Tim Thornton

Psychiatry’s inchoate wish for a paradigm shift and the biopsychosocial model of mental illness’ critically examines the much discussed goal of a paradigm shift in psychiatric taxonomy. The chapter first highlights some illustrative calls for such a change and then sets these against the Kuhnian account of science from which the idea is taken, highlighting the connection to incommensurability. Relative to a distinction drawn from Winch, between putative sciences where the self-understanding of subjects plays no role and those where it is fundamental, psychiatry falls into the latter kind. This suggests that the wish for a paradigm shift in psychiatry is either incoherent or a wish for a radical but unpredictable overhaul of a significant aspect of our self-understanding as subjects and agents. The biopsychosocial model of mental illness is thus a helpful reminder of the cost of a paradigm shift in psychiatry.

Decision-making depends on bringing evidence together with values: decision theory for example employs probabilities and utilities; health economic decisions employ measures such as quality of life. The hypothesis guiding this chapter is that bringing evidence together with values in clinical decision-making requires an exercise of phronesis. Our aim however is not to justify our guiding hypothesis. It is rather to outline an account of phronesis that is in principle fit for the purposes of clinical decision-making if our guiding hypothesis is correct. The chapter has three sections. Section 1 describes the growing gap between evidence and values in clinical decision-making: the missing link, we suggest, required to bridge this gap, is an appropriate account of phronesis. Section 2 provides an initial characterisation of the required account of phronesis via Michael Polanyi’s twin stipulation on the nature of tacit knowledge. Section 3 then fills out the required account using John McDowell’s characterisation of phronesis as a situation specific but at the same time conceptually structured form of practical discernment. A McDowellian account of phronesis, we argue, in satisfying Polanyi’s twin stipulation, provides an in-principle bridge between evidence and values. We conclude with a note on some of the further requirements if the gap is to be bridged not only in principle but in practice too.

This chapter gives an illustrated overview of recent philosophical work on the concept of delusion. Drawing on a number of case vignettes, examples are given of the wide range of theories that has been advanced to explain this most challenging of experiences. Some have agreed with the philosophical founder of modern descriptive psychopathology, Karl Jaspers, that delusions are “ununderstandable.” The large majority, though, has sought to understand delusion in terms of aberrations of one kind or another either of beliefs or of the grounds or preconditions for beliefs. As a project in understanding, these theories offer helpful insights. A further group of theories focuses on the agential aspects of delusion as reflected, for example, in their role in the insanity defense. Agential theories converge with the person-centered approaches of contemporary empirical and clinical work on delusion. Such approaches bring an additional level of complexity in the form of delusions that are not pathological but adaptive in the life of the person concerned. As such they show the challenge of understanding delusion to be a project not just of understanding but of mutual understanding.

In Paradoxes of Delusion, Sass aims to use passages from Wittgenstein to characterize the feeling of “mute particularity” that forms a part of delusional atmosphere. I argue that Wittgenstein’s discussion provides no helpful positive account. But his remarks on more everyday cases of the uncanny and the feeling of unreality might seem to promise a better approach via the expressive use of words in secondary sense. I argue that this also is a false hope but that, interestingly, there can be no interesting or substantial explanation of this failure

This chapter sets out an account of tacit knowledge as conceptually structured, situation specific practical knowledge. It sets this out against two claims from Michael Polanyi which conjoin the idea that we know more than we can tell with the suggestion that knowledge is practical. Any account of tacit knowledge which attempts to respond to Polanyi’s first claim faces a twofold test of adequacy. It must be tacit and it must be knowledge. To count as knowledge some content must be known but that puts pressure on its tacit status. What stops such a content being put into words? I reject Polanyi’s attempt to answer this based on a distinction between focal and subsidiary awareness. And I reject Harry Collins’ process-based approach that looks more to ontology than epistemology or reference more than sense. By equating tacit knowledge with conceptually structured, situation specific practical knowledge or know-how, I show the respect in which it remains tacit. Although it can be expressed in demonstrations, and is related to concepts, it cannot be expressed in words alone.

The two main psychiatric taxonomies set out codifications of psychiatric diagnoses via lists of symptoms with the aim of maximizing the reliability of diagnostic judgements. This approach has been criticized, 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 two related 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. Second, the conception of criteria implicit in the 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 that directly expresses the underlying psychopathological state of patients or clients.

The World Psychiatric Association has emphasised the importance of idiographic understanding as a distinct component of comprehensive assessment but in introductions to the idea it is often assimilated to the notion of narrative judgement. This paper aims to distinguish between supposed idiographic and narrative judgement. Taking the former to mean a kind of individualised judgement, I argue that it has no place in psychiatry in part because it threatens psychiatric validity. Narrative judgement, by contrast, is a genuinely distinct complement to criteriological diagnosis but it is, nevertheless, a special kind of general judgement and thus can possess validity. To argue this I first examine the origin of the distinction between idiographic and nomothetic in Windelband’s 1894 rectorial address. I argue that none of three ways of understanding that distinction is tenable. Windelband’s description of historical methods, as a practical example, does not articulate a genuine form of understanding. A metaphysical distinction between particulars and general kinds is guilty of subscribing to the Myth of the Given. A distinction based on an abstraction of essentially combined aspects of empirical judgement cannot underpin a distinct empirical method. Furthermore, idiographic elements understood as individualised judgements threaten the validity of psychiatric diagnosis. In the final part I briefly describe some aspects of the logic of narrative judgements and argue that in the call for comprehensive diagnosis, narrative rather than idiographic elements have an important role. Importantly, however, whilst directed towards individual subjects, narratives are framed in intrinsically general concepts and thus can aspire to validity

According to the recovery model, mental healthcare should be aimed towards a conception of recovery articulated by a patient or service user in accord with his or her own specific values. The model thus presupposes and emphasises the agency of the patient and opposes paternalism. Recent philosophical work on the relations between respect, self-respect, self-esteem, shame, and agency suggests, however, two ways in which mental illness itself can undermine self-respect, promote shame and undermine agency, suggesting a tension within the recovery model. I argue, however, that this is a tension rather than a fatal flaw by distinguishing between paternalist and non-paternalist clinical responses to this failure of agency.

Psychiatry is unique in medicine in being on the border between science and the humanities. Science provides insight into the 'causes' of a problem, enabling us to formulate an 'explanation', while the humanities provide insight into its 'meanings' and helps with our 'understanding'. The new interdisciplinary field of 'philosophy of psychiatry' has developed to explore the range of issues relevant to this border country. The Oxford Textbook of Philosophy and Psychiatry is a unique textbook which provides a detailed introduction to the field, a framework for study and skill development, and an overview of current research. It focuses on case studies in 5 key topic areas. Each case study is supported by selected readings from both philosophy and mental health, thinking skills exercises, self-test questions, key learning points and detailed guides to further reading

Psychiatric diagnosis depends, centrally, on the transmission of patients’ knowledge of their experiences and symptoms to clinicians by testimony. In the case of non-native speakers, the need for linguistic interpretation raises significant practical problems. But determining the best practical approach depends on determining the best underlying model of both testimony and knowledge itself. Internalist models of knowledge have been influential since Descartes. But they cannot account for testimony. Since knowledge by testimony is possible, and forms the basis of psychiatric diagnosis, its very existence is a factor in support of an externalist model of knowledge in general. Internalist and externalist models of knowledge also suggest different ways of responding to the practical challenges of basing psychiatric diagnosis on testimony. Thus the argument in favour of externalism also supports a potentially empirically testable hypothesis about interpretation of non-native speakers for accurate psychiatric diagnosis: interpretation of non-English speakers should be as transparent and unhindered by specialised medical knowledge as possible

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

Wittgensteinian Themes gathers together 14 previously published essays written towards the end of Malcolm's life. The majority of essays provide exegeses of Wittgenstein's thought. It is arguable that both Wittgensteinian exegesis and Wittgensteinian philosophy run the risk of parochialism. This collection makes a commendable effort to escape that charge. Even in the exegetical essays, issue is taken with conflicting contemporary philosophers whilst four essays are direct attacks on opposing philosophical perspectives, albeit using Wittgensteinian methods.

Tacit knowledge is the form of implicit knowledge that we rely on for learning. It is invoked in a wide range of intellectual inquiries, from traditional academic subjects to more pragmatically orientated investigations into the nature and transmission of skills and expertise. Notwithstanding its apparent pervasiveness, the notion of tacit knowledge is a complex and puzzling one. What is its status as knowledge? What is its relation to explicit knowledge? What does it mean to say that knowledge is tacit? Can it be measured? Recent years have seen a growing interest from philosophers in understanding the nature of tacit knowledge. Philosophers of science have discussed its role in scientific problem-solving; philosophers of language have been concerned with the speaker's relation to grammatical theories; and phenomenologists have attempted to describe the relation of explicit theoretical knowledge to a background understanding of matters that are taken for granted. This book seeks to bring a unity to these diverse philosophical discussions by clarifying their conceptual underpinnings. In addition the book advances a specific account of tacit knowledge that elucidates the importance of the concept for understanding the character of human cognition, and demonstrates the relevance of the recommended account to those concerned with the communication of expertise. The book will be of interest to philosophers of language, epistemologists, cognitive psychologists and students of theoretical linguistics.

In response to the concern that criteriological psychiatric diagnosis, based on the DSM and ICD classifications, pigeon-holes patients, there have been calls for it to be augmented by an idiographic formulation [IDGA Workgroup, WPA 2003]. I have argued elsewhere that this is a mistake [Thornton 2008a, 2008b, 2010]. Looking back to its original proponent Wilhelm Windelband yields no clear account of the contrast between idiographic and nomothetic judgement. Abstracting from Jaspers’ account of understanding an idea of idiographic judgement based on the contrast between singular and general causal relations also fails. I argue, however, that Windelband does provide a helpful clue in his remark that ‘every interest and judgement, every ascription of human value is based upon the singular and the unique... Our sense of values and all of our axiological sentiments are grounded in the uniqueness and incomparability of their object’ [Windelband 1980: 182]. This suggests a role for the idiographic not as the content of a particular kind of judgement but rather as characterising its aim. I argue that this connects to the issue of the generalisability of small scale qualitative social science research and to the critique of ‘looking away’ in moral philosophy.

The harmful dysfunction account of disorder separates an explicitly normative or evaluative notion of harm from the idea of dysfunction which is subject to a reductionist naturalistic account. Dysfunction is analysed as a failure of function which is itself reduced via evolutionary biology. In this paper, I question this latter aspect of the account. Light can be shed on the prospect of reducing the apparently normative notion of dysfunction by comparing it with two distinct reductionist projects in the philosophy of content which stand to each other as do the contrasting options in the euthyphro dilemma. A more modest project takes for granted the structure of normative relations between concepts and attempts to solve an engineering problem of how human thought can fit that structure. A more ambitious project aims to explain that structure itself in naturalistic terms. The ambitious project, however, is undermined by an argument from Wittgenstein. I argue that the harmful dysfunction analysis of disorder has to be interpreted as isomorphous with the latter project and is thus subject to the same objection.

In lieu of an abstract, here is a brief excerpt of the content:Evidence-Based Medicine and EvaluativismTim Thornton (bio)KeywordsPhilosophy, psychiatry, values, causalThe rise of evidence-based medicine (EBM) in psychiatry has brought, in its train, a concentration on the validity of psychiatric taxonomy to augment the previous focus on reliability (in the medical sense of inter-subject agreement). This is not surprising. If EBM is to be a trustworthy guide to future events, such as patient recovery, it must be based on projectible predicates (Goodman 1983). Not all the predicates that apparently fit past observations would produce true predictions for the future. Furthermore, there is reason to think that employing projectible predicates goes a long way to satisfy the (widespread if contested) aim of being based on a nomological science (Papineau 1986). Thus, the successful implementation of EBM within psychiatry requires the successful articulation of a valid psychiatric taxonomy.This connection helps to explain why fears about the application of EBM to psychiatry often turn on fears about the application of the criteriological model of diagnosis to individuals. In her commentary in this issue, Gloria Ayob has examined some of the arguments concerning the application of EBM to individuals. In this brief commentary, I examine a different potential source of disquiet focused on the underlying nature of psychiatric taxonomy.Dimensions for Psychiatric TaxonomyIn their recent paper, Peter Zachar and Kenneth Kendler suggest a number of different dimensions according to which rival conceptions of psychiatric taxonomy can be mapped. These include (1) causalism–descriptivism, (2) essentialism– nominalism, (3) objectivism–evaluativism, (4) internalism–externalism, (5) entities–agents, and (6) categories–continua (2007, 557). At the heart of the objectivism-evaluativism dimension is the question:Is deciding whether or not something is a psychiatric disorder a simple factual matterY (objectivism), or does it inevitably involve a value-laden judgment (evaluativism)?(Zachar and Kendler 2007, 558)Objectivists argue that the concept of disorder is a simple or plain factual matter by contrast with an evaluation. The apparently evaluative connotations of disorder, they argue, can either be reduced to, or explained away in, more basic terms, which are not themselves essentially evaluative. Thus, for example, the attempt to explain disorder in statistical terms is a form of objectivism. The more plausible attempt to explain disorder through the idea of a biological or proper function is also usually presented as a form of objectivism. (The most famous proponent of a biological approach, however, Jerome Wakefield, adds to an objectivist-aspiring core an explicit value in the form of harm [End Page 175] [Wakefield 1999].) Whether or not it can be successful as a form of objectivism, in addition to whether an analysis in biological terms is possible, depends on whether the account of function can fully discharge any initial evaluative or normative assumptions.There seems to be good evidence that current psychiatric taxonomy, at least, contains values. John Sadler, for example, makes a powerful case for this in his substantial work Values and Psychiatric Diagnosis (2005). Sadler, furthermore, addresses in some detail a further set of questions concerning the kinds and nature of the values involved. I outline just one further question about the nature of values involved.Zachar and Kendler contrast the presence of values with objectivism. Objectivity has at least two relevant senses reflecting contrasts with two senses of subjectivity. It—objectivity—might mean requiring no special subject for the conception and framing of relevant judgments. (This mirrors primary, by contrast with secondary qualities, and Williams' idea of an absolute conception [Williams 1978]). Or, it might mean disciplining and providing a contrast between correctness and incorrectness, or truth and falsity, for the relevant judgments. This contrasts with subjective whimsy.Although it seems relatively straight forward that the conception and framing of value judgments requires that subjects have a particular kind of mind, that still leaves open the other issue. Are value judgments disciplined by anything or does the "truth" of a value judgment collapse back into its being sincerely made?Evaluativism in Psychiatric Taxonomy and EBMThis question relates to the application of EBM to psychiatry in this way. On a disciplined account, psychiatric taxonomy can aim to get right the mixture or, better, the compound of simple facts and values...

In lieu of an abstract, here is a brief excerpt of the content:Compelling ReasonsTim Thornton, MA, MPhil, PhD, DLitt (bio)There are many compelling reasons to have an interest in the philosophy of/and psychiatry. In 1994, when persuaded by Bill Fulford to walk down the corridor at Warwick University to join in his teaching of what seemed a newly developing subject—against my protestations that I knew nothing about mental health care—my main interest was in the irreducibility of meaning to the 'realm of [natural scientific] law,' in Sellars's phrase. This had the bonus of complementing Bill's championing of the irreducibility and centrality of values in psychiatry. (It was only later we realized we disagreed about the not inconsequential issue of whether norms and values were subjective preferences or objective features of the world.) It seemed plausible to me that the irreducibility of the space of reasons to the realm of law might have interesting consequences for psychiatry. But mine was a purely disinterested academic interest. This is perhaps the usual approach to what is in part a professionalized academic subject with its formal rules for publication and dissemination of research.It has only been in the last decade that I have experienced things in a more personal way, following what I would term, though psychiatry would not, a nervous breakdown. My image of a breakdown came from reading Saul Bellow's novel Herzog. The titular Herzog has been left by his wife, cruelly, and retires from academic life to write letters. For example, to Heidegger. "Dear Doktor Professor Heidegger, I should like to know what you mean by the expression 'the fall into the quotidian.' When did this fall occur? Where were we standing when it happened?" I thought I would be able to maintain some sort of inquiring mind and write experientially grounded philosophy of psychiatry as a catharsis. I could study my own illness. This immediately proved a ridiculous hope.As a philosopher with a cognitivist bent—language, thought, and intentionality being guiding interests—I had always assumed that madness was only really a matter of what Jaspers calls 'primary delusions,' belief-like states that strain their belief-status, are hard for others to make sense of, and occur only with particularly severe forms of mental illness. But madness is also a matter of doing, saying and feeling as well as pure reasoning. What I would, previously and disinterestedly, have described as a dysregulation of emotional reactions turned out to transform my entire experience of the world and my ability to think rationally about it. I lost the ability to put my experiences into words. In truth, I lost all interest in that project. Only when not distressed could I take a view on my loss of world. Distressed, I did not understand myself.This is a neat illustration of epistemic disjunctivism. But it also highlights a challenge for, and some of the brilliance in those who have contributed to, the philosophy of mental health care, through their expertise by experience. While experience may be a necessary condition for particular forms of expertise, my own case reveals that it is not sufficient. Further, even an everyday and familiar mental illness (like my own) can render the articulation of experience, in a way that makes sense to others, very much harder. Hence the fact [End Page 11] that there is a thriving mental health service and patient movement, making their own experiences available to others combining first-person narratives with conceptual and phenomenological insight is both admirable and helps to set a part of PPP's future agenda: bringing first-person experience within a philosophically and clinically informed discipline. [End Page 12]Tim Thornton Tim Thornton, MA, MPhil, PhD, DLitt, is Professor of Philosophy and Mental Health and Mental Health and Deputy Head for Research in the School of Nursing at the University of Central Lancashire. As well as contemporary philosophy of thought and language, his research concerns conceptual issues at the heart of mental health care. He has published research papers on clinical judgement, idiographic and narrative understanding, the interpretation of psychopathology and reductionism and social constructionism in psychiatry.Copyright © 2023 Johns Hopkins University Press...

In “semantic vagueness in Psychiatric Nosology,” Nicholas Tilmes offers a conditional claim for further consideration. The conditional is that “if psychiatric vagueness exists, there is reason to think that some cases of it are at least partially semantic.” From this, some conclusions worth investigating follow. In this brief commentary I will set out a question Tilmes introduces by, like him, drawing on a paper by Miriam Schoenfield, which also examines vagueness as semantic, epistemic or ontic though she draws a contrasting conclusion for her subject matter: moral judgment. Highlighting a supposed contrast between semantic and ontic vagueness will also highlight an issue for...

In response to concerns about the subsuming of individuals under essential general psychiatric diagnostic categories, there have been calls for an idiographic component in person specific diagnostic formulations. The distinction between the idiographic and nomothetic was introduced by Windelband as his contribution to the Methodenstreit. However, as I have argued elsewhere, it is unclear what the distinction is supposed to comprise. In this chapter, I attempt to shed light on the motivation for the distinction by looking at a number of recent approaches to healthcare that share a concern with a focus on individuals. Despite this shared element in their motivation, I argue that none help to articulate the nature of the idiographic itself. This chapter broadens the central claim of my chapter in the 2019 Yearbook of Idiographic Science, here drawing on a clue from Windelband’s student Rickert to argue that there is a role for the idiographic in healthcare though not as a form of judgement, understanding or intelligibility but rather a specific singular interest in an individual. It is this that also underpins developments in healthcare related to the individual or person.

The inclusion of Elizabeth Shore in Thomas More’s History of King Richard III offers important insights into the decisions made by More in shaping his text. This article explores the evidence available to More as he wrote, emphasizing the near-complete absence of Shore from earlier narratives. Shore’s activity in the 1470s and 1480s is examined, along with evidence for her survival and that of her husband, Thomas Lynom, into the 1510s when More was writing. Lynom’s connections are considered, providing an understanding of intersections of his activities with the environment in which More was shaping the History. As a central figure in the events of 1483 who survived into the 1520s, Shore was a prompt to the creation of More’s account—she was not simply a product of More’s literary and philosophical imagination, but part of his effort to respond to the immediate legacies of conflict in politics and society.

The paper begins by asking, in the context of McDowell's Mind and World, what guides empirical judgement. It then critically examines David Bell's account of the role of aesthetic judgement, or experience, in Kant and Wittgenstein, in shedding light on empirical judgement. Bell's suggestion that a Wittgensteinian account of aesthetic experience can guide the application of empirical concepts is criticised: neither the discussion of aesthetic judgement nor aesthetic experience helps underpin empirical judgement. But attention to the parallel between Wittgenstein's discussion of understanding rules and the question of how empirical concepts can be applied to particulars suggests how to dissolve the felt need for an answer. This in turn helps shed light on McDowell's conceptualist account of experience.

John McDowell is one of the most widely read philosophers in recent years. His engagement with a philosophy of language, mind and ethics and with philosophers ranging from Aristotle and Wittgenstein to Hegel and Gadamer make him one of the most original and outstanding philosophical thinkers of the post-war period. In this clear and engaging book Tim Thornton introduces and examines the full range of McDowell's thought. After a helpful introduction setting out McDowell's general view of philosophy Thornton introduces and explains the following topics: • Wittgenstein on philosophy, normativity and understanding • value judgements • theories of meaning and sense • singular thought and Cartesianism • experience, knowledge and openness to the world • Mind and World and idealism • action and the debate with Hubert Dreyfus on conceptual content and skilled coping. This second edition has been significantly revised and expanded to include new sections on: McDowell's work on disjunctivism and criticisms of it; a new chapter on McDowell's modification of his account of perceptual experience and conceptual content and criticisms by Charles Travis; and a new chapter on action and McDowell's engagement with Hubert Dreyfus and the debate concerning skilled coping and mindedness. The addition of a glossary makes John McDowell, second edition essential reading for those studying McDowell, philosophy of language, philosophy of mind, ethics and epistemology, as well as for students of the recent history of analytical philosophy generally. Tim Thornton is Professor of Philosophy and Mental Health at University of Central Lancashire, UK. He is author of Essential Philosophy of Psychiatry (2007), Wittgenstein on Language and Thought (1998), co-author of the Oxford Textbook of Philosophy and Psychiatry (2006), and Tacit Knowledge (2013) and co-editor of the Oxford Handbook of Philosophy and Psychiatry (2013).

Harry Collins’s Tacit and Explicit Knowledge characterises tacit knowledge through a number of antonyms: explicit, explicable, and then explicable via elaboration, transformation, mechanization and explanation and, most fundamentally, what can be communicated via “strings”. But his account blurs the distinction between knowledge and what knowledge can be of and has a number of counter-intuitive consequences. This is the result of his adoption of strings themselves rather than the use of words or signs as the mark of what is explicit and, I suggest, it may stem from his earlier response to Wittgenstein’s rules regress.