Tim Thornton

On the very idea of a recovery model for mental health

The recovery model has been put forward as a rival to the biomedical model in mental healthcare. It has also been invoked in debate about public policy for individual and community mental health and the broader goal of social inclusion. But this broader use threatens its status as a genuine model, distinct from others such as the biomedical model. This paper sets out to articulate, although not to defend, a distinct recovery model based on the idea that mental health is an essentially normative or evaluative notion. It also aims to show that, supposing this suggestion were to be followed, the norms informing our notion of recovery would be more appropriately construed as eudaimonic than as hedonic in character.

Thought insertion, cognitivism, and inner space.

Introduction. Whatever its underlying causes, even the description of the phenomenon of thought insertion, of the content of the delusion, presents difficulty. It may seem that the best hope of a description comes from a broadly cognitivist approach to the mind which construes content-laden mental states as internal mental representations within what is literally an inner space: the space of the brain or nervous system. Such an approach objectifies thoughts in a way which might seem to hold out the prospect of describing the “alienated” relation to ones own thoughts that seems to be present in thought insertion.1 Method. Firstly, I examine the general structure of cognitivist accounts of intentional or content-laden mental states. I raise the general difficulty of explaining how free-standing, and thus world-independent, inner states can still have bearing on the outer world. Secondly, I briefly examine Friths model for explaining thought insertion and other passivity phenomena by postulating a failure of an internal monitoring mechanism of inner states. I question what account can be given of non-pathological cases and raise two specific objects. Results. Cognitivist accounts of the mind face a general, and possibly insuperable, challenge: explaining the intentionality of mental states in non-intentional, nonquestion-begging terms. There have so far been no satisfactory solutions. Cognitivist accounts of passivity phenomena in terms of a failure of internal monitoring face two objections. Firstly, accounting for non-pathological cases generates an infinite regress. Secondly, no account can be given of the paradoxical nature of utterances of the form of Moores paradox: “it is raining but I do not believe it”. Conclusions. A cognitivist approach presents an alienated account of thought in normal, non-pathological cases and is no help in accounting for thought insertion.

Radical liberal values-based practice

Values based practice is a radical view of the place of values in medicine which develops from a philosophical analysis of values, illness and the role of ethical principles. It denies two attractive and traditional views of medicine: that diagnosis is a merely factual matter and that the values that should guide treatment and management can be codified in principles. But it goes further in the adoption of a radical liberal view: that right or good outcome should be replaced by right process. I describe each of these three claims but caution against the third.

Language, games and the role of interpreters in psychiatric diagnosis: a Wittgensteinian thought experiment

British society is becoming increasingly culturally and linguistically diverse. This poses a major challenge to mental health services charged with the responsibility to work in ways that respect cultural and linguistic difference. In this paper we investigate the problems of interpretation in the diagnosis of depression using a thought experiment to demonstrate important features of language-games, an idea introduced by Ludwig Wittgenstein in his late work, Philosophical investigations. The thought experiment draws attention to the importance of culture and contexts in understanding the meaning of particular utterances. This has implications not only for how we understand the role of interpreters in clinical settings, and who might best be suited to function in such a role, but more generally it draws attention to the importance of involving members of black minority ethnic (BME) communities in working alongside mainstream mental health services. We conclude that the involvement of BME community development workers inside, alongside and outside statutory services can potentially improve the quality of care for people from BME communities who use these services.

Wittgenstein and the limits of empathic understanding in psychopathology

The aim of this paper is three-fold. Firstly, to briefly set out how strategic choices made about theorising about intentionality or content have actions at a distance for accounting for delusion. Secondly, to investigate how successfully a general difficulty facing a broadly interpretative approach to delusions might be eased by the application of any of three Wittgensteinian interpretative tools. Thirdly, to draw a general moral about how the later Wittgenstein gives more reason to be pessimistic than optimistic about the prospects of a philosophical psychopathology aimed at empathic understanding of delusions.

Psychopathology and Two Kinds of Narrative Accounts of the Self

THE SELF PLAYS an important role in psycho pathology. Conditions such as dementia raise the question of how much loss of memory and awareness there can be before there is, if ever, also a loss of the self. Syndromes such as Dissociative Identity Disorder (DID) or Multiple Personality Disorder (MPD) raise the possibility of a fragmentation of one self into a number of selves. Depersonalization disorder suggests a kind of diminution both of the sense of self and the reality of the world. Symptoms such as thought insertion suggest a different kind of fragmentation of the coherence of thought within a self. At the same time there is something prima facie paradoxical about the very idea of the fragmentation or loss of self. It seems to be one thing for a self to suffer loss, quite another to think of the self as being lost. Although the experiences or beliefs had or entertained by a self might be disordered or chaotic, how can a self be anything other than whole and seem real and whole to itself? The narrative approach to the self looks like a tool purpose built to shed light on some aspects of psychopathology. The papers in this issue have examined its application to four revealing case histories and questioned its effectiveness in accounting for features of psychopathology. But in this short note I wish to stand back from the particular cases discussed in previous papers and to shed light on the general approach by setting out two contrasting versions of it. Crudely put, the first forges a connection between the concepts of self and personality; the second between the concepts of self and person. I will use the contrast between these two to draw some general lessons for the philosophy of psychopathology.

Reliability and Validity in Psychiatric Classification: Values and neo-Humeanism

“On those remote pages [of the Celestial Emporium of Benevolent Knowledge] it is written that animals are divided into (a) those that belong to the Emperor, (b) embalmed ones, (c) those that are trained, (d) suckling pigs, (e) mermaids, (f) fabulous ones, (g) stray dogs, (h) those that are included in this classification, (i) those that tremble as if they were mad, (j) innumerable ones, (k) those drawn with a very fine camel hair brush, (l) others, (m) those that have just broken a flower vase, (n) those that resemble flies from a distance.” (Borges 1966, 108)

Judgement and the role of the metaphysics of values in medical ethics

Despite its authors’ intentions, the four principles approach to medical ethics can become crudely algorithmic in practice. The first section sets out the bare bones of the four principles approach drawing out those aspects of Beauchamp and Childress’s Principles of biomedical ethics that encourage this misreading. The second section argues that if the emphasis on the guidance of moral judgement is augmented by a particularist account of what disciplines it, then the danger can be reduced. In the third section, I consider how much the resultant picture diverges from Beauchamp and Childress’s actual position.

Capacity, Mental Mechanisms, and Unwise Decisions

The notion of capacity implicit in the Mental Capacity Act is subject to a tension between two claims. On the one hand, capacity is assessed relative to a particular decision. It is the capacity to make one kind of judgement, specifically, rather than another. So one can have capacity in one area whilst not having it in another. On the other hand, capacity is supposed to be independent of the ‘wisdom’ or otherwise of the decision made. (‘A person is not to be treated as unable to make a decision merely because he makes an unwise decision.’ [Department of Constitutional Affairs 2005: section 1].) One may have capacity even if the decision one arrives at is seen as unwise by one’s doctor. In this short note I will explore this tension. By saying that there is a tension between these two claims, I do not mean that they are inconsistent. They can both be true. But there is a natural way of thinking about the first claim, suggested by the second, which is false and accommodating both in its absence puts limits on just how atomic or decision specific capacity can be.

Narrative rather than Idiographic Approaches as Counterpart to the Nomothetic Approach to Assessment

As part of its Institutional Program on Psychiatry for the Person, the World Psychiatric Association has called for an idiographic element to be added to psychiatric diagnosis to complement criteriological and dimensional elements. Such a call, however, prompts the question of what kind of additional element this is. Just what is meant by idiographic understanding and how, exactly, does it complement, by being distinct from, other elements within psychiatric diagnostic judgement? The first half of this paper continues discussion from an earlier paper [Thornton: Eur Arch Psychiatry Clin Neurosci 2008;258 (suppl 5):104–109] to consider the idea, inspired by Wilhelm Windelband’s rectoral address of 1894, that idiographic judgement is distinct because it is a special kind of ‘individualised’ judgement about individuals. I argue, however, that the most promising interpretation of this idea falls prey to Wilfrid Sellars argument against the Myth of the Given and thus it cannot be a genuine complement to criteriological diagnosis. In addition to this idea, however, ‘idiographic’ has also been used to label narrative judgement. The second half of the paper highlights how narrative judgement, shorn of any connection to metaphysical theories of the self, is an essentially normative form of judgement that contrasts with, and can thus complement, criteriological diagnosis.