant behaviour. It is defined in terms of behaviour.<o:p></o:p>

2. Mental illness is supposed to be a cause of deviant behaviour.<o:p></o:p>

3. Nothing can cause itself.<o:p></o:p>

4. So there is no such thing as mental illness.<o:p></o:p>

The argument is driven by a tension between the claims in the first two premises. But on reflection, there is a natural view of mental illness that captures what seems right about the first premiss without leading to the tension with the second. We can concede that mental illnesses are identified via someone's behaviour (for example, what they say and do) without thinking that the illness is the behaviour. It may be that the illness is the cause of the deviation such that, even though it is picked out by its characteristic effects, it is not identical to them. <o:p></o:p>

Here is an example of this sort of reasoning from a different and clearer context. Lee Harvey Oswald's action of pulling the trigger on 22nd November 1963 may be described as his mudering president John F Kennedy, the action of the moment described by its slightly later effect. The action of pulling the trigger thus both caused the death of the president but is also labelled using that later event. But no defence lawyer could have argued that, because nothing can cause itself, there could be no such act. If the analogy holds then Szasz' argument fails. To succeed he would need some independent reason to rule out the idea that the idea of a mental illness is the idea of something that causes characteristic behaviour. <o:p></o:p>

The same objection applies, also, to the argument from different norms. Just because mental illness is identified via divergence from psychological, ethical, and legal norms does not rule out the idea that it comprises some underlying biological cause of such divergence and hence might be subject to medical treatment thus undermining Szasz' argument.<o:p></o:p>

Despite these objections, however, it may seem that such a defence of mental illness concedes too much in conceding that it is a defined in essentially value-laden terms. After all, that alone suggests that mental illness status cannot be objective. Hence it is worth briefly examining two responses from Christopher Boorse and Robert Kendell which challenged just this point.<o:p></o:p>

Kendell, Boorse and value-free accounts of mental illness<o:p></o:p>

Like Thomas Szasz, RE Kendell was a Professor of Psychiatry but unlike Szasz, he was an establishment figure becoming Chief Medical Officer for Scotland and President of the Royal College of Psychiatrists in the UK. In 'The concept of disease and its implications for psychiatry' he argues in defence of mental illness or disease by suggesting a method for assessing the status of mental illness:<o:p></o:p>

before we can begin to decide whether mental illnesses are legitimately so called we have first to agree on an adequate definition of illness; to decide if you like what is the defining characteristic or the hallmark of disease. [Kendell 1975a: 306]<o:p></o:p>

Reviewing the history of the debate he comments:<o:p></o:p>

By 1960 the 'lesion' concept of disease, and its associated assumptions of a single cause and a qualitative difference between sickness and health had been discredited beyond redemption, but nothing had yet been put in its place. It was clear, though, that its successor would have to be based on a statistical model. [ibid: 309]<o:p></o:p>

But, as Kendell goes on to say, whilst a statistical model may address some of the weaknesses of a single lesion model, statistical abnormality by itself cannot distinguish between 'deviations from the norm which are harmful, like hypertension, those which are neutral, like great height, and those which are positively beneficial, like superior intelligence' [ibid: 309]. It cannot distinguish disease from mere difference. Some further criterion is needed to address the fact that illness is a specific kind of deviation from the norm.<o:p></o:p>

Kendell's preferred solution is based on the work of the British chest physician, JG Scadding. <o:p></o:p>

Scadding was the first to recognise the need for a criterion distinguishing between disease and other deviations from the norm that were not matters for medical concern, and suggested that the crucial issue was whether or not the abnormality placed the individual at a 'biological disadvantage'... He defines illness not by its antecedents – the aetiological agent or the lesion producing the overt manifestations – but by its consequences. [ibid: 309]<o:p></o:p>

Kendell goes on to argue that 'biological disadvantage' must involve increased mortality and reduced fertility, 'whether it should embrace other impairments as well is less obvious' [ibid: 310]. Thus he uses this criterion to test the idea of mental illness. Do they produce biological disadvantage by reducing fertility or life expectancy? After some investigation – which turns on empirical facts about the effects of these putative illnesses – he is able to come to a modest, positive conclusion. <o:p></o:p>

Schizophrenia, manic depressive illness, and also some sexual disorders and some forms of drug dependence, carry with them an intrinsic biological disadvantage, and on these grounds are justifiably regarded as illness; but it is not clear whether the same is true of neurotic illness and the ill-defined territory of personality disorder.[ibid: 315]<o:p></o:p>

Two things are worth noting about Kendell's approach. <o:p></o:p>

His criterion of illness is general. It applies to physical and mental illness. Any condition is an illness if it leads to biological disadvantage of the right sort. That said, it is originally derived from considerations of paradigmatic physical illnesses.<o:p></o:p>

The criterion is purely factual and value-free. It is a matter simply of empirical fact whether a condition increases mortality and reduces fertility. If it does, then it is an illness. If not, then not.<o:p></o:p>

Kendell's approach faces a dilemma, however. On the one hand, there is ambiguity about what 'biological disadvantage' means. Without some further specification, it will not shed light on the nature of mental illness. But on the other, attempting to solve that problem by appeal to the idea of increased mortality and reduced fertility produces a theory of illness or disease which is vulnerable to the objection that it does not articulate what is essential to the idea of all illnesses. Roughly speaking, it seems plausible that one might be genuinely ill without this leading to increased mortality and reduced fertility. Whilst those measures might well address illnesses which, specifically, are life-threatening and undermine reproductive ability, neither risk seems to be an essential feature of everything that we might call 'illness' or 'disease'.<o:p></o:p>

At the same time, the US philosopher Christopher Boorse also attempted to articulate a value-free, purely descriptive account of disease – which he contrasts with illness, although we will ignore that distinction here – but using a conceptually richer notion: biological function. In 'On the Distinction between Disease and Illness' Boorse claims that: <o:p></o:p>

The state of an organism is theoretically healthy, i.e. free of disease, insofar as its mode of functioning conforms to the natural design of that kind of organism… the single unifying property of all recognized diseases of plants and animals appears to be this: that they interfere with one or more functions typically performed within members of the species. [Boorse 1975: 57]<o:p></o:p>

More precisely the theory runs:<o:p></o:p>

An organism is healthy at any moment in proportion as it is not diseased; and a disease is a type of internal state of the organism which:
i) interferes with the performance of some natural function—ie some species-typical contribution to survival and reproduction—characteristic of the organism's age
ii) is not simply in the nature of the species, ie is either atypical of the species, or, if typical, mainly due to environmental causes. [Boorse 1998: 108]<o:p></o:p>

Like Kendell, Boorse suggests that there is more to being diseased than being different. His is not a merely statistical approach. Instead, the sense that there is something wrong about having a disease is captured by the idea that it threatens natural biological functions. But whilst there is a connection between such functions and the contribution they make to an organism's overall fitness, not every such failure of function need be directly correlated with actual increased mortality and reduced fertility. Biological function is thus a more fine grained approach to the concept disease or illness that Kendell's appeal to biological disadvantage.<o:p></o:p>

Critical thinking stop point: think about the idea that illness or disease is a failure of biological function. Is this a good definition? Are there any illness that are not such failures and are there any failures that are not illnesses? How well does the idea apply to mental illness?<o:p></o:p>

There are two main difficulties with Boorse's approach. The first is that failure of biological function seems more widespread than disease. In other words, not every failure of function deserves to be called a disease. For example, the function of sperm is surely to fertilise an egg. That function explains why sperm production continues in populations. But very little sperm actually does this. The benefit is so great that widespread failure can be accommodated without any implication of disease. To cope with this problem, Jerome Wakefield has proposed more recently that disease be restricted to the harmful failures of function. His approach combines biological function and dysfunction with the value: harm [Wakefield 1999]. Although his is perhaps the most famous contemporary account, it faces the second of the objections to Boorse.<o:p></o:p>

The second problem concerns the application of the idea of function and dysfunctions to mental phenomena: to thoughts and experiences. It seems relatively straightforward to describe the function of the eye, for example, but rather less clear what the function is of the profound sadness of bereavement or even whether it is functional – since it is widespread – or the dysfunctional consequence of emotional bonds that are elsewhere functional (see the critical thinking box at the end). In such cases it may be that our assumptions about what is and is not mental illness drives our assumptions about mental functions rather than the other way round. If so, the account does not shed light on what we mean by 'illness' or disease'.<o:p></o:p>

Fulford and value-laden accounts of mental illness<o:p></o:p>

So far we have contrasted Szasz' claim that mental illness is value-laden and Kendell's and Boorse's claims that it is value-free. How can we referee their dispute? A useful perspective is provided by the psychiatrist and philosopher Bill Fulford. The significant feature of the debate, he argues, is not so much on what they explicitly disagree but on what they implicitly agree and disagree. Once this is highlighted, a different conclusion can be drawn. Taking Szasz and Kendell to represent the poles of the debate, Fulford argues that:<o:p></o:p>

Both authors assume that mental illness is the target problem: Szasz wants to 'raise the question, is there such a thing as mental illness'? Kendell, similarly, seeks to 'decide whether mental illnesses are legitimately so-called'. Both then turn to the concept of physical illness, acknowledging certain difficulties of definition, but suggesting criteria which they take to be self-evidently essential to its meaning: Szasz' criterion is 'deviation from the clearly defined norms of the structural and functional integrity of the body'. Kendell's is 'biological disadvantage, which must embrace both increased mortality and reduced fertility'. Finally, both return to mental illness. Szasz points out that for mental illness, the relevant norms of bodily structure and functioning are not available: on the contrary, he argues, the norms of mental illness are 'ethical, legal and social'. Kendell, on the other hand, draws on epidemiological and statistical data to show that many mental illnesses are biologically disadvantageous in his sense, being associated with reduced life and / or reproductive expectations. Hence by Szasz' criteria of physical illness, mental illness is a myth, whereas by Kendell's it is not. [Fulford 1999a: 169]<o:p></o:p>

According to Fulford, Szasz and Kendell both agree that mental illness is conceptually difficult and, by contrast, physical illness is straight-forward in part because the latter is value-free. From this they deduce value-free criteria for illness and apply them to mental illness with different results. As described above, Szasz argues that supposed mental illnesses are deviations from value-laden norms and thus do not meet the value-free criteria for illness. Kendell argues that they do fit his preferred criteria of increased mortality and decreased fertility.<o:p></o:p>

Fulford argues, however, that the assumption that Szasz and Kendell, and Boorse for that matter, share is wrong. Physical illness is not value-free. It merely seems that way because we tend to agree on the values that underpin physical health and illness whilst there is much more variation in the values governing mental health and illness. Further, it is a general feature of value judgements that when we agree on underlying values they can become disguised by value-free criteria. <o:p></o:p>

What's the evidence? RM Hare on value terms<o:p></o:p>

Fulford's account of value terms draws on the work of philosophers such as RM Hare (1919-2002) and JL Austin (1911-1960), writing particularly in the middle decades of the 20th century, in the 'Oxford school' of linguistic analytic philosophy. In his Language of Morals, Hare discusses the logical properties of value terms [Hare 1952]. <o:p></o:p>

The value judgments expressed by (or implicit in) value terms are made on the basis of criteria that, in themselves, are descriptive (or factual) in nature. The value judgment expressed by 'this is a good strawberry', in one of Hare's examples, is made on the basis that the strawberry in question is, as a matter of fact, 'sweet, grub-free'. Hare points out that where the descriptive criteria for a given value judgment are widely agreed, the descriptive criteria that may come to dominate the use of the value term as a consequence of repeated association. In the case of strawberries, most people in most contexts prefer or value strawberries that are sweet and grub-free. Hence the use of 'good strawberry' comes to be associated with descriptions such as 'sweet, grub-free, etc'. This contrasts with, say, pictures where there are no settled descriptive criteria for a good picture because there is no general agreement about pictorial aesthetics. <o:p></o:p>

Hare's general conclusion is this: value terms by which shared values are expressed may come, by a process of simple association, to look like descriptive (or factual) terms, whereas value terms expressing values over which there is disagreement, remain overtly value-laden in use.<o:p></o:p>

Fulford argues that the same contrast applies to mental and physical illness. It is because mental healthcare is concerned with areas of human experience and behaviour, such as emotion, desire, volition, and belief, where people's values are particularly highly diverse that it seems more value-laden than physical illness.<o:p></o:p>

Fulford's positive account of the nature of illness draws on the idea of ordinary doing as the kind of action that one 'gets on and does' without having to try, without having intentions explicitly in mind [Austin 1957]. A failure to be able to do this kind of thing, in the absence of external constraint, captures, Fulford argues, the character of experiences of illness. As a hypothesis, moreover, it helps to explain a number of the key features of medicine. In particular, the idea that illness comprises an internally generated failure of ordinary doing explains its values-ladenness because the ineliminable concept of failure of ordinary doing itself suggests an ineliminable negative value judgement. <o:p></o:p>

This is true of physical illness as well as of mental illness but because there is much more agreement about the sorts of things we should be able physically or bodily to be able to do, the underlying values can become hidden behind factual criteria for working muscles, hearts and lungs etc. This contrast between divergent values in mental healthcare and shared values in physical medicine explains why there is an Anti-Psychiatry movement but not an Anti-Cardiology one.<o:p></o:p>

Having now sketched some competing views of mental illness, and highlighted the potential connection between illness and values, we can now see what connections there are to the other questions raised at the start. <o:p></o:p>

Applications to other questions?<o:p></o:p>

First, is there a connection between mental illness and a justification for compulsory treatment? Fulford argues that his account sheds light on why psychotic illness justifies coercion. On his account, illness is an internally caused failure of ordinary doing. In the case of other illnesses, the failures concern difficulties in the execution of actions. But psychosis involves a loss of insight. It thus involves a defect in the reasons someone has for acting. And because actions are identified as the actions they are on the basis of why someone did them this leads to a constitutive failure to frame, rather than merely to carry out, an action. However, in general, peoples' actions can excused when there is a breakdown in intention. If one does something which might normally deserve blame merely by accident, mistake or impaired consciousness, one can be excused because one is not responsible for the act. Illness can also act as an excuse.<o:p></o:p>

All non-psychotic illnesses… involve… instrumental failures of 'ordinary' doing, difficulties in doing what one intends to do. And difficulties of this sort often mitigate and, if very severe, may even excuse. But in the case of psychotic illness, the failure of 'ordinary' doing … is a failure in the very specification of what is done. The psychotic, therefore… lacks intent… [H]e is thus in the same position as others who lack intent in that he is not responsible for what he does, and, hence, excused. [Fulford 1989: 242-3]<o:p></o:p>

This idea that lack of intent excuses an action can be connected through two links to the problem of justifying compulsory treatment. First, psychotic illness, in which a subject lacks insight into his or her condition, undermines the subject's capacity to form reasons and thus connects to defective intent. Secondly, a subject whose purported actions can be excused by defective intent, which may undermine their status as actions, is also by that fact the kind of subject whose autonomy can justifiably be overridden.<o:p></o:p>

As Fulford spells out, there is of course a sense in which people with psychotic loss of insight clearly do form intentions, just as there is a sense in which they clearly do have reasons for their actions. The point is rather that, to the extent that their actions reflect psychotic loss of insight, their reasons are defective, in whatever (as yet to be determined) way delusional reasoning is defective. Defective reasons for action imply defective intentions, hence, excuse and hence also a rationale for compulsion by others.<o:p></o:p>

This general approach promises to shed light on the key justification for compulsory treatment. There are, however, still some questions remaining. Do all cases that merit compulsory treatment involve defective intent? Why precisely does such a defect justify treatment? What exactly is the connection between the possibility of excusing purported actions because of some failure of intent and overriding the agent's remaining autonomy? And what precisely comprises a relevant defect of intent? Is it right to say that there is a lack of intent, or a failure within the specification of intention, or an impaired intention or what? Nevertheless, it suggests that psychiatry carries with it quite specific medical ethical complexities which flow from the fact that it centres on disorders of human agency.<o:p></o:p>

This line of reasoning suggests one factor in an answer to the next question raised at the start, too: should someone with a mental illness have less say over the nature of their recovery than someone with a physical illness? The extent to which mental illness can undermine a capacity to frame decisions has to be addressed in decisions about treatment and management. But there is another factor which pulls in the opposite direction. Just as both Fulford and to a lesser extent Wakefield argue the very idea of mental illness is value-laden, so it seems that recovery in mental healthcare is value-laden. This is because it is not merely a matter of getting batter, or returning to how one was before its onset, or returning to a statistically normal set of mental capacities. Rather it involves the section of a way of living which is right for the person concerned.<o:p></o:p>

The Sainsbury Centre for Mental Health policy paper 'Making recovery a reality', begins by summarising some key points of emphasis which, it is suggested, characterise any broadly conceived recovery-based approach. These points include:<o:p></o:p>

Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems.
Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness.
Hope is central to recovery and can be enhanced by each person seeing how they can have more active control over their lives ('agency') and by seeing how others have found a way forward.
Self-management is encouraged and facilitated. The processes of self-management are similar, but what works may be very different for each individual. No 'one size fits all'…
Recovery is about discovering – or re-discovering – a sense of personal identity, separate from illness or disability. [Shepherd Boardman and Slade 2008: 0]<o:p></o:p>

The Scottish Recovery Network summarises its views of recovery in similar terms:<o:p></o:p>

Recovery is about living a satisfying and fulfilling life.
Recovery is about more than the absence of the symptoms of illness. Some people describe themselves as being in recovery whilst still experiencing symptoms….
Some people consider recovery as being 'back to the way things were' or back to 'normal' but for others recovery is more about discovering a new life or a new way of being. [Scottish Recovery Network 2007: 3]<o:p></o:p>

On this conception, recovery involves a value-rich personal choice. But given, as we have already described, there is a wide divergence of views about the values relevant to mental health and illness, especially to living a good life, this places much greater need for those with mental illnesses to be centrally involved in decisions about their care and there hopes for recovery.<o:p></o:p>

The final question is harder. Can a classification or taxonomy of mental illness, such as the recently published DSM-5, aspire to be as objective as the Periodic Table in chemistry. Or is it more like the Top 40? According to Kendell and Boorse, mental illness (or more precisely disease in Boorse's case) is a value-free, purely factual notion. But vas we have seen, their accounts face objections. According to Fulford and Wakefield, it is a value-laden notion. For Wakefield, this is a single value: harm. For Fulford, there may be a plethora of values. Indeed, the US psychiatrist John Sadler published a lengthy book on the wide variety of values and even kinds of values in DSM-IV [Sadler **]. If this is the case, what kind of classification or taxonomy can underpin mental healthcare?<o:p></o:p>

First, any value-laden classification will be different from the value-free Periodic Table in chemistry. Even if the criteria for including symptoms or experiences into a particular category are factual and descriptive – like the criteria for a good apple – they will reflect original value judgements which cannot be measured by any instrument.<o:p></o:p>

But second, the issue of the objectivity of a value-laden classification depends on the nature of the values involved. If they are mere expressions of subjective preference, like the Top 40, then they do not answer to anything objective and cannot aspire to being true. On the other hand, they might be thought to be expressions of something independent of any individual's judgement as moral codes are often thought to be. If so, whilst distinct from the purely descriptive objectivity of the Periodic Table, classifications of mental illnesses would still have a more complex form of objectivity. This raises a key question: what is it to get such judgements right?<o:p></o:p>

Conclusions<o:p></o:p>

By its very nature, mental healthcare raises profound conceptual questions which call for philosophical rather than empirical research aimed at arriving at a clearer understanding of the underpinning ideas guiding healthcare. This chapter has illustrated this by addressing a fundamental question of what, if anything, mental illness is and briefly sketching some of the key ideas advanced over the last fifty years. One question these rival views differ on is whether mental illness, or disease, is a value-laden or value-free concept and, if the former, what kind of values.<o:p></o:p>

Addressing that question, however, suggests connections to others, such as the justification of coercion, the nature of recovery and decisions made about it, and the objectivity of basic psychiatric taxonomy. A full and proper understanding of the nature of mental illness – the very idea of it – connects to other pressing areas. Philosophical understanding of mental healthcare is thus not merely an optional extra but a key guide to and resource for good practice.<o:p></o:p>

Critical debate box: Grief, depression and the bereavement exclusion criterion<o:p></o:p>

[To be added: Brief summary of the debate about the exclusion from DSM-5 of the bereavement exclusion criterion for depression.]<o:p></o:p>

Bibliography<o:p></o:p>

Austin, J.L. (1957) 'A plea for excuses' Proceedings of the Aristotelian Society 57: 1-30<o:p></o:p>

Boorse, C. (1975) 'On the distinction between disease and illness' Philosophy and Public Affairs 5: 49-68<o:p></o:p>

Boorse, C. (1998) 'What a theory of mental health should be' in Green, S.A. and Bloch, S. (eds) An Anthology of Psychiatric Ethics, Oxford: Oxford University Press: 108-115<o:p></o:p>

Brown, W. and Kandirikirira, N. (2007) Recovering mental health in Scotland. Report on narrative investigation of mental health recovery. Glasgow: Scottish Recovery Network. <o:p></o:p>

Fulford, K.W.M. (1989) Moral Theory and Medical Practice,Cambridge: Cambridge University Press<o:p></o:p>

Fulford, K.W.M. (1999a) 'Analytic philosophy, brain science and the concept of disorder' in Bloch, S. Chodoff, P. and Green, S.A. (eds) Psychiatric Ethics (third edition) Oxford: Oxford University Press: 161-192<o:p></o:p>

Hare, R.M. (1952) The language of morals, Oxford: Oxford University Press <o:p></o:p>

Kendell, R.E. (1975) 'The concept of disease and its implications for psychiatry' British Journal of Psychiatry 127: 305-315<o:p></o:p>

Shepherd, G., Boardman, J. & Slade, M. (2008) Making Recovery a Reality London: Sainsbury Centre for Mental Health<o:p></o:p>

Szasz, T. (1972) The Myth of Mental Illness, London: Paladin <o:p></o:p>
Wakefield, J.C. (1999) 'Mental disorder as a black box essentialist concept' Journal of Abnormal Psychology 108: 465-472Tim Thorntonhttp://firstname.lastname@example.com:blogger.com,1999:blog-6658432996374251907.post-5936948681261920062015-04-24T15:03:00.002+01:002015-04-24T15:03:21.800+01:00Durham IAS Fellowship Recruitment 2016/17"Dear former IAS Fellow,

I am delighted to announce that the IAS Fellowship Scheme for 2016/17 is now open for recruitment. The theme for 2016/17 is 'Scale' and I would be very grateful if you could alert relevant colleagues in your department, institute or networks about this opportunity and indeed encourage them to apply for a fellowship.

As ever, the IAS is very keen to attract applications from prominent scholars and non-academics to support our commitment to recruiting fellows from across the world. We think this theme will be of great interest to a wide range of scholars from across the disciplines. The closing date for applications is 05 June 2015.

All details are available via the IAS website at
http://www.dur.ac.uk/ias/fellows/apply/ and https://www.dur.ac.uk/ias/themes/scale/

 Thank you very much for your help with this matter. If you have any queries please do not hesitate to contact me.

 With best wishes, Linda"Tim Thorntonhttp://firstname.lastname@example.com:blogger.com,1999:blog-6658432996374251907.post-36675251728629109462015-04-23T14:35:00.000+01:002015-04-23T14:35:33.283+01:00Mind and Society 2.0 videosA link to the talks given at Mind & Society 2.0: a conference on philosophy and ethnomethodology held at MMU, Manchester, March 30th and 31st 2015.

The idiot in the first talk keeps walking out of frame.Tim Thorntonhttp://firstname.lastname@example.com:blogger.com,1999:blog-6658432996374251907.post-88564744848462986412015-04-22T10:11:00.003+01:002015-04-22T10:11:54.656+01:00Bootstrapping conceptual normativity?
Abstract

Both anti-reductionist and reductionist accounts of linguistic meaning and mental content face challenges accounting for acquiring concepts as part of learning a first language. Anti-reductionists cannot account for a transition from the pre-conceptual to conceptual without threatening to reduce the latter to the former. Reductionists of a representationalist variety face the challenge of Fodor's argument that language learning is impossible.
This paper examines whether Ginsborg's account of 'primitive normativity' might provide some resources for addressing these issues. I argue that primitive normativity can be understood in either of two ways: a 'no conception' version and a 'local conception' version. Rejecting the 'no conception' account of normativity in favour of a 'local conception' of a rule expressed in context-dependent demonstrations and examples provides one response to Fodor's argument. It also provides anti-reductionism with at least one stepping stone to learning full-blown linguistically articulated concepts based on a more primitive local form of normativity.

The problem of concept learning<o:p></o:p>

One of the challenges for an anti-reductionist account of linguistic meaning and mental content is making space for an account of concept learning. If, following John McDowell for example, one takes the 'space of reasons' to answer to a distinct constitutive ideal from that of the 'realm of law', it is hard to see how the route from the latter to the former can be described or articulated into steps [McDowell 1994]. Any such description of the steps taken would threaten to provide – what the anti-reductionist denies – a reduction of the concepts of the space of reasons to those of the realm of law.

McDowell himself suggests that Wittgenstein's phrase 'light dawns gradually over the whole' provides a natural metaphor for learning a first language 'for one's dealings with language to cease to be blind responses to stimuli: one comes to hear utterances as expressive of thoughts , and to make one's own utterances as expressive of thoughts' [McDowell 1998: 333]. But he suggests that this process cannot be limited to a few sentences but involves working one's way 'into a conception of the world'. Suggestive though Wittgenstein's phrase is, it does little to shed light on how the process of language learning might come about so much as summarise, albeit neatly, the fact that some such process does come about.

Whilst anti-reductionists face a principled problem of shedding light on first language learning, the most striking recent philosophical argument about language learning comes from one of their reductionist opponents. In LOT2: The language of thought revisited, Jerry Fodor sets out a specific argument for the difficulty of accounting for concept acquisition [Fodor 2008]. Or rather, he argues that such language learning must be impossible.

Fodor's argument has four steps:

1. Concept learning is a rational process.

2. The only plausible rational process is hypothesis formation and testing.

3. But that requires the conceptual representation of the hypothesis, which presupposes possession of the concept to be learnt.

4. So concept learning is impossible.

The first step contrasts learning as a rational process with any form of non-rational process of concept acquisition such as by surgical implantation, swallowing a pill or hitting one's head against a hard surface. Fodor then argues that the only plausible candidate for such a rational process is a 'process of projecting and confirming hypotheses about what the things that the concept applies to have in common' [ibid: 132].

The argument for the third step is couched in the terms of Fodor's 'Representational Theory of Mind' (RTM) and is, initially at least, restricted to primitive, that is non-definable, concepts.

Consider any concept that you're prepared to accept as primitive, the concept GREEN as it might be. Then ask 'What is the hypothesis the inductive confirmation of which constitutes the learning of that concept?' Well, to acquire a concept is at least to know what it's the concept of ; that is, what's required of things that the concept applies to. So, maybe learning the concept GREEN is coming to believe that GREEN applies to (all and only) green things; it's surely plausible that coming to believe that is at least a necessary condition for acquiring GREEN. Notice, however, that (assuming RTM) a token of the concept GREEN is a constituent of the belief that the concept GREEN applies to all and only green things. A fortiori, nobody who lacked the concept GREEN could believe this; nobody who lacked the concept GREEN could so much as contemplate believing this. A fortiori, on pain of circularity, coming to believe this can't be the process by which GREEN is acquired. [ibid: 137-8]

And hence, he argues, no primitive concepts can be learnt. He goes on to lift this restriction to merely primitive concepts and generalise to all concepts but I will ignore that further step of the argument here.

Fodor's Representational Theory of Mind is implicit in the way he sets out the third stage: that a token of the concept is a constituent of the belief about the extension of the concept. This reflects his idea that concept possession is explained by inner vehicles of content – mental representations – which have the same degree of internal structure as the content they carry. So complex thoughts are represented by complex mental representations or inner vehicles of content.

But even without RTM, it is possible to frame a version of Fodor's argument against concept learning. Given the idea, from step 2, that concept learning involves testing a hypothesis, one needs to be capable of entertaining, or thinking, that hypothesis. In this case it is the hypothesis that the concept GREEN applies to (all and only) green things. But even without any speculation – in accord with RTM – about how such a thought is represented by inner mental representations, this seems to raise a problem as holding the hypothesis needed to learn the concept presupposes already possessing the concept one was supposed to be learning. Thus the argument about concept learning floats free of Fodor's particular views of the nature of mind.

The principled problem of describing a process of concept learning from an anti-reductionist perspective and Fodor's specific argument that concept learning is impossible present a two-fold challenge. Can Fodor's argument be blocked and if so can the materials used to do that shed light on concept learning even from an anti-reductionist perspective? In the next section I will set out the ground rules for addressing this question and then set out the structure of the rest of this paper.

Ground rules<o:p></o:p>

In what follows, I will make two substantial but related assumptions. First, that concept learning is normative or prescriptive. Second, that it is, in some sense, a rational process.

The assumption that concept learning is normative might be thought to flow from the prior assumption that concept use itself is normative. Such an assumption is shared by a number of philosophers influenced by Wittgenstein. John McDowell, for example, begins his paper 'Wittgenstein on following a rule' saying:

We find it natural to think of meaning and understanding in, as it were, contractual terms Our idea is that to learn the meaning of a word is to acquire an understanding that obliges us subsequently - if we have occasion to deploy the concept in question - to judge and speak in certain determinate ways, on pain of failure to obey the dictates of the meaning we have grasped. [McDowell 1984b: 325; 1998b: 221 italics added]

Michael Luntley is even more explicit.

Meaning is normative. That is the starting point to our investigations. The normativity of meaning comes from the fact that the content of our utterance or thought is something assessed as true or false… Without adding anything further about the nature of the concept of truth, this basic fact about meaning forces the following constraint. For any utterance or thought to possess meaning its meaning must be such that it demarcates between those conditions that would render the utterance true and those that would render it a failure in aiming for truth…So, if I utter the words
(1) Grass is blue
with their conventional meaning I am obliged, on being presented with a grass sample, to withdraw my utterance. For in uttering (1) I am bound by the meaning of the utterance to acknowledge that there are conditions which would render the utterance correct and conditions that would render it incorrect. That is just what meaning something with our words is like. We take on obligations. [Luntley 1991: 171-172 original italics]

This passage exemplifies an inference made in a number of normativist accounts of meaning. The meaning of any utterance distinguishes between cases where the utterance would be true and those where it would be false. From this distinction it is argued that meaning itself is normative and imposes prescriptions or obligations concerning word use or utterance.

This inference has, recently, been contested. Anti-normativists such as Anandi Hattiangadi agree that meaning is connected to a notion of correctness and incorrectness but deny that that implies meaning is a normative notion [Hattiangadi 2007]. Correctness itself is not normative. For example if R states a rule for the correct use of a term t which applies in virtue of features f

R (x)(t applies correctly to x ↔ x is f)

then, Hattiangadi argues, this 'simply states the correctness conditions of an expression; it does not tell me what to do' [Hattiangadi 2007: 223]. A mere descriptive sorting of correct from incorrect uses or applications or true from false utterances implies no obligations or prescriptions for use. Correctness conditions do not prescribe that a true (or more broadly correct) use should be made unless also combined with a prescriptive norm that one ought to speak the truth (or more broadly correctly). And that additional norm seems – contra Luntley – too strong for specifically semantic normativity and more like a prudential or a moral norm.<o:p></o:p>

Nevertheless, whether or not meaning is normative, a rational process of concept acquisition or learning does look to be normative. In this context, correctness conditions are not merely a neutral way of sorting subsequent utterances but rather constitute the aim or goal of developing linguistic competence, whether or not linguistic competence itself is thought to have correctness as a goal. If an anti-normativist were to argue that the relevant prescriptive ought applies to concept acquisition not directly in virtue of the rules of correctness of words themselves but an additional adoption of taking those rules as the goal of a distinct activity of concept learning, so be it.

My second assumption is that concept learning is, in some sense, a rational process. McDowell calls the acquisition of a first language a matter of being 'cajoled' [McDowell 1998: 333]. It is possible that being the recipient of such cajoling is not so much a rational response as being brutely changed in such a way that one can become a rational subject and make subsequent rational responses. But I will assume that it is possible to say something about rationality of the proto-linguistic responses of a subject in such a position.

My stalking horse will be Hanna Ginsborg's account of 'primitive normativity' [Ginsborg 2011]. Since Ginsborg's account is developed as a response to Krike's meaning scepticism, the next section will outline Kripke's argument. The following section will set out Ginsborg's strategy to block that argument and the role of primitive normativity in it. I will then argue that primitive normativity can be interpreted in either of two ways: a 'no conception' view and a 'local conception' view. But I will argue that Ginsborg seems to, and has to, subscribe to the former which, however, is flawed. But, as I will argue in the final section, a 'local conception' view sheds light on concept acquisition.

Kripke's sceptical argument<o:p></o:p>

Ginsborg's account of primitive normativity is – like many of the anti-normativists she opposes - designed as a response to Saul Kripke's interpretation of Wittgenstein which Kripke presents as a sceptical argument concerning meaning [Kripke 1982]. His argument aims to cast doubt on what appears, pre-philosophically, to be an everyday 'metalinguistic' fact: the fact that one can mean something by a word. He considers the case of meaning addition by the word 'addition' and asks: what justifies the claim that answering '125' is the correct response to the question 'what does 68 + 57 equal?'. Two simplifying assumptions are made:

· that 'correct' means in accordance with the standards of one's previous usage of the signs involved: what one meant by them; and,

· that one has never calculated that particular result before. In fact, Kripke assumes that one has 'added' no number larger than 57.

Normally if called upon to justify the answer '125' one might give either of two sorts of response. Arithmetically, one might ensure that one had carried out the computation correctly. Metalinguistically, one might assert: 'that "plus", as I intended to use that word in the past, denoted a function which, when applied to the numbers I call "68" and "57", yields the value 125' [Kripke 1982: 8].

Kripke now introduces the sceptical hypothesis that in the past one might have followed or meant a different mathematical function, the quus function. On the assumption that one has never previously encountered numbers greater than 57, this is defined to agree with the plus function for all pairs of numbers smaller than 57. (Obviously, this number is arbitrary and inessential to the argument.) For numbers greater or equal to 57 the output is 5. Kripke now presses the question: what facts about one's past performance show that one was calculating in accordance with the plus function rather than the quus function, that one meant plus rather than quus?

Kripke imposes a further condition on any satisfactory answer to the question. It must show why it is correct to respond 125 rather than 5 and, in the dialectic at least, Kripke construes this as supporting normativism. (According to Martin Kusch this assumption is merely part of the reduction ad absurdum, an immanent critique of a package of ideas that includes normativism [Kusch 2006].) A satisfactory answer should show why one ought to answer 125. This precludes citing facts about one's education or training which now dispose one to answer 125. It may be true that one has such a disposition, but that will not show that one should answer 125. (One may equally be disposed to make mistakes when adding large columns of figures but that does not imply that one should, that that is what one meant to do.)

Kripke then deploys arguments based on Wittgenstein's Philosophical Investigations paragraphs 139-239 to show, apparently, that no facts about one's past actions, utterances or dispositions can justify an answer [Kripke 1982: 7-54, Wittgenstein 1953]. Anything one did or said in the past could equally be interpreted as following or meaning the quus rule. For example, perhaps one said allowed that one was adding the numbers and by adding one meant counting up to the first number and then continuing counting by as many steps along the line of integers as the second number. However, as Kripke points out, perhaps the word 'count' meant quount which is defined as the same as counting but only as far as the number 57 [ibid: 108]. It appears that nothing that one said or did or thought to oneself can justify the claim that, now, answering '125' is going on correctly in the same way one was before, in accord with what one previously meant.

Ginsborg on primitive normativity<o:p></o:p>

In response to Kripke's sceptical argument, Ginsborg denies the first of his simplifying assumptions. She denies that in order to claim that one ought, now, to say '125' one needs first to establish that one previously meant addition. She argues that the fact that one ought to say '125' is independent of any assumption about one's past meanings and depends instead on 'primitive normativity'.

I maintain that there is a sense in which you ought to say '125,' given the finite list of your previous uses, independent of what meaning, if any, those uses expressed. The sense of 'ought' I am invoking here expresses what I am going to call 'primitive normativity': very roughly, normativity which does not depend on conformity to an antecedently recognized rule. [Ginsborg 2011: 232-3].

'Primitive normativity' is a basic form of normativity independent of, and prior to, grasp of meaning. Ginsborg suggests three possible interpretations of the example of a child who is able to recite numerals, has learnt to count up in twos and who, on reaching '40' continues with '42'.<o:p></o:p>

A conceptual-normativist account of the child's saying '42' would be as follows:<o:p></o:p>

[T]he 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]

On this higher level view, the correctness of the move – saying '42' – depends on grasping a rule or a concept governing it although lacking a linguistic label for that concept or rule. Primitive normativity involves less than that. But, at the same time, it involves more than thinking of the child's behaviour as akin to the reliable dispositional reactions of a suitably trained parrot. By contrast with such a comparison, Ginsborg argues that 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, Ginsborg claims that she has a sense of appropriateness, fitting or belonging which merits the label 'normativity'. The parrot lacks any such sense and hence is merely governed by dispositions not norms. I will return to the nature of this sense of appropriateness shortly in the contrast between 'no conception' and 'local conception' versions of primitive normativity.

Ginsborg gives a second example of the kind of middle level behaviour she has in mind. She describes a child sorting coloured objects but who has not yet acquired 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]

Again, like the child saying '42', Ginsborg's description is supposed to suggest the prima facie plausibility of a description which, unlike the dispositions of a trained parrot, is genuinely normative but which does not presuppose full conceptual mastery.

In addition to these examples, Ginsborg suggests two further general considerations in support of the idea of primitive normativity. The first concerns her specific dialectical context of responding to Kripke. Neither dispositions nor full-blown conceptual normativity answer Kripke's sceptical challenge. The former fails to sustain the normativity of meaning. The latter is specifically targeted by the possibility of alternative sceptical hypotheses of what was meant in the past. Primitive normativity, by contrast, promises a novel way to block the argument at the start. By denying that the justification of answering '125' to the question Kripke considers presupposes establishing what one previously meant, the sceptical argument is halted before it gets off the ground.

The second consideration concerns the acquisition of concepts and is thus of relevance to Fodor's argument described at the start of this paper. Invoking parrot-like dispositions as the basis for concept acquisition seems to leave too much of a gap still to cross to reach conceptual mastery. By contrast, invoking a prior understanding of concepts or rules to characterise the counting child is to provide no answer to the question how basic concepts can be learnt.

There are, however, two options for characterising primitive normativity based on two distinct things Ginsborg says, either of which might fit this second consideration. She says of the counting child both that:

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]

but also:

2: '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. Which does Ginsborg hold?

A 'no conception' view of primitive normativity<o:p></o:p>

There is a general strategic reason and textual reasons to think that Ginsborg holds the more radical, minimal version of primitive normativity. I will begin with the textual evidence and return to the strategic reason at the end of this and the end of the next section.

One suggestive passage runs:

The utterance, from [the counting child's] 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 as a context-independent general specification of a rule. In the case of a mathematical series, that is a plausible way of cashing out full-blown conceptual normativity. What one understands when one understands a series is a rule which is independent of any particular context. And, hence, if what Ginsborg precludes from her definition of primitive normativity is full-blown conceptual normativity this might still allow for a merely demonstratively specified local conception of the demands of a rule to count as primitive normativity. On this view, whilst the child does not have a general conception of what it is to add two, cannot grasp its relation to other aspects of arithmetic for example, she can, nevertheless, recognise in some particular context that saying '42' accords with what she has been doing.

But the phrase 'antecedently applicable rule' might equally be taken to mean, and hence to rule out, any conception of a rule. If so, the context imposes what move belongs with previous moves, or what next move is right, brutely, independently of any conception the child herself has of what she is doing. The way the quotation continues supports this latter 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]

This suggests a picture according to which facts about the context external to the child's conception (if she has any) of her situation and what she is doing nevertheless make normative demands on her. 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 thus normatively connected to it, but she does not recognise that this is the demand that the rule, grasped in whatever way, makes in the context. I will call this the 'no conception' view of primitive normativity.

A second passage provides a distinct argument for this 'no conception' view on the assumption that even a local conception of what the next move is requires some grasp that this is relevantly the same as previous moves.

[T]he 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 here is that grasp of sameness is insufficient for knowing how to continue and so no local conception view based on just that idea would work. In addition to understanding what sameness amounts to, the child would also need to understand the further rule that she should go on in the same way, that this is what the relevant normative demand is.

There is something to this worry. There seems little prospect of factoring understanding the demands of following a rule into an understanding of what relevant sameness is and an additional realisation that sameness is what one ought to aim at. Wittgenstein stresses the fact that agreement is internal and relative to the particular rule [cf Wittgenstein 1953 §224]. Thus grasp of the rule, grasp of what agrees with it and hence what is relevantly the same in virtue of according with the rule, go hand in hand.

But this point applies equally to what Ginsborg thinks does occur to the child in her examples. The child thinks that the next number or coloured item, depending on the example, fits, belongs or is appropriate to the context. But those notions are also insufficient for going on correctly. Again, the child needs also to understand that fitting, belonging or being appropriate is the right characteristic of a 'move' in the game she is playing. After all, a rule could dictate that the next move should stand out from, rather than fitting, what has gone before. Thus whilst this passage suggests that Ginsborg favours the 'no conception' view, it does not succeed in supporting it.

There is a further reason to think that Ginsborg has to hold the 'no conception' rather than the 'local conception' view which results from the strategic role of primitive normativity in blocking Kripkean scepticism. The blocking move is the denial that the correctness of answering '125' now, in Kripke's example, depends on what one meant, the rule one conceived, in the past. The sceptical argument targets knowledge now of that past meaning or conception and hence dodging that argument requires denying that one needs accord with any prior conception. That also rules out a merely local conception. If primitively following a rule requires fidelity to a prior local conception of what one was doing, expressed in local demonstrations and examples, it would be just as vulnerable to Kripke's alternative sceptical hypotheses as a conception expressed in context-independent general terms. Thus to block the sceptical argument in the way Ginsborg advocates requires the adoption of a 'no conception' rather than a 'local conception' contrast to full-blown conceptual normativity.

In addition to these arguments, Ginsborg seems not to be alone in this view. In a passage in which she discusses how little may be necessary for rule following, Julia Tanney considers the conceptual possibility of rule following without the ability to cite higher level rules, or to repeat the performance or without training. She comments:

[I]f we agree with the thought that someone might be able to solve Rubik's Cube even if she had never been trained by anyone, then this gives us a reason to reject the idea that there must be an internal connection between the rules that govern an activity and the individual who makes the moves. We can say that it is sometimes enough to credit someone with playing the game if she acts in accordance with the rules. Knowledge (implicit or otherwise) has dropped out of the picture. To insist that someone cannot solve the puzzle unless she somehow conceives the rules (even if she cannot articulate them, even to herself) and acts in the light of her conception of the rules is simply dogmatic. What would justify such insistence? If this person were suddenly entered in a contest and produced the cube with the colours in the right places, we would not withhold the prize because she merely acted in accordance with, but did not follow, the rules. Acting in accordance with the rules is solving the puzzle in certain cases. [Tanney 2013: 85-6]

On this account, having rejected a number of potentially necessary substantial claims as in fact unnecessary for rule following, Tanney concludes that, in the right context, mere accord with a rule constitutes rule following. Further, this does not seem to be merely a claim about the epistemology of the ascription of rule following – where, indeed, in the right context, apparent accord warrants the further ascription of intentional rule following – since Tanney connects it to the rejection of an internal connection between rules and agent. An epistemological interpretation, by contrast, is consistent with maintaining that accord in performance is evidence for such a connection, amounting to the grasp of the rule by the agent. Instead, and in response to a number of bogus explanations of rule following which fail because they presuppose precisely the abilities they purport to explain, Tanney offers a kind of deflationary approach. The failure of cognitivist explanations of rule following leads to a rejection of cognition.

To insist that someone must conceive the rules somehow – even if what it would be for her to conceive these rules is inaccessible to us – is misguided; it fails to explain anything. [ibid: 86].

Despite this support, the 'no conception' version of primitive normativity faces a key objection. It severs the connection between even primitively rule-governed behaviour and intentional action and blurs the distinction between mere accord with a rule and intentionally following it. Unless the child thinks of her actions, whether uttering numbers or physically sorting colours, as expressive of some conception of what she is trying to do, and thus might fail to do, it is hard to see how this can count as even primitively normative. Furthermore, it opens up the possibility of deploying Kripkean arguments about the interpretation of the actual moves made. Without the possibility of invoking the rule – expressed in local demonstrations – that the child's finite moves expressed there seems no possibility, short of simply imposing some external platonic standards of correctness which has nothing to do with the child's view of things, for narrowing down the infinite possibility of divergent ways of going on but which happen to accord with the child's actual moves so far. One needs at least some conception of the rule being followed to uphold the difference in principle between a merely dispositional parrot, whose behaviour may accord with a rule available to a third person description, and a human subject with some sense of her new moves fitting or belonging with what went before, some sense of normative correctness.

A 'local conception' view of primitive normativity

There is, however, no need to get into such difficulty if the aim is merely to fit an intuitive description of the phenomenology of the child's early performance in, as we might say though they cannot, counting in twos or grouping by colour. The middle ground between dispositional accord with a rule and full-blown conceptual normativity is not the primitive normativity of someone with no conception of what she is doing but rather the primitive normativity of someone with a merely local conception. Such a conception is not tied to the local context of counting or sorting objects brutely or merely externally in virtue of an ascription of rule-accord by an observer. Rather, it is expressed by the demonstrative judgements of the child and her capacity to demonstrate and explain by example what fits with what she has been doing.

This idea runs counter to one of Ginsborg's explicit claims: 'I maintain that there is a sense in which you ought to say "125," given the finite list of your previous uses, independent of what meaning, if any, those uses expressed' [Ibid: 232-3 italics added]. On the 'local conception' view, this is wrong. Correctness is tied via a local conception to what a speaker's past utterances expressed even if the speaker is unable to offer a context-independent linguistic codification of her actions as instances of following the plus-two rule or the sorting of green objects. Her conceiving of her actions might not extend very far up the natural numbers (eg beyond 100) or to cover darker or lighter shades of green (by contrast with the vivid colours of children's toys). So it is potentially doubly local: expressible only in some particular contexts of practical demonstration (by contrast with context-free linguistic codification) and covering only some particular instances and thus not actually extensionally equivalent to our concepts of plus two, or green but rather a primitive version of them.

I suggested that there is a further strategic reason why this view is unavailable to Ginsborg. She deploys the idea of primitive normativity as a novel response to Kripke's sceptical argument in contrast, for example, to McDowell's argument that Kripke's argument presupposes unargued reductionism [McDowell 1984]. Her aim is to sidestep the arguments Kripke deploys against any justification one can currently offer for knowing what one meant in the past by one's words which thus seem to undermine a standard of correctness for current use. Primitive normativity must, for those strategic purposes, be independent of any conceptual conception. A local conception is, however, a form of conceptual conception and its expression in a past finite pattern of examples is just as much subject to Kripke's argument as a full-blown linguistic concept. It cannot be part of a new defence of meaning against Kripke's argument. Thus a commitment of such a view is that more direct rebuttals of Kripke, such as McDowell's, can turn aside the sceptical argument without particular appeal to primitive normativity.

A 'local conception' view of primitive normativity and language learning<o:p></o:p>

Primitive normativity guided by a local conception of what a speaker is doing promises a partial answer to the initial two-fold challenge of describing language learning. One aspect of Fodor's challenge was to sketch a rational mechanism for concept acquisition or learning. On the assumptions that a) the only plausible option is hypothesis formation and testing and b) hypothesis formation presupposes the very conceptual mastery in question, no rational mechanism seems possible.

Primitive normativity understood as involving a local – rather than no – conception of a rule or concept is a plausible intermediary between mere dispositional accord with rules and full-blown linguistic mastery. The intermediate stage involves testing the hypothesis that a new linguistic concept either expresses a content previously grasped in some local demonstrative manner or refines and extends it. As suggested above, the grasp of a full-blown linguistic concept may require the piecemeal extension of a more primitive, merely local conception of a rule. But there may be some gradations of understanding between having no and a first language.

Of course, the very idea of an essentially situation-dependent conceptual understanding does not fit within the basic idea of Fodor's representational theory of mind according to which content always has an inner vehicle. So no such middle ground is available to Fodor himself. Thus for anyone uneasy with Fodor's innativism, his argument against language learning remains a powerful reductio ad absurdum of his representationalism. But the idea does provide a way to begin, at least, to address the version of his argument against learning, mentioned at the start of this paper, framed in terms of prior concept possession but agnostic about Fodor's account of inner vehicles of content. Other people's use of the word 'green' – expressing in their case full-blown conceptual mastery – can be compared by the novice with their own prior local conception. Fodor's charge of circularity – that the same concept is both learnt and presupposed – can thus be avoided.

What of concept acquisition given an anti-reductionist view of meaning? A local conception offers only partial progress here. By contrast with Ginsborg's own account of primitive normativity, the idea that normativity always presupposes that the subject has some, albeit local, conception according to which she acts provides no middle ground between the 'space of reasons' and the 'realm of law' or the 'manifest image of man in the world' and the 'scientific image'. Even a local conception belongs in the space of reasons. So it cannot be part of a route into that space from outside. But it does help put a little flesh on the bones of the idea that 'light dawns gradually over the whole'.

'The whole' need not merely be understood to be the gradual acquiring of a world view, as Wittgenstein describes in On Certainty (from where the phrase comes) [Wittgenstein 1969 §141]. It can also include the piecemeal acquisition of particular primitive, albeit still conceptually structured, rules. Acquiring a new linguistic concept can be mediated through the grasp of normative rules picked out by only some instances. The sorting of green objects, in Ginsborg's example, may express a rule which governs only a subset of green objects leaving the learner baffled or undecided by very dark or light greens or clear green glass or green light. It would then be a further step to a full-blown linguistic concept of green construed, for example, as a property of objects. The primitive local conception would be consistent with a range of possible extensions and developments and serve as just a step, or part of the route, towards full-blown conceptual normativity. On the other hand, however, understanding primitive normativity as expressive of a local conception governing a local standard of correctness already places it within the conceptual realm or the space of reasons. It does not offer an account of how conceptual normativity can be bootstrapped from non-conceptual dispositions but does suggest how more complex and abstract concepts cane be developed from more primitive local forms.

Conclusions<o:p></o:p>

Ginsborg's account of primitive normativity promises both to underpin a novel response to Kripkean scepticism and also to suggest a halfway house for concept learning. In this paper, I have outlined two possible versions of primitive normativity: a 'no conception' and a 'local conception' version. Only the former could plausibly be thought to underpin a novel response to Kripkean scepticism but it fails to account for a key aspect of normativity. That is, that an agent acts intentionally under some conception of what he or she is doing. The alternative 'local conception' cannot form part of a novel response to Kripkean scepticism because it is as vulnerable to sceptical hypotheses concerning what one meant in the past, or the rule one was following, expressed in either general or context-independent terms. Of course, whether or not it is so vulnerable depends on whether such scepticism can be turned aside by other arguments [eg McDowell 1984]. However, the local conception does suggest at least a partial response to the question of how concept acquisition or language learning is possible. An intermediate step to full-blown conceptual mastery is the acquisition of locally expressed concepts. These both require context-bound demonstrative expression and may, additionally, under-determine the extension of subsequent linguistically codified concepts.

References<o:p></o:p>

Fodor, J. (2008) LOT2: The language of thought revisited. Oxford: Oxford University Press

Ginsborg, H. (2011) 'Primitive Normativity and Skepticism about Rules' The Journal of Philosophy 108: 227-254

Hattiangadi, A. (2006) Oughts and Thoughts: Rule-Following and the Normativity of Content. Oxford: Oxford University Press

Kripke, S. (1982) Wittgenstein on rules and private language. Oxford: Blackwell

Kusch, M. (2006) A Sceptical Guide to Meaning and Rules: Defending Kripke's Wittgenstein, Chesham: Acumen

Luntley, M. (1991) 'The transcendental grounds of meaning and the place of silence' in Puhl, K. (ed) (1991) Meaning Scepticism, Berlin: de Gruyter: 170-188<o:p></o:p>

McDowell, J. (1984) 'Wittgenstein on following a rule' Synthese 58: 325-363<o:p></o:p>

McDowell, J. (1994) Mind and World. Cambridge, MA: Harvard University Press

McDowell, J. (1998) Meaning knowledge and reality. Cambridge, MA: Harvard University Press

Tanney, J. (2013) Rules, Reason and Self Knowledge. Cambridge, Mass.: Harvard University Press

Wittgenstein, L. (1953) Philosophical Investigations, Oxford: Blackwell

Wittgenstein, L. (1969) On Certainty. Oxford: Basil Blackwell
Tim Thorntonhttp://email@example.com:blogger.com,1999:blog-6658432996374251907.post-56035027280081599672015-04-22T09:57:00.000+01:002015-04-22T09:58:54.119+01:00Student experience and the proper aim of a university

My university has launched an admirable initiative to ask its staff what our conception of the University is. One discussion prompted me to think about one specific aspect.

Two initial caveats. UCLan successfully serves a laudable educational and social function. Many of its students are first generation university attenders. They seek out and get a good, and I think life-transforming, education. The contrast between that idea and going to university as a mere upper middle class finishing school is one of the reasons I found being in Durham less inspiring than I had hoped. (I wore a UCLan hoodie out and about when my social hackles rose.)

Interestingly, also, UCLan students enjoy life in the city of Preston which might not seem as obviously lovely as other northern cities such as York. The relation between the university, the city and what the students manage to make of things themselves makes the experience a good one. They report good things about living here and hence enjoy their time at the university.

UCLan prides itself on that last idea. And why not, given the sacrifice that many of our students and their families make to come? Why would we not worry about the nature of their overall experience? We do and this is reflected in careful attention to national student survey results, SSLCs, and committees called Student Experience Committees (on one of which I serve). Nothing to follow, goes against that.

But although I think that the positive nature of our students' experiences of the university is something to be actively sustained, there is something a little odd first about the way that becomes a kind of singular but general abstract noun: 'the student experience'. Now one might worry that such a phrase undermines or ignores the variety of student experiences. But I wonder more broadly whether we should make the high quality of student experience – important though it is – our aim.

Here's the thought. Whilst the outcome of a good 'student experience' is to be desired, perhaps we should not aim at it. By aiming at it, we'll miss. But if we aim at a different target we might get it as well.

So first: there's a distinction between a description and an aim. Universities might or might not support an outcome. It may or may not be – descriptively – true that their students have a good experience of university life. A distinct question is whether that is an aim. There is then a subtle further prudential issue: even if such an outcome is desirable, should it be the target of university policy? My hunch is that it shouldn't be the primary policy.

Two problems strike me about taking student experience as the aim. First, it fails to distinguish between a proper aim for a university and for the pubs and clubs that also cater to student life. Since the university's conception of 'experience' is implicitly distinct why not say so. The word 'experience' misleads. Second, although that word might be understood to mean 'overall' or 'over time' or even 'over a lifetime', it suggests something both more momentary and concerning which the student him or herself is an authority. Again, although that seems appropriate when thinking about the service a pub or club offers, it doesn't seem right for a university.

The reason for this is that getting an education should be a profoundly transforming experience, moulding and shaping adult character, affecting one's capacity for thought, reflection and sensitivity to the demands of whole new tracts of the space of reasons. Given that it changes the subjects who undergo it, there is no reason to think them authoritative about its nature in the short term nor that that it should always seem, at the time, a positive experience. For example, changing one's mind about something, coming to see that one was wrong, that one weighed the factors hastily or was blind to some important reasons can be an unpleasant experience but no less right for that. But even reading Kant, or Wittgenstein, McDowell or Travis can be less than enjoyable at first, can be a bad experience in one sense of that word.

If we aim to educate our students, they will overall have a positive experience. Surely better to aim at education, in the deepest sense of that word, and let the experience follow than to aim at the experience and hope that the education follows.
Tim Thorntonhttp://email@example.com:blogger.com,1999:blog-6658432996374251907.post-23198572795422147752015-04-08T15:10:00.002+01:002015-04-08T15:11:29.042+01:00Health Research with Real Impact Conference June 24-25 2015

Health Research with Real Impact Conference
June 24-25 2015
University of Central Lancashire
Westleigh Conference Centre

Day 1 – How evidence synthesis can have a real impact
The focus of the first day will be around evidence synthesis with Keynote speakers:

Professor Jenny Popay – Mixed Method Reviews,

Dr Justin Jagosh – Realist synthesis and

Dr Claire Glenton – Cochrane EPOC Reviews

Day 2 – Implementing evidence in practice
The second day will be around Implementation science with Keynote speakers:

Professor Kate Seers – Findings from the FIRE randomized controlled trial,

Professor Christopher Burton – Co-producing evidence for improvement and

Dr Henna Hasson – Implementation in complex interventions.

Attending the conference will be a range of staff from health and social services, methodologists, academics and health care users.

Day delegate rate: £30 for 1 day, £50 to attend both days

UCLan staff & students – book early for a free place (numbers limited)

Lunch and networking opportunities for all

To register please contact the Research Support Team at email@example.com Thorntonhttp://firstname.lastname@example.com