Tuesday, 20 February 2018

moral character, illness, and the mind

What is it that makes for illness? In trying to answer this question we are perennially tempted to look toward the causes of illness - diseases for example - and away from the work that the concept does for us. In what follows I pay closer attention to that work by relating the concept of illness to that of character. The discussion also considers the question of what we are to make of the concept of mental illness and how it relates to physical illness. I shall both draw on and dispute a claim of Wittgenstein's and a claim made in a paper by T S Champlin. The remark from Wittgenstein is (Culture & Value p.54) 'Madness need not be regarded as an illness. Why shouldn't it be seen as a sudden - more or less sudden - change of character?' First however I turn to Champlin's paper.

Champlin is amongst those who consider the concept of 'mental illness' to be derived from 'physical illness' or, more perspicuously, from what, before the concept of 'mental illness' was invented, was simply called 'illness'. Unlike those (like Neil Pickering) who consider 'mental illness' a conceptual metaphor, Champlin considers it formed by 'secondary sense' and offers an analogy to help us grasp this. The analogy suggests the model of a 'rhyme for the eye' which stands to a 'rhyme for the ear' in the same kind of relation as 'mental illness' stands to 'physical illness'. So just as we may call the end of two lines of poetry which look the same even if sounding differently (...he'd read quite enough / ...of The Golden Bough) a 'rhyme for the eye', so too we may talk of an 'illness of the mind' even when we don't have to do with such features as are essential to illnesses 'of the body'.

But what is it that grounds (by way not of justification but of inspiration) the extension? Champlin suggests that 'the counterpart to position at the end of the line which facilitated the extension of the word 'rhyme' to cover rhymes for the eye but not the ear was that, typically, the mentally ill have in common with the physically ill the fact that they behave in ways similar to the physically ill. They often look ill and fail to carry on with their normal lives and need to be cared for by others.' Well, I don't buy this. For those who are mentally ill often don't look ill, they may never really have had normal lives or may be carrying on with what for them is a normal life in a mentally ill way, and they may not need to be cared for by others to a greater extent than the rest of us. These consequential difficulties do not take us into what it is for the mind to itself become 'ill'. So I suggest we keep the analogical idea - mental and physical illness needn't share something in common in virtue of which they are both illnesses; instead of something in common we need to look for a counterpart - but think again about what the counterpart is.

Wittgenstein asks - in what was presumably intended as a rhetorical question, although I shall treat it otherwise - why we don't talk not of mental illnesses but of sudden changes in character. The remark does the helpful work it does by virtue of shaking us out of the idea that we could, with our concept of 'mental illness', meaningfully be said to here have hit upon 'the right concept'. (We play the language game, and that's enough.) It also helpfully brings the concept of 'illness' into relation with that of 'character'. But what I want to suggest is that the whole point of the concept of 'illness' is that, precisely, we don't sanction an inference to the idea of a change of moral character, and that the whole point of 'mental illness' is that we may continue to draw on such exculpatory benefits in cases where the attribution of a character change is even more tempting.

Here's my main claim: Illness essentially involves changes in personal disposition which would, unless we reference that defeating condition which is the illness ascription itself, be seen as constituting a decline in moral character. Thus when we are ill we are disinclined to work, to take care of our responsibilities to others, to exercise our talents, to enjoy our appetites for life, to cultivate and spread hope. We are instead inclined to withdrawal, sloth, pessimism, self-preoccupation. Were such changes to happen to someone in the absence of disease we should say of that person that they had developed a poorer character. Such habits essentially find a negative moral evaluation, but thankfully we may be excused by being ill! The concept of 'illness' allows us to keep our virtues intact, if you like. In this way the concept of 'illness' does important work in regulating our social and occupational interactions. We cut the ill person some moral slack, discharge them of responsibilities, give them a sick note, do not hold them accountable for incompetencies to the same extent, etc. That the concept should be open to abuse by the pity-seeker or the work-shy is an important part of it. But another important part of it is that the mentally competent adult who is ill is able to acknowledge that he is ill. That he can do this is also an important part of our not ascribing character change to him. He himself offers illness as a legitimate excuse.

Now what about mental illness? What I suggest is that the excusing function of the concept of 'illness' is also central to the identity of 'mental illness'. And the person we call 'mentally ill' also starts to do things which would, were it not for the leeway we afford her, be judged as showing failure of moral character. She becomes preoccupied with herself, she stops respecting the shared norms that constitute conversational sense, she shows failures in courage and resolve, she shows less solicitude with others and does not make genuine heartfelt emotional contact with them. In short she demonstrates what looks to be a deficiency of humanity. Were it not for our saying of her that she is mentally ill then we should say of her that she was not being her better self, and if the difficulties were enduring then we should say that she had a change of character for the worse. However, the person who is the paradigm of the mentally ill has 'lost touch with reality'. Unlike the physically ill adult, she does not say of herself that she is ill. She may have moments of insight and during those say that she is unwell at the moment. Or she may look back at her past thoughts and deeds and say 'I was really ill during that time'. But in the moment of mental illness itself she does not say of herself 'this is illness'.

It is this, I am suggesting, which discriminates the mentally from the physically ill. In both cases the positive functioning of the concept is to defeat a moral judgement to do with bad character. In the physical case it works through citing bodily ailment: the person, we now allow, has the same good character, it is just that his character enactment is currently blocked by his bodily infirmity. In the mental case we also find the same helpful defeating function, and here we also say that the person is 'not herself' rather than that she has succumbed to vice. And we do this even though she in her adult self is not willing to say 'I am ill'. She 'lacks insight' and this lack is constitutive of her illness being a mental illness; she suffers a detachment from reality i.e. a foundational disturbance in her reason (notice I do not write: 'in her reasoning').


Addendum: The above discussion aims to discern some underlooked necessary, although not of course sufficient, conditions for talk of illness. I thought just append here what seems essential to me in illness generally and mental illness in particular. Whilst we may have what today we call a disease without feeling dis-easy, we become ill when we are, for example, overwhelmed by a disease. When you get the flu, for example, your body is overwhelmed. For a while you might have been 'fighting off' the virus. But then it gets to a point when your usual homeostatic mechanisms that maintain ordinary energy and balance collapse. You get a temperature, can't muster energy, feel hot and cold and achey all at the same time. Your health has broken down.

In mental illness you also suffer a 'break down'. The breakdown here is of the normal processes which keep you from being overwhelmed by painful emotional experience. Normally we find ways to deal with shame, grief, guilt, envy, fear, anxiety, and anger. We symbolise them in words and encase them in narratives, we take appropriate assertive action, we take time out to grieve i.e. to accommodate to loss. When this doesn't work we sublimate or repress. But when even these defences break down we become overwhelmed. This, I believe, is the basis of the use of illness talk when it comes to the mind. What we analogise between is the overwhelm of the normal self-regulating mechanisms in the case of bodily illness and in the case of emotional experience. The person who breaks down is no longer able to cope with reality. In the case of mental illness it is because what we call 'symbolisation' breaks down (i.e. the ability to put as yet inchoate affect into thinkable form is overwhelmed). In the case of physical illness it is because the regulation of appetite and energy provision and temperature breaks down. The analogy is so natural that it is surprising that the concept of mental illness didn't become more widespread earlier than it did.

Monday, 19 February 2018

real hallucinations

Here are some merits of Matthew Ratcliffe's new book: 
  • He listens to what patients say and so develops a discussion which (like Merleau-Ponty's)
    turns away from philosophers' idealised hallucinations to look at the symptoms of actual hallucinators.
  • He attends to disturbances to the modal structure of intentionality itself. He considers that psychotic experience, in particular, may involve breakdowns in the individuating polarities of different modes of experience (imagination, perception, etc.). So we don't have a business-as-usual set of psychological categories (faculties) in which to place hallucination.
  • He draws on the promising phenomenological idea of a form of anticipation which is constitutive in different ways of different kinds of experience. Different types of experience, he says, incorporate their own characteristic patterns of anticipation and fulfilment. 
  • He inscribes sociality at the heart of selfhood, rather than preserving some notion of a 'minimal self' which precedes or underpins such self-experience as is constituted by or in relationship.
  • He draws on this relational conception of selfhood to make really important links between form of social engagement, phenomenological matters of form, and emotional and psychodynamic matters of content. This, as I see it, really is the oft-unacknowledged holy grail of psychopathology: to grasp the relationship between the emotionally salient meanings of a person's life and the form taken by their psychopathology.
Here are what I take to be the central elements of his theory:
  • Hallucinations obtain on continua - for example they are experienced as arising both within (as more thought-like - in which case they are also on a continuum with thought insertion) and without (more sensory).
  • Those experienced as arising without are due in part to misperception. Shame - a pervasive social emotion in those who suffer psychosis - may prevent using other's minds to reality test the experiences (p. 98).
  • Hallucinatory voices may constitute what R. E. Hoffman calls the 'repopulating' of a 'barren interpersonal world' - one might say that they are not just hallucinations of voices but of otherwise absent relationships (p. 99).  
  • Those experienced as arising within are due in part to (p. 82) anxiously anticipating an increasingly determinate thought content.
  • Just as (p.85) 'fear of something that is taken to be past could disrupt the sense of that event as firmly anchored in the past', so might 'anxious anticipation induces verbal hallucinations... by shaping the sense of which intentional state one is in. ... Anxious anticipation of p ... contributes to the experience of relating to it in a perceptual or perception-like way. Anxiety is not ordinarily associated with our own thought contents and, when it is associated with them, they are experienced as the contents of a perception-like intentional state that also retains some of the features of thought.'
  • Against the objection that we often anxiously anticipate what we are thinking about - without thereby hallucinating it (for example we might anxiously anticipate an intruder hiding in the cupboard) Matthew replies that he is not talking about our anticipation of what we are thinking about (the robber) but about the thinking itself (we are anxiously anticipating our thoughts about the robber).
  • Consider abusive voices (p.89): 'in the case of an abusive "voice", there is an unpleasant emotional content p, which provokes anxious anticipation of a more determinate linguistic content q, one that is elicited by p and also consistent with p. Anxiety is intrinsically alienating and so its object, the thought that q, is experienced as alien, as something unpleasant that one faces and is unable to avoid. Whatever forms of anticipation our thinking more usually involves, anxious anticipation of thought content is not one of them. That style of anticipation is more typical of certain affectively charged perceptual experiences. So an unfamiliar, perception-like experience of thought content arises.'
  • Such hallucinations are experienced as not being self-caused, even if experienced within, because (92) 'the sense of being immersed in a shared world is already altered and diminished. None of the person's perceptions and thoughts are embedded in a public world in the way they once were, and so the ordinarily taken-for-granted distinction between a consensus reality and his own experience of it is eroded.'
  • Verbal hallucinatory 'contents ...are crystallisations of negative, self-directed emotions that reflect ... estrangement from the social world.'
  • Why are hallucinated voices are attributed by 'voice hearers' to particular subjects? Matthew suggests (95) that the thematic consistency of what the voice 'says', the 'voice-hearer's' imaginative elaborations, and confusions between imagining and perceiving all feed into what he calls the 'personification' of the hallucinated voice.
Here are some issue-takings:
  • Matthew accepts the notion that to perceive, think, remember etc is to be in an intentional state. I take no issue with the philosophical idea of intentionality; it's the relevance of the category of state I object to here. We (and other things) are in states and do not have them; states progress from one form to another; we are not in more than one at a time (if we are in a state of confusion and tiredness, we are in one not two states); states have no composition or location (Roger Squires 1970). Perhaps this seems phenomenologically fussy of me; well, perhaps I am fussy. But I think this kind of talk has risks - that it encourages a tacitly objectified conception of the exercise of perceptual and intellectual powers which illegitimately turns such exercises themselves into possible objects of transitive consciousness - objects of a transitive consciousness which may then go wrong (resulting in psychopathology as conceived by the philosophical psychopathologist). That it does encourage a reified conception of intentionality is, I think born out by the rest of my concerns which now follow.   
  • Matthew's approach seems to me to reify or psychologise the notions of 'thought' or 'content'. As I see it, thought qua content, rather than qua thinking, is a purely formal, logical notion. What it is for my hearing and seeing and thinking and imagining a cat to share the same content (a cat) is that I would use the same words to express what they were of ('a cat'). This content is not any kind of thought in the mind and is not something to which we can turn our attention (er unless by 'turn our attention to a content' we simply mean 'answer the question as to what we think or hear or...'). (I will revise this if I've got it wrong!)
  • Matthew appears to accept the notion, popular amongst certain phenomenologists who sit close to the philosophy of mind (e.g. Dan Zahavi), that our exercises of our perceptual and agential and rational powers come along with a a form of automatic 'self-consciousness'. Where by 'self-consciousness' here is not meant the ordinary idea of awkwardly feeling under inspection but rather a form of awareness of our own exercise of such powers which awareness is of both the type of the power (seeing, remembering, etc.) and the content of the intentional act (that cat again). He tells us that 'if I look at something and have a visual experience of it, I appreciate that I am perceiving it (and, more specifically, perceiving it visually), rather than imagining or remembering it. ... Put crudely, it is like something to remember, which differs from what it is like to perceive.' I think this approach is wrongheaded (i.e. not right or wrong) and will now try to say why (see also Peter Hacker 2006 and Joseph Schear 2009).
    • So, yes, I'm not going to claim instead that there isn't anything it is like to remember or perceive or... My claim instead is that talk of there being something it is like to remember or perceive is misconceived, as is talk of appreciating that we are exercising this or that mental power (hearing, remembering, etc); the idea that seeing and remembering strike us similarly or differently itself strikes me as peculiar. 
    • What is it that motivates the idea that there is something it is like to see a black cat? I suspect that one motivation is the notion that knowledge requires reasons. So let's accept (which I don't really) that it definitely makes good sense to say (in whatever context - that of us looking at a cat, say) that you know that you see a cat - both that it's a cat and that you see it. Then we might think to ask 'How do you know that you are experiencing it visually?' And then we might think we need an answer like 'Seeing strikes me a particular way', or 'Part of my visual experience is a pre-reflective auto-affection in which the modality is 'given' to me in self-consciousness. It is because of the deliverances of this inner sense that I know what sensory modality I'm in.' But, ok then, what is it like to see as opposed to smell a cat? Please tell me! It's no use waving around vague words like 'something', 'it', etc. - for, surely, if someone asks what it was like to go on the big bouncy castle then there being something that could form the content of an answer itself supplies the question with a purpose and a sense. 
    • So too I may sensibly ask my neighbour how she knows that her cat - this cat here, wrapping itself around our legs, of visually indeterminate sex (the cat not the legs) - is a boy and not a girl. There is something about the cat (the just about locatable genitals) or the shared testimony (the certificate from the cat breeder) which justifies her claim to knowledge. But I may not sensibly ask her, in that same vein, how she knows that the colour sample in front of her which she is looking at, in normal daylight and with no perceptual barriers or other peculiarities in play, is pink rather than blue. An answer would be possible - for example she could tell me that she learned the names of the colours at school. But note the difference between the two situations: in the one we justify empirical knowledge, in the other we acknowledge the ancestry of conceptual know-how. I suggest that we know that we are seeing rather than hearing only in the same kind of sense that we know that the sample in front of us is blue not pink, or e.g. know what our name is. There is nothing about pink that tells us that it is pink, and there is nothing about seeing that tells us that we are seeing. We don't need telling when it comes to know-how! There isn't something about seeing which tells us that we are seeing. It's not as if we're in the predicament of needing to sort out whether our knowledge is visual or auditory. Similarly with remembering: remembering is not a nothing or a something and there isn't something it is like or unlike to do it. What it is to remember - to exercise this capacity - is to retain knowledge. (Perhaps we could say: what it is like to remember is to not be forgetful!)
    • Finally, there are clear uses of the 'what's it like to...?' question. We use it to compare one thing to another. And we also use it to describe an experience where by 'experience' we don't now mean a perceptual act but rather a multifaceted event like going on a bouncy castle or taking a long walk in the rain. Talk of 'what's it like' and talk of 'appreciating' has its place here. But Matthew is not envisaging such a use for 'what's it like', and so I want to ask 'what use did you have in mind?' (I think there isn't one - i.e. that phenomenologists are here suffering from what Rupert Read calls a 'delusion of sense'. However it occurs to me I may be wrong - and that perhaps the idea of different senses being constituted by differently articulable anticipations gives us the content we need. I will revise this if it turns out I've been confused.)
    • To take it back to hallucination: Matthew theorises hallucination as content apprehended in a modality which modality is appreciated as other than the one it is. I am claiming that content (being merely formal) is not apprehended and that modalities are not appreciated.
  • Matthew's theory (along with various approaches taken by other philosophical psychopathologists) seems to me to sublime the logic of the notion of inner speech. (This is somewhat akin to the psychologising of thought qua content.) What I have in mind is that such theories of hallucination tend to imagine that it is both straightforwardly coherent and informative to say of a hallucinator that they are talking to themselves without realising it - that they have inner speech but mistake it for something more like hearing (or something which in some respects is between thinking and hearing). The idea is coherent yet uninformative if taken as simply definitional of hearing voices. But if it is supposed to do some explanatory work then we will need a criterion for talking to oneself other than one's sincere say-so. But none is forthcoming. Well, I don't think one is... Is there?
  • Finally, on 'personification'. Matthew asks why it is that someone experiences hallucinated voices as coming from particular people. The question is made room for, within the theory, by the fact that it is what I call a 'psychological' theory: namely, it attempts something of a psychological reduction of voice hearing - seeing it as an experience which is made sense of in certain ways. (Unlike certain psychological theorists, Matthew at least allows the sense-making to go on within the experiencing itself. And that surely takes us closer to the phenomenological facts.) I suggest that this gets the phenomenology wrong: hallucinations of voices present themselves ab initio in a range of distinct voices, voices which have tones (high female, low male, etc) utterly different from the speaker's.
Here are some alternative suggestions:
  • Sensori-motor anticipation is an important notion to draw on in a theory of hallucination, and, yes, this anticipation is not to be hived off from the hallucinatory experience itself. However what is anticipated is not that a particular thought qua content will have a particular form. Rather what is anticipated is, after all, the experience of something happening (not 'in the mind' but) in the world (that one will hear someone being mean to you by saying 'you stink', for example). 
  • Such anticipations are forms of readiness or preparedness essential for negotiating social reality.
  • Normally the subject who is in contact with reality 'cancels' or 'relinquishes' such sensori-motor anticipations when they are unfulfilled. This happens automatically. The cancelling of sensori-motor anticipations enables the experience of changelessness.
  • The psychotic subject is not well connected with reality. Some of his or her sensori-motor anticipations are therefore not cancelled despite the absence of the anticipated stimuli.
  • A sensori-motor anticipation which is both unfulfilled and uncancelled simply is an hallucination. A hallucination stands to a perception like a photographic negative stands to a positive (the photo): it is an anti-experience if you like.
  • We can grasp this most easily by thinking on the experience of getting on a broken escalator. We can see that it's broken, and so in one sense do not anticipate that it will move. However in another sense our body still readies itself for getting onto a moving staircase. This is the sense in which we do still anticipate that it will move. But then, of course, the broken escalator does not move. What we then tend to experience, unless we've really gotten used to it, is a lurch. This may seem daft because, after all, you can see that the thing is not moving. However that lurch, which is a feeling as of the escalator moving backwards, is itself the form taken by an unrelinquished anticipation of forward movement in a situation in which no actual movement is detected. It is, if you like, a haptic hallucination; it is a kind of shadow thrown by the sensori-motor anticipation.
  • Other aspects of Matthew's theory I should very much want to maintain. I'm thinking here, in particular, of the focus on loneliness, terror, and especially shame and social anxiety - not just as the psychological context which happens to inspire (be the efficient cause of) the hallucination but as the existential matrix which in-forms or de-forms the modal structure of intentionality. Anxiety doesn't relate to what for some silly reason we call reality-testing ('maximal grip' gets it better, but really we're talking about the ability to instantiate a distinction between perceiving and imagining, not some merely epistemic capacity to tell the two apart - i.e. the problem is that there aren't two modes here any more!) by way of one thing (anxiety) making something else (reality testing) hard to do. Anxiety is the shaking apart of reality-contact itself. When we are badly anxious we find it hard both i) to imagine anything much and ii) to achieve a good experiential understanding of our situation. Finally I should like to retain the idea of crystallisation (pp. 88, 94). Here we have the idea that hallucination involves the condensation of quasi-sensory solid out of an initially diffuse existential atmosphere. I would relate this to the human disposition to 'symbolism' (Langer) more generally - i.e. to what psychoanalysts also call 'dreaming' or 'thinking' - the giving distinct shape to as-yet-unthinkable-because-too-diffuse experiences. However if I read him right I think that Matthew might be thinking that the crystallisations into hallucinations involves the quasi-realisation of what is anticipated, whereas I think they are a function of a failure of the relinquishing of anxiolytically crystallised anticipations despite the absence of their manifest non-realisation. 

Sunday, 18 February 2018

explanation and treatment

In a previous post I urged the importance of distinguishing matters of causal explanation from matters of causal constitution. What I have in mind is that the answer to 'why is he angry?' is not typically to be answered by reference to what happens in his brain, but rather by reference to what happens in his life. Such reference essentially refers to what the angry person says when he gives his reasons for feeling angry. The exceptions however are important. Thus when there is no answer (or no decent answer) to be had from him as to his reasons, then matters to do with changes in bodily constitution, injury, overwhelm, diet etc. are now 'released' to play the role of reasons. What they are 'released' from is their mereological subordination to reasonable reaction (since here, in such exceptional cases, we don't have to do with reasonable reaction). It isn't of course that constitutional matters - bodily mechanisms and bodily changes - suddenly spring onto the scene when reason goes down, but that they can now play a role in that discourse which has to do with reason provision i.e. which has to do with answering 'why?' questions about actions and reactions. What I claimed in that post too was that reasons which appeal to our psychology (dynamic motivational reasons that is - one's which cite the motivated deployment of defences, the motivated avoidance of anxiety and pain, etc.) become available (are 'released') when the provision of ordinary personal reasons (my reasons for acting, the one's I avow) give out. And I suggested too that subpersonal reasons (hormonal, neurophysiological and neurotransmitter anomalies etc) only become available as explanations when both the personal and the psychological reasons fail.

So what I am specifically writing against here is that form of thought which is so keen to demonstrate its all-encompassing scientifically and philosophically unprejudiced prowess that it fails to do adequate justice to the 'helpful prejudice' that is already embedded within our explanatory practices - to the 'prejudice' which says we've gotta start at the top (with my reasons) and only work down (to neural anomalies) when those forms of explanation at the top fail. I am writing against the throw-it-all-into-the-mix bio-psycho-socio-spirituo explanatory models of mental illness, for example. I am claiming that our being constituted by matters chemical, biological, psychological, social, spiritual, etc., and the dependency of our healthy minds on bodies that politely function to support them, do not mean that observations at lower levels of description (how a certain hormone affects amygdala functioning for example) could play a role in explaining why someone acts as they do unless the levels of personal and of psychological reasons fail us. If someone says 'but why can't we have both?' they are still, I think, in the grip of an unhelpful picture, a picture which without warrant transposes stories from a context of inquiry into matters constitutional (about the processes and structures which constitute or subtend our psychological functioning) into the context of inquiry into matters of reason ('why did he wave his arm?' is not helpfully answered by mentioning the tightening of his muscles).

What I want to add here is that this all has implications for rational treatment of psychological disturbance. If I am crazy because my neurotransmitters are de trop then it will not make sense to treat me psychologically. But the reason for this is that what it is for neurotransmitter levels to be de trop is something which has to determined relative to the (un)availability of reason-giving or dynamic motivational explanations for an emotional reaction. For it is perfectly conceivable (even if not actual) that the same level of neurotransmitter activation may obtain in the context of a healthy grief reaction as in the context of an endogenous depression. But in the former case there is no meaning to be had for 'de trop'. This, by the way, gives the lie to those evolutionary accounts of 'neuropsychiatric disorders' (a stupid term which begins ('neuro') where it often shouldn't even end) which want to define what counts as excessive or as misfiring or what-have-you in relation to proper function, where 'proper function' is given in evolutionary terms: is it performing the task it evolved to perform? Such accounts start in the wrong place - from the bottom up - whereas we ought to start from the top down - from the availability or otherwise of personal-level reasons for action. Sure, 'excessive activation' buggers up our psychological functioning, but what makes such activation count as excessive is that what it is doing is not playing its part in the mechanics of what on quite independent grounds we find to be rationally intelligible reactions, but is rather causing reactions which, again on quite independent grounds, we find to be rationally unintelligible. And that, I imagine, should come to all but the excitable theory mongerer as something of a relief - for it might have felt like an exciting intellectual project, but it was surely always rather a desperate long shot, to try and milk normativity out of evolution, and to milk the concept of something like a natural kind so hard that it would explain how our unscientific concept of mental illness, used with normative aplomb by many a scientifically illiterate person, could contain such hidden intricacies.

Back to treatment. The point I want to make is that whilst, with an eye on matters merely constitutional, it might seem to make a breezily unprejudiced kind of sense to say 'well, we could treat the problem with a talking cure, with exercise, or with a pill; all that's happening here is that we're intervening on different levels', in fact this really is far too breezy for its own (and the patient's) good. For a rational treatment, surely, is one which tries to address the reasons why someone is distressed. And if they are distressed because they are grieving their father, or alternatively if they are differently, anxiously/depressively, distressed because their repressed anger at the father leads to aborted grieving, then even if any of this distress or instead this anxious depression is partly (what-shall-we-call-it) 'realised' in a statistically-abnormal-for-them level of dopamine (or whatever), then 'treating' the abnormal dopamine levels will not be treating the cause of the problem. (Where what 'the cause' is is coextensive with the reason, and not with the constitutional mechanics.) ('Treating' goes in inverted commas because it can't really be called treatment if what is 'treated' isn't itself a problem.) In fact, far from being helpfully unprejudiced, such an approach tramples all over the humanity of the patient. For being given extra, or being caused to have reduced, neurotransmitters may reduce the healthily-grieving person's sadness but, since their sadness is their grief, and since what they need to do is to get used to the fact that their father is dead, and since 'grieving' is the name of that process of getting used to his being dead, then to reduce sadness is to interfere with their reality contact itself. Which, er, is not normally what we take for the goal of psychiatric treatment. Or, if we imagine that we have to do with the patient whose depression obstructs healthy grief, then having agitation removed will remove the clue that here we have to do with conflicted feelings (anger and loss) and will leave them in emotional limbo (welcome to zombie land). Only if we had a situation, as yet here un-described, in which the reason why the patient was struggling to grieve was not because of grief's intrinsic hardness nor because of their neurotic ambivalence, but because they have too much dopamine (or whatever), would it make any rational sense to treat them using drugs.

NB the different responses to Prozac: 'I feel numb now' vs 'now I feel far more myself'. Even if they had, pre- and post-treatment, the same level of (say) serotonin as each other, only the second patient had, we might rationally infer, been suffering a serotonin imbalance, and only patient's who had a serotonin imbalance could meaningfully be said to be being treated with Prozac, regardless of the efficacy of the treatment.

Friday, 16 February 2018

how matters mereological constrain reason-giving

Last week I got angry because once again you borrowed my paints without asking. We've talked about this before. It annoys me. Please remember to ask. When this happens my amygdala activation contributes, qua part to whole, to my angry reaction. We could say: it is part of the mechanism of, but not a reason for, my anger.

(Just en passant: we cannot describe this anger for what it is unless we mention its intentional object, since what the anger is is anger at you for borrowing my paints. This gives meaning to the idea that we cannot ‘reduce’ anger to amygdala activation or any other physiological goings on.)

Today you are playing with my toys without asking. We've talked about this before too and, when we talked about it, I said I was just fine with it - there's really never any need to ask. But today I'm angry, and when asked I say that I'm angry because you didn’t ask if you could play with my toys. As you can see, the reason I give doesn’t really make much sense. Caprice vitiates reason.

We overcome enough of my awkward moodiness to dust down the brain scanner and have a look inside my cranium. It turns out that my amygdala has had a spasm! The amygdala spasm caused my anger at you! Now we might want to say that the amygdala activation is part of the why of my anger.

This is interesting! If someone thought that ‘why?’ questions were after answers citing meanings, and that ‘how?’ questions asked for information about causal relations, they'd have to think again. They're wrong!

It is because the reason I gave for my angry reaction was, given what I'd said before, unintelligible, that it now makes sense to look for a different explanation - in fact a different kind of explanation - as to why I got angry at you. We think of my reference to your not asking before playing with my toys as a mere rationalisation. So, barring my being forthcoming with something we would want to call my actual reason for being cross with you, we start instead to look for answers which don't make reference to my reasons.

Such answers might be psychological (I'm still mad at you for using my paints last week, and it kind of spilled out of me again and then I spuriously rationalised it by saying that you should have asked to play with my toys) or neurological (that amygdala spasm, for example) or any number of other things (I accidentally drank some 'angry juice' with my breakfast).

My suggestion now is that unless we have no apt 'personal' reasons (unless I don't have reasons to give which are what we call my reasons for acting or reacting as I did) then we cannot have 'psychological' reasons (we cannot have reasons that make reference to my psychology - i.e. to my character and defences etc.), and unless we have no apt psychological reasons then we can't give 'neurological' reasons (amygdala spasms) for the action.

This is interesting too! What I'm saying, in effect, is that reference to the kinds of neurological goings on as might always constitute parts of the mechanism of my anger can only meaningfully be offered as reasons answering the 'why?' question if they are 'released' into play by the failure of personal level reasons to explain the reaction.

Consider: what is the sense in which my amygdala had a spasm? I mean, perhaps it often gets very activated - there was that time, for example, when you not only borrowed but also jumped up and down on my toys smashing them to bits. Boy was I angry, but once again our scientific dedication enabled us to get over the emotional agitation enough to set up the brain scanner together. And what we saw then was an amygdala activation that was just as much through the roof as it was when earlier today I got mad and said - in what turned out to be a mere rationalisation - that you made me angry by not asking to borrow the toys.

So: whether or not it makes sense to offer a subpersonal level phenomenon by way of reason for a personal level reaction does not depend on what is going on at the subpersonal level. This is because whether or not we are to count that degree of amygdala activation as a spasm itself depends on whether the whole personal level phenomenon of which it is a part is understandable in personal level terms (e.g. in terms of such reasons as I give as my own). If it is thus intelligible then talk of spasms will be out of place.

In the present case, whilst you understand the words I am saying (‘I am angry because you didn’t ask to borrow the toys’), it isn’t intelligible how those words can really be the expression of a reason (since, in the past, I’d already told you that it’s always fine to borrow my toys). So we now appear to have an anger which is not intelligible in terms of my giving my reasons. It’s not really clear how it - the anger - can be about what I say it's about (the toy borrowing). My say-so does not suffice; clearly I've gone nuts. Yet now, when we look at my brain, we find an extreme level of amygdala activation. Yep, it's a spasm. And now we can answer the why? question - the ‘why did I get so angry with you?’ question - by saying ‘yeah, Richard had an amygdala spasm’. (I think we should rule out the psychological (i.e. dynamic-motivational) level first, but leave this aside for now.)

Again: for a brain event to even count as a spasm depends on its not forming part of a rationally intelligible reaction of the person whose brain it is.

So, whether or not a subpersonal event can feature as a reason in an explanation of why a personal level reaction occurs depends, as I said, on whether the personal level reaction is intelligible in personal-level terms. And to answer such a question of intelligibility we look not only to what is going on in the person right now, but also to their context. This context is not merely social and spatial but also historical. For it is only in relation to our past that certain words I now offer ('I’m angry because you took my toys') do or don’t count as good reasons. If I previously said 'you can always borrow my toys' then what I now proffer as a reason for my action must be rejected. Because the reason fails, the powerful amygdala activation now counts as a spasm and is also now 'released' to play its own part as reason for my anger.

Behold the marvellously expansive holism of the personal level, and the radically constraining effect it has on what at the here-and-now subpersonal level may contribute by way of answers to 'why?' questions!

Let's now consider the psychological rather than the personal level. So, my patient is depressed. Is the depression a function of his repressed anger, or is it because he doesn’t have enough serotonin (or whatever)? It might seem like a strange question because we might find a lack of serotonin as part of the mechanism in both cases. So it might seem like there is no room for the ‘or’. But, surely, it's a perfectly decent question! We mustn't let our possibly dubious philosophical intuitions get in the way of our appreciation of the intelligibility and character of our ordinary questions and explanations. Furthermore, following what I wrote above, I think we already have the resources to make reflective sense of the ‘or’.

In both (repressed anger, neurotransmitter) cases the low serotonin forms a mereological part of the depression. If you ask ‘how does the depression come about?’ then you might (depending on what exactly you were after) be happy with an answer which cited low serotonin in both cases. What makes it not just part of the constituting mechanism, but a good answer to a ‘why?’ question, though, is nothing to do with what goes on at the subpersonal level. Instead, reference to serotonin levels becomes available as an answer to the ‘why?’ question (why did he get depressed?) only when there isn't a psychological understanding available. With an effective psychological understanding (the patient's repressed anger) in place, there's just no way that mention of the low serotonin can provide an answer to the ‘why did he get depressed?’ question.

I reiterate: none of this is to say that low serotonin may not be a component of being in a low mood for whatever psychological reason. We may even find a decent use for the word 'cause' when thinking about the contribution of low serotonin to such low mood as is due to repressed anger.

If someone doesn’t understand this then it probably won’t help to tell her more about the phenomena. What she needs to do instead is think more about when and how we ask and answer ‘why?’ questions.

This all goes to show that what we need to do to understand the causal and mereological relations at play between mind and brain is to look at the logic of our explanations of the phenomena, which inter alia involves looking at the contexts (both the circumstances and the character and standing beliefs of the person - which itself involves looking back in time to their past utterances and actions too) of the phenomena, and not simply try to 'peer into' the phenomena themselves.

Someone might ask: But why should it be that subpersonal events can only feature as answers to 'why?' questions about behaviour if personal-level psychodynamic or rational answers fail?

The question is either misconceived or is answerable with reference to such interests as underlie people having evolved such language games in the first place. It is misconceived if it fails to appreciate that moves within language games are not justifiable with reference to facts. 'This just is how the reason-giving game is played!' might be a way to address the questioner who is in that kind of a muddle. (Q: Why does 2+2=4? A: There's no reason at play here, it's rather that '4' just is what we call 'the product of 2+2'.) On the other hand the questioner might be asking about how the language game evolved in relation to our interests - why it is that we ask people for their reasons, why we take an interest in failures of reason, and so on. And now we do well to explore phenomena such as our social commitments, responsibilities, the law, ethics, the management of personal relationships, and a myriad other matters.

Thursday, 15 February 2018

augustine the little boffin

I recently attended a very helpful presentation on the opening sections of the Investigations, and amongst other things it got me asking myself what it is that makes us want to say that Augustine's description of his younger self's word learning is hyperbolic. Here is the Augustine and here is Wittgenstein's critical remark:
PI 1: "When they (my elders) named some object, and accordingly moved towards something, I saw this and I grasped that the thing was called by the sound they uttered when they meant to point it out. Their intention was shewn by their bodily movements, as it were the natural language of all peoples: the expression of the face, the play of the eyes, the movement of other parts of the body, and the tone of voice which expresses our state of mind in seeking, having, rejecting, or avoiding something. Thus, as I heard words repeatedly used in their proper places in various sentences, I gradually learnt to understand what objects they signified; and after I had trained my mouth to form these signs, I used them to express my own desires."
PI 32. Someone coming into a strange country will sometimes learn the language of the inhabitants from ostensive definitions that they give him; and he will often have to guess the meaning of these definitions; and will guess sometimes right, sometimes wrong.And now, I think, we can say: Augustine describes the learning of human language as if the child came into a strange country and did not understand the language of the country; that is, as if it already had a language, only not this one. Or again: as if the child could already think only not yet speak. And "think" would here mean something like "talk to itself". 
At this point one might ask, 'Wittgenstein - what's the problem?' 'Don't children learn the meaning of words for things by - amongst other things, sure - seeing adults use and repeatedly name and otherwise deploy these names in talk about these things? Of course they do!'

Imagine if the Augustine Confessions passage cited in PI 1 was describing not his own earlier self but rather the word-learning of another little boy. Augustine is watching little Geoffrey watching Aunty Helen gesturing towards a toy car, listening to her name it repeatedly, seeing her facial expressions, the play of her eyes, etc. From all of this he grasps the meaning of the word 'car', which is to say, he starts to use 'car' in appropriate ways and so on. Would it really be such a stretch to say that Geoffrey is 'grasping' 'seeing' 'understanding' what Aunty Helen means? I suggest it wouldn't and that, in such a case Wittgenstein would be wrong to say that a description of Geoffrey in such terms would be as if to imply he already had a language or was talking to himself.

However Augustine is not writing about little Geoffrey. He is writing about himself. And, despite what Augustine tells us in the Confessions - that his account is a reconstruction from the recollections of others - his description of his own learning is written in the voice of personal recollection. It is the use of this voice, I suggest, which gives rise to the jarringly implausible appearance of precocious boffinhood in the toddler. For if I say of myself 'then I realised what was going on' we default to seeing this as the expression of a memory of a judgement, and then, if the expression of the recollection is indeed to be criterial for the memory, we should expect it to have been the case that, were little Augustine to himself have had an Aunty Helen from whom he picked up the apt use of 'car', and were he to be asked what he saw, he could back then have said 'well yes, then I grasped that, of all the blasted things, it was that funny little car that Aunty Helen was going on and on about', which, of course, he couldn't have. 

What causes the mischief, then, is the use of 'and then I grasped' etc. Imagine Augustine the adult looking at a video of himself as a child playing with Aunty and describing what he sees in two voices. In the first he is saying 'Oh look, there I am looking at her and finally, yes, I grasp what she's on about regarding the blinking toy car'. No problem. In the second he says 'Yes, this concurs with my memory of her going 'car' 'car' 'car' and my grasping what she was on about'. Big problem.

The point, note, is not about memory fallibility. It is not that it's empirically unlikely that anyone could remember all sorts of things about learning the word 'car'. Maybe someone could. Maybe they could remember Aunty Helen coming round with her red polka dot dress on and banging on about cars. But what that person ('logically') couldn't do would be to express that kind of memory of their own learning experience which is individuated with words like 'and then I remember grasping what she was on about'. Whilst it makes sense to say that the retrospecting adult remembers Aunty Helen teaching him the word 'car', remembers her saying 'car' and waving the toy car around, remembers himself soon thereafter talking of cars and going to fetch a toy car when his dad asked him, it doesn't make sense to suggest that the retrospecting adult remembers grasping the meaning of 'car'. It is one thing to grasp and retain the meaning of 'car', another thing to know that that is what one has done. When Augustine tells us he remembers grasping the meaning of 'car' this is tantamount to his saying that he has unimpaired-by-time knowledge of learning the meaning of 'car'. But when he was young he couldn't have known that what he was doing was learning the meaning of 'car' - since such knowledge, unlike coming to know what 'car' means, is only intelligibly had by someone with a rather larger linguistic repertoire than was enjoyed by little Augustine. In short it is only to be had by someone who can amongst other things wield descriptions like 'I am learning the meaning of 'car''. And to be able to do that would be tantamount to already having a language, even if not the one that is currently being learned.

Wednesday, 14 February 2018

reality testing and reality contact

It is tempting to try to impugn the very concepts of 'reality testing' and 'reality contact' - by asserting that the pictures associated with such notions are themselves epistemically misleading. But in doing so one mistakes the unimpeachable grammar (use) of a term with the virtue or otherwise of the various uses to which a picture of that term's use can be put.

'Reality testing': when we hear this psychiatric term we may be inclined to think of hypothesis testing. We might be inclined to think that, underlying the very idea of reality testing is the idea of taking a belief or an hypothesis or a supposition or an idea and deploying hopefully reliable procedures to test whether it obtains in fact. More specifically we might be inclined to imagine that what the user of the concept of 'poor reality testing' is imagining, simply in virtue of using that concept, is someone who has an idea 'in their head' which they fail to true up against 'external reality'. We might, even more strongly, imagine that such pieces of imagining, on the part of the user of the concept of poor reality testing, are constitutive of the very meaning of the term. Similarly we may think that the user of the concept of 'reality contact' has started to imagine that our minds could become detached from the world yet remain minds for all of that. The person in a 'psychotic retreat' then becomes someone who has thoughts all right, it's just that his thoughts are no longer congruent with the facts. And we may rightly be very suspicious of the cogency of such an idea as to what psychotic unworlding consists in.

What I'm registering is my belief that the error here lies not with the psychiatrist but with the philosopher who takes herself to be offering a critique of the very ideas of reality testing and reality contact. For it has always been the case that competent speakers of a language - including a psychiatric language - will be perfectly capable of misleading themselves as to what they mean by the terms they use. We may all be misled by, or mislead ourselves with our, pictures. But what makes for the meaning of our clinical terms is not the use of the pictures they inspire but the practical uses of the terms in the midst of clinical practice. And when we look at the uses of the notions of 'reality testing' and 'reality contact' we find something which is often rather far from what the pictures seem to suggest.

With poor reality testing what we find is not a failure to test inner thoughts against outer reality to see if they are more than imaginary. (Although in an extraordinary passage in his book on The Cognitive Neuropsychology of Schizophrenia, Chris Frith suggests that thoughts come labelled with something like tags which advertise whether they have an internal or an external origin, and that this tagging system - or is it the system which reads what's on the tags (!) - breaks down in schizophrenia.) What instead we find is a failure to instantiate a distinction between the imaginary and the real in the first place, so that the question of whether a thought is a mere fancy or concerns a fact cannot come about. The very character of the thoughts is damaged, and not just what we do with these thoughts. This is what makes for delusionality and psychosis: a loss of the essential oppositionality of imagination and reality. 'But that isn't referenced by the idea of a failure of reality testing!' you complain. Well, on the one hand, I want to say, it is in fact precisely what it means. But on the other, I see what you mean: the phrase may readily mislead us if we pick it up by the wrong end. Sure, but, well, don't pick it up by the wrong end then.

The notion of lost contact with reality is a bit easier. For nothing in the phrase ought by itself be take to imply that what loses contact with reality is a representational mind whose inner representations are no longer reliably caused or helpfully trued up with the facts of the now receding world. After all, what loses contact with reality is not a mind but a person. To lose contact with reality is in truth to suffer a mental breakdown - to have a breakdown, and not simply a retreated dislocation, of the mind. What I am saying is that here it is rather more obvious that it is the reflective interpreter of the concept of 'reality contact' who is bringing along the picture which she wants to go on to reject, rather than the mere deployer of it. What is rather more helpful in the notion of reality contact or being in touch with reality is the sensorimotor physicality of the idioms of touch and contact. What actually breaks down in psychosis is the in-dwelling of the person in their proximal environment with its ready-to-hand objects. The certainties which lie at the heart of our practices of mind are lived, practical, embodied certainties, certainties in action, and particular shared forms of them form the foundations of our reason.

The moral: the psychiatric idioms are fine just by themselves; please leave them alone! A philosophy which challenges the idioms rather than the uses of the pictures which the idioms can inspire in those unskilled in reflective interrogation of concepts has itself suffered a moral short-circuit. The short-circuit in question has to do both with the projection of confusion and culpability and with laziness. Projection: it is we who mislead ourselves in taking up our phrases in reflectively misleading ways - yet then we try to blame it on the phrases themselves! Laziness: it doesn't take too much work to look at how the phrases are used in practice.