Constitutive evaluativist externalism and Values-Based Practice

In the previous session we examined Szasz’ argument in his paper ‘The myth of mental illness’. Although it seems possible to block his argument to the mythical status of mental illness (Szasz assumes a kind of behaviourism without justification), his premiss that mental illness answers to different norms or values to physical illness is of interest in itself. If mental illness answers to societal values, does that mean that what counts as an illness (at a time and a place) is determined by what a society, contingently, values?

This question remains even if one assumes, against Szasz, that a mental illness is whatever underlying condition causes the symptoms which are then identified in the way he describes. A full understanding of the biological underpinnings of a condition by itself does not address its pathological (or not) status. Even if sexual orientation, for example, were the result of known endogenous biological factors that would not address the question of its healthy status or not.

One response is to deny that mental illness is identified relative to norms which are distinct from those for physical illness and then to offer a non-evaluative account of the norms: a value-free or values-out account. The most prominent such approach is to deploy the idea of biological or proper function and thus failure of that or dysfunction to begin to define illness. Wakefield’s harmful dysfunction model is one such (it invokes the value-laden term: harm but preserves a value-free scientific account via dysfunction). But it faces difficulties.

But on the assumption that illness (including mental illness) is essentially evaluative, how is pathological status to be decided? And is this a decision about the truth of the nature of illness, or the desirability of a particular model of illness?

The readings for this session are [Zachar and Kendler 2007] which sets out a fairly neutral view of the choices involved in a conception of mental illness. The two key dimensions of relevance to SAMI are objectivism versus evaluativism and internalism versus externalism. It is worth reading about these and looking at the applications of the dimensions in a couple of models even if you do not have time to read the whole paper. Those two dimensions are then picked up in the short commentary [Thornton 2009] which considers, in the light of them, how debate about putative pathologies or illnesses should be decided on the assumption, for the moment at least, that illness is evaluative and externalist (a plausible view for at least one version of SAMI). The short reading from the Oxford Textbook outlines Bill Fulford’s influential view of values based practice. Fulford argues that VBP concerns diagnosis as well as management and involves skills for approaching values-disagreement.

([Thornton 2011] summarises three key elements of VBP but contests with Fulford whether the third element is reflexively stable.)

The key question is: If illness is essentially evaluative - that is constituted by values external to the individual - does the kind of process described as Values Based Practice look right to address issues of what is and is not illness?

Essential reading

- Fulford, K.W.M., Thornton, T. and Graham, G. The Oxford Textbook of Philosophy and Psychiatry Oxford: Oxford University Press pp520, 597-602
- Thornton, T. (2009) ‘Constitutive evaluativist externalism (Commentary on Zachar, P. and Kendler, K. ‘Psychiatric Disorders: A Conceptual Taxonomy’)’ Association for the Advancement of Philosophy and Psychiatry Bulletin 15: 9-12
- Zachar, P. and Kendler, K. (2007) ‘Psychiatric Disorders: A Conceptual Taxonomy’ American Journal of Psychiatry 164: 557-565