Special Topic Section: Classification and Psychopathology Editor: C. Mundt

Original Paper Psychopathology 2010;43:252–261 DOI: 10.1159/000315124

Received: May 13, 2008 Accepted after revision: June 30, 2009 Published online: May 29, 2010

Narrative rather than Idiographic Approaches as Counterpart to the Nomothetic Approach to Assessment Tim Thornton International School for Communities, Rights and Inclusion University of Central Lancashire, Preston, UK

Key Words Philosophy ⴢ Psychiatry ⴢ Comprehensive diagnosis ⴢ Windelband

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

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narrative judgement. The second half of the paper highlights how narrative judgement, shorn of any connection to metaphysical theories of the self, is an essentially normative form of judgement that contrasts with, and can thus complement, criteriological diagnosis. Copyright © 2010 S. Karger AG, Basel

Introduction

Psychiatric diagnosis and assessment is being pulled in opposite directions by two prima facie opposing intellectual virtues. On the one hand, after a long period of concentration by the developers of both the major international diagnostic codifications on reliability, there are signs that DSM V, at least, will concentrate on the validity of its categories [2, pp. 7–9]. On the other hand, there is a reaction against the application of general medical categories to individuals and the advocacy, instead, of person-centred mental health care. In this paper, I will examine how this latter aim is best met in such a way as not to undermine the former. As part of its attempt to improve person-centred mental health care, the World Psychiatric Association has esTim Thornton International School for Communities, Rights and Inclusion University of Central Lancashire PR1 2HE Preston (UK) Tel. +44 1772 895 412, Fax +44 1772 892 964, E-Mail tthornton1 @ uclan.ac.uk

tablished an Institutional Program on Psychiatry for the Person. It advocates a ‘comprehensive’ model of diagnosis or assessment which would include an idiographic component alongside conventional criteriological diagnosis. But such a call for an idiographic component risks blurring two motivations for, and two conceptions of, the kind of element that should be added to conventional criteriological diagnosis. Whilst both are directed at understanding individuals, one calls for a kind of ‘individualised’ judgement which rejects implicit comparison between individual cases. Such a conception of judgement, derived from Windelband’s distinction between idiographic and nomothetic understanding, however, puts the idea of validity at risk. Summarising and building on arguments from an earlier paper [1], I will outline an argument proposed by the philosopher Wilfrid Sellars that no such form of judgement is possible. A radically individualised form of judgement is no form of judgement at all. But an individualised form of judgement is not the only alternative to criteriological judgement recently discussed. The same psychiatrists who call for idiographic judgement as part of the WPA’s Institutional Program on Psychiatry for the Person sometimes equate it with narrative judgement. This is aimed at individual people but does not depend on an individualised judgement. I will explore this conception of judgement, explain why it does not fall prey to Sellars’ argument and relate it to the overall quest for validity in psychiatric assessment.

Background

The idea that psychiatric diagnosis or, more broadly, psychiatric formulation should include an idiographic element is explicit in recent publications by psychiatrists working on the WPA initiative Psychiatry for the Person. It forms part of the explicitly broad conception of diagnosis called a comprehensive model or concept of diagnosis. The Idiographic (Personalised) Diagnostic Formulation closely connects a comprehensive model with an idiographic component: ‘This comprehensive concept of diagnosis is implemented through the articulation of two diagnostic levels. The first is a standardised multi-axial diagnostic formulation, which describes the patient’s illness and clinical condition through standardised typologies and scales … The second is an idiographic diagnostic formulation, which complements the standardised formulation with a personalised and flexible statement’ [3, p. 55].

Idiographic versus Narrative Approaches to Assessment

The role of the idiographic aspect is to complement and contrast a general approach through ‘typologies and scales’ with something personal and individual. Writing in this journal the psychiatrist James Phillips makes this individual focus explicit: ‘In the most simple terms, a[n] idiographic formulation is an individual account’ [4, p. 182, italics added]. But this raises the following question. If an idiographic element is to be a genuine complement to general typologies and scales, what kind of understanding of an individual does it comprise? How is it different from criteriological diagnosis, for example? Note, for example, that the use of the term in psychology which stems from Gordon Allport (1897–1967), in which ‘idiographic’ is used to describe case study-based qualitative research by contrast with quantitative cohortbased research (although whether Allport’s use of nomothetic accords with Windelband’s is a matter of dispute [5]), is of no help in this case. The proposed use in psychiatric assessment is to add to criteriological diagnosis which, though general in form, is, nevertheless, aimed at a single individual. So the notion it is designed to contrast with is already supposed to be focused on individuals and thus the way the distinction is drawn in psychology will not apply. To address this question I will turn initially turn to the philosopher Wilhelm Windelband, who first introduced these terms to psychology and psychiatry in his rectoral address of 1894. Windelband, as a post-Kantian philosopher, was familiar with the debate about the relation of the human and natural sciences called the Methodenstreit, a debate which shaped Karl Jaspers’ views of the importance of empathy for understanding psychopathology [6, pp. 90–92]. But his paper suggests a specific focus on the role of judgements about individuals. Idiographic judgement seems to be a form of ‘individualised’ judgement. My aim is not to attempt to provide a nuanced historical account of Windelband, rather I aim to use his influential rectoral address to illustrate a general problem. Insofar as psychiatry wishes to deploy a notion of idiographic understanding or judgement (terms I will use interchangeably) in its aim to have a better understanding of individuals, it needs to articulate exactly what such understanding or judgement involves and how it differs from other forms (such as criteriological diagnosis). But, as I will argue, this is a formidable task. In the longer second part of the paper, I will turn to a second aspect of the WPA characterisation of idiographic which I have not mentioned so far. This is the idea that Psychopathology 2010;43:252–261

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the ambitions of idiographic understanding can be satisfied by a notion of narrative understanding. Further, this suggests the key respect in which criteriological understanding can be augmented.

Idiographic Judgement

Windelband introduces the notion of idiographic understanding through a contrast with nomothetic understanding in the following way: ‘In their quest for knowledge of reality, the empirical sciences either seek the general in the form of the law of nature or the particular in the form of the historically defined structure. On the one hand, they are concerned with the form which invariably remains constant. On the other hand, they are concerned with the unique, immanently defined content of the real event. The former disciplines are nomological sciences. The latter disciplines are sciences of process or sciences of the event. The nomological sciences are concerned with what is invariably the case. The sciences of process are concerned with what was once the case. If I may be permitted to introduce some new technical terms, scientific thought is nomothetic in the former case and idiographic in the latter case. Should we retain the customary expressions, then it can be said that the dichotomy at stake here concerns the distinction between the natural and the historical disciplines. However we must bear in mind that, in the methodological sense of this dichotomy, psychology falls unambiguously within the domain of the natural sciences’ [7, pp. 175–176].

Prior to this characterisation in the rectoral address, Windelband has already distanced the distinction he is attempting to frame from one that depends on distinction of substances: sciences of nature or natural science (Naturwissenschaften), versus the sciences of the mind (Geisteswissenschaften). Such a distinction is hostage to the fortunes of that dualism. If the reductionist project of explaining mental properties in physical terms were successful, then that contrast would be undermined. That project is of particular relevance to psychiatry. Further, and in accord with Windelband’s own remarks, it places psychiatry and psychology on the other side of a divide from the natural sciences when at least aspects of both disciplines belong on the same side. ‘[B]oth psychology and the natural sciences establish, collect, and analyze facts only from the viewpoint and for the purpose of understanding the general nomological relationship to which these facts are subject’ [7, p. 174].

Even with these characterisations in play, however, the distinction as so far introduced is not clear. Consider the contrast between ‘what is invariably the case’ and ‘what was once the case’. There are three prob254

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lems with using this contrast to characterise a notion of ‘idiographic’ which might help psychiatry for the person. First, it threatens to slip back from a methodological distinction of how a subject matter is approached to the underlying nature of the events in question (whether, as a matter of fact, they are invariant or unique). Second, a substantive distinction does not explain in what way an idiographic understanding differs from any other sort. Third, the uniqueness of its subject matter cannot separate the idiographic and nomothetic. The gravitational forces on a mass, for example, depend in principle on a vector sum of its relation with every other object in the universe and thus some of the events described by physics are likely to be unique. It is no good saying, as an earlier referee of this paper said, that ‘Windelband was seeking to characterise the nature of explanation in history, for example. The circumstance of a particular event in history are unique. The individual motivation of a Napoleon has to be understood on its own … It is this insight into the individual that characterises the nature of “sciences” (in the German sense) such as history and indeed psychiatry.’ Even though Windelband himself comments that idiographic sciences ‘provide a complete and exhaustive description of a single, more or less extensive process which is located within a unique, temporally defined domain of reality’ [7, p. 174], neither of these comments explains how historical explanation works and, given that uniqueness is not helpful in this regard, simply to state that idiographic understanding concerns individuals is not yet to make progress on that task. Windelband’s own comments about historical judgement are significantly unhelpful. He says: ‘[H]istory seeks structural forms …’ [7, p. 178]. ‘[I]n the historical sciences, … [thought] is devoted to the faithful delineation of the particulars …’ [7, p. 178]. ‘The historian’s task … is to breathe new life into some structure of the past in such a way that all of its concrete and distinctive features acquire an ideal actuality or contemporaneity. His task, in relation to what really happened, is similar to the task of the artist, in relation to what exists in his imagination’ [7, p. 178].

But the task of ‘describing structure’ is shared by some nomothetic sciences like chemistry. ‘Delineation of particulars’ is also the common aim of both idiographic and nomothetic sciences. (The physics of a particular mass concerns that individual.) Talk of ‘ideal actuality’ may be uniquely appropriate for the idiographic sciences but hardly sheds light on what this amounts to.

Thornton

Nor is the connection to human motivation (made by the referee just cited, nor to ‘cultural artifacts’ as another referee suggested) justified by Windelband’s own account since one of his examples of idiographic understanding is a merely biological process: ‘Consider … the subject matter of the biological sciences as evolutionary history in which the entire sequence of terrestrial organisms is represented as a gradually formative process of descent or transformation which develops in the course of time. There is neither evidence nor even a likelihood that this same organic process has been repeated on some other planet. In this case, the science of organic nature is an idiographic or historical discipline’ [7, p. 176].

Thus, to summarise so far, the task is to extract from Windelband or elsewhere an account of idiographic judgement which contrasts with other forms of judgement (centrally, for psychiatry, criteriological diagnosis) and that proves more difficult than it might first seem. Elsewhere, I have suggested that the appeal of idiographic judgement stems from the idea that judgements about individuals requires a tailor-made judgement [1]. This ‘individualising intuition’ is supposed to be satisfied by a kind of one-off judgement, a judgement designed – by contrast with generalised judgements – to fit individuals. It is worth pausing to think what form such an individualised judgement might take (as I do more thoroughly in that earlier paper). Perhaps ‘judgement’ is the wrong word – it is too intellectual – and the kind of understanding aimed at is pre-epistemic. Perhaps the judgement is what is called a ‘singular judgement’, i.e. one whose subject matter is fixed by a contextual relation such as a demonstrative (pointing at someone). Perhaps the predicate is unique and framed for just this one person. Or perhaps the judgement is such that it is epistemically independent of all other judgements. That is, it is individualised because it does not depend on any other general knowledge and answers only to a particular person. But, as I have argued at greater length elsewhere, none of these will do [ibid]. It is not pre-epistemic because, as an aspect of a comprehensive model of diagnosis, it aims at getting individuals right and thus is a matter for judgement. It is not merely a singular judgement because it is the predicate, rather than the way the subject is picked out, that matters. (That is, it is not how a patient is referred to but what is said about him or her.) It is not a necessarily unique predicate because any such judgement would be merely a baptism not the reporting of information. This leaves the fourth and final option: an epistemologically individualised judgement.

Idiographic versus Narrative Approaches to Assessment

Windelband’s rectoral address gives some exegetical support to this intuitive idea. Idiographic judgement is presented in part as a reaction against an overly deductive conception of it. Rather than stressing the role of topdown deduction from general concepts, some passages suggest the role for a bottom-up notion of judgements driven by particulars themselves. ‘[T]his distinction connects with the most important and crucial relationship in the human understanding, the relationship which Socrates recognized as the fundamental nexus of all scientific thought: the relationship of the general to the particular’ [7, p. 175]. ‘The commitment to the generic is a bias of Greek thought, perpetuated from the Eleatics to Plato, who found not only real being but also real knowledge only in the general. From Plato this view passed to our day. Schopenhauer makes himself a spokesman for this prejudice when he denies history the value of a genuine science because its exclusive concern is always with grasping the specific, never with comprehending the general … But the more we strive for knowledge of the concept and the law, the more we are obliged to pass over, forget, and abandon the singular fact as such … In opposition to this standpoint, it is necessary to insist upon the following: every interest and judgment, 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’ [7, pp. 181– 182].

The suggestion here is that examining value judgements helps to reveal the fundamental importance of particular cases as opposed to general kinds in our judgements about the world. This implies that there is an important role for a kind of judgement in which there is no implicit comparison with other cases. Such a judgement would be individualised. But if the most promising way to interpret this idea is that the judgements he wishes to champion are epistemically individualised, then this is an instance of what the US philosopher Wilfrid Sellars (1912–1989) calls the ‘Myth of the Given’ and thus subject to his criticism of it. Sellars uses the phrase ‘Myth of the Given’ to characterise a form of philosophical foundationalism. Such foundationalism aims to base empirical knowledge on immediate (thus, for empirical knowledge, perceptual) judgements which ground, and do not themselves depend on, other beliefs. ‘One of the forms taken by the Myth of the Given is the idea that there is, indeed must be, a structure of particular matter of fact such that (a) each fact can not only be non-inferentially known to be the case, but presupposes no other knowledge either of particular matter of fact, or of general truths, and (b) such that the non-inferential knowledge of facts belonging to this structure

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constitutes the ultimate court of appeals for all factual claims – particular and general – about the world. It is important to note that I characterized the knowledge of fact belonging to this stratum as not only non-inferential, but as presupposing no knowledge of other matter of fact, whether particular or general’ [8, pp. 68–69].

This schematic account fits the notion of an individualised judgement I have sketched as epistemically independent. Sellars goes on to accept that experience can provide non-inferential knowledge and that such experience can constitute the ultimate court of appeals for factual claims. But he denies the claim that it can presuppose no other knowledge of particular matters of fact. The reason for denying this third claim is that Sellars takes there to be a dual dependence between the kind of knowledge expressed in perceptual reports and an overall worldview. He suggests that perceptual knowledge has to jump two hurdles. The first concerns the reliability of the perceptual report. ‘The second hurdle is, however, the decisive one. For we have seen that to be the expression of knowledge, a report must not only have authority, this authority must in some sense be recognized by the person whose report it is. And this is a steep hurdle indeed. For if the authority of the report ‘This is green’ lies in the fact that the existence of green items appropriately related to the perceiver can be inferred from the occurrence of such reports, it follows that only a person who is able to draw this inference, and therefore who has not only the concept green, but also the concept of uttering ‘This is green’ – indeed, the concept of certain conditions of perception, those which would correctly be called ‘standard conditions’ – could be in a position to token ‘This is green’ in recognition of its authority. In other words, for a Konstatierung (perceptual report) ‘This is green’ to ‘express observational knowledge’, not only must it be a symptom or sign of the presence of a green object in standard conditions, but the perceiver must know that tokens of ‘This is green’ are symptoms of the presence of green objects in conditions which are standard for visual perception’ [8, pp. 74–75].

The point here is that for a perceptual report (or for the perceptual experience reported) to have authority it must not only actually be a reliable indicator of the state of the world but also its subject must know that it is reliable. Such knowledge makes the report depend more generally on the subject’s world-view: in particular that specific types of perceptual experiences, and thus reports, correspond to specific types of states of affairs. But knowledge of this sort requires the kind of generality rejected by idiographic judgement. It requires knowledge of how types of experiences relate to types other people. Thus, perceptual reports cannot underpin epistemically indi256

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vidualised judgement. But that was the most promising idea of idiographic judgement, inspired by Windelband’s account and which – unlike the sense found in psychology – might fit the requirement of a novel addition to psychiatric diagnosis. My argument so far has aimed to show that a particular way of characterising idiographic judgement fails. The requirement was both that it should be a genuine complement to psychiatric judgement and that it should be drawn from the very idea of a judgement tailor made for individuals. (Either of these requirements rule out the sense of idiographic that is legitimately deployed in psychology to refer to small-scale qualitative research.) That is not to say, however, either that there is no other sense of idiographic available nor even that Windelband himself was unaware of it. In the second half of this paper, I will outline an alternative conception of idiographic. But if it were true that this is the kind of distinction that Windelband really had in mind, it would make his contribution to the post-Kantian debate about scientific method called the ‘Methodenstreit’ less original and more modest than the rectoral address suggests.

Narrative versus Nomological Understanding

As I reported at the start of this paper, the WPA’s Idiographic (Personalised) Diagnostic Formulation is closely connected to a ‘comprehensive model’ of diagnosis. Juan Mezzich, former President of the WPA, describes the latter as follows: ‘The emerging comprehensive diagnostic model aims at understanding and formulating what is important in the mind, the body and the context of the person who presents for care. This is attempted by addressing the various aspects of ill- and positivehealth, by interactively engaging clinicians, patient and family, and by employing categorical, dimensional and narrative descriptive approaches in multilevel schemas’ [9, p. 91, italics added].

Thus, according to Mezzich, in the service of an idiographic diagnostic formulation, a comprehensive model includes a narrative descriptive approach. James Phillips also equates idiographic with narrative elements and describes them both thus: ‘In the most simple terms, a narrative or idiographic formulation is an individual account with first-person and third-person aspects. That is, the patient tells her/his story, with its admixture of personal memories, events and symptoms, and the story is retold by the clinician’ [4, p. 182, italics added].

Thornton

Both Phillips and Mezzich run together ‘idiographic’ and ‘narrative’. Whilst narrative understanding is tied to the kind of person-centred focus of contemporary psychiatric care, it need not presuppose the uniqueness of subjects as most definitions of the idiographic do [10, pp. 125–129]. I will suggest that construing the distinction between narrative and criteriological judgement in normative terms is more successful than the distinction between idiographic and nomothetic (construed as individual vs. general) in explaining how a broader notion of psychiatric formulation – rather than a narrower notion of criteriological diagnosis – should be framed. There are, however, two initial questions to be answered. The first question is: what is meant by a narrative? Phillips says ‘the patient tells her/his story’. And thus a narrative might be equated, in this clinical context as it is more generally, with a story. But not every style of story will fit present purposes. The style of narrative, for example, of medieval hagiography differs from that of a Jane Austen novel in a crucial respect. Cora Diamond gives these two examples from The Little Flowers of St. Francis. ‘First, an extraordinary event. We are told that in an ecstasy Brother Pacificus saw the soul of his brother ascend direct to heaven at the moment it left his body. We are told that that is what he saw, but we are not told at all what it was like to see such a thing. In fact we do not have any idea what he saw and how he knew it was his bother’s soul. But in this context of the narrative, that is not something that is felt as an omission. I do not mean that there is nothing that we could imagine here if we were asked to fill in the story, but simply that what we have is a narrative style, a texture of story, in which such gaps are not felt as gaps … There is something similar in the narration of perfectly ordinary events. We are told of St. Francis that he ‘did his utmost’ to conceal the miraculous wound in his side, and we are told of the ways in which some of the friars nevertheless got to see or find out about the wound. The methods of discovery were not very ingenious, and anyone who was so easily found out as St. Francis appears to have been cannot very well be described as having tried his utmost to conceal his wound. Now although it would seem that the words ‘St. Francis tried his utmost’ would have to be withdrawn or modified, in the light of what follows in the narrative, unless some explanation were given how someone trying his utmost could so easily have been found out, the difficulty is simply not noticed by the writer. But his not doing so is no slip; it is rather characteristic of the texture of the stories that realistic coherence is not demanded, and its absence is not felt as a fault’ [11, p. 51].

My purpose in selecting this example is not to say, especially in the context of accounts of psychopathology, that a first person narrative of the sort Philips mentions could not contain such lacunae. But, unlike medieval hagiography, it should not be the case with a proper underIdiographic versus Narrative Approaches to Assessment

standing of narrative understanding that the further inquiries at which Diamond hints are ruled out. On a proper understanding of narrative understanding, the gaps Diamond mentions are properly felt as gaps, calling for further account. (I will return to this point.) The second question is determining the role that narratives are supposed to play and their connection to the idea of a person or a self. Some grand claims have been made. The psychiatrist Clive Baldwin argues as follows: ‘The view that we are narrative beings is well argued by authors such as MacIntyre, Bruner and Taylor. For these authors, among others, not only do we exist in a story-telling world, but our very Selves are constituted by the stories we and others tell about ourselves. Our experience (of both the world and ourselves) is not reality put into narrative form but rather our narrative form made real. In other words, we are our stories. In these stories, we constitute ourselves as people in accordance with concepts of ourselves. These self-concepts are not static and our identity is a combination of historical narrative and literary fiction … Lives, like stories, have a trajectory through time’ [12, p. 1023].

Baldwin is here making a constitutive claim. Not only are narratives useful in making sense of people, but people are constituted as the people or selves they are by narratives. In making this claim, Baldwin is following an influential line of thinking from philosophy. Daniel Dennett, for example, has defended a similar picture of the self as narrative. He claims that a self is a centre of narrative gravity. To outline his view, he suggests an analogy with the physical notion of a centre of gravity. ‘A centre of gravity is just an abstractum. It’s just a fictional object. But when I say it’s a fictional object, I do not mean to disparage it; it’s a wonderful fictional object, and it has a perfectly legitimate place within serious, sober, echt physical science’ [13, p. 104].

The idea of a centre of gravity is deployed within a branch of physics to describe and predict the behaviour of physical systems acting under physical forces. What a centre of gravity is depends on this theoretical context and it is one of the useful tools and ideas that go to make that context. The concept is one amongst others interdependent on a theoretical stance. Selves are given similar treatment. Like centres of gravity or mental states, they are theoretical, even fictional, entities articulated within an interpretative theoretical stance. ‘A self is also an abstract object, a theorist’s fiction. The theory is not particle physics but what we might call a branch of peoplephysics; it is more soberly known as a phenomenology or hermeneutics, or soul-science (Geisteswissenschaft). The physicist does

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an interpretation, if you like, of the chair and its behaviour, and comes up with the theoretical abstraction of a centre of gravity, which is then very useful in characterising the behaviour of the chair in the future, under a wide variety of conditions. The hermeneuticist or phenomenologist – or anthropologist – sees some rather more complicated things moving about in the world – human beings and animals – and is faced with a similar problem of interpretation. It turns out to be theoretically perspicuous to organise the interpretation around a central abstraction: each person has a self (in addition to a centre of gravity). In fact we have to posit selves for ourselves as well. The theoretical problem of self-interpretation is at least as difficult and important as the problem of other-interpretation’ [ibid, p. 104].

Fully assessing such a radical claim about the connection between self and narrative lies outside the scope of this paper. But it is worth noting that, influential though it has been, it faces at least three significant difficulties: First, what is the claim actually being made? Are selves narratives or are they the authors of narratives? They cannot be both. But in many published accounts, these two ideas are not consistently distinguished. Baldwin, for example, blurs both together because, in addition to the claim above that selves are stories, he also says: ‘If we are narrative beings and the primary narrative of our life is the one we construct for ourselves in relationship with others, then the maintenance of narrative agency takes on major importance’ [12, p. 1025, italics added].

According to this second passage, we construct, or are authors, of the narrative rather than being the narrative itself. Similarly, in the quotation above, Dennett says ‘In fact we have to posit selves for ourselves as well’ (italics added). But if selves are authors of narratives, then what constitutive work is the idea of narrative doing, after all? Second, if selves are, literally, narratives, then how do narratives have meaning? A narrative is made up of a collection of signs (written or spoken). So how can those signs come to carry a meaning? The problem is this. Most plausible accounts of how linguistic meaning is possible presuppose an embodied agent whose beliefs and actions are appealed to to explain meaning. Gricean theories, for example, explain linguistic meaning by appeal to a speaker’s intentions to communicate his or her beliefs by such and such signs [14]. But a narrative account of self inverts that order of priority and thus must, somehow, explain the meaning of a narrative without appealing to agents. And that seems a difficult venture. Third, if selves are constituted by narratives, then the component elements of the narratives must not presuppose any concept of self. But it is difficult to see how a narrative account of self could avoid including elements 258

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which correspond to psychological states. A narrative which avoided all mention of mental phenomena would be useless to explain the notion of a self. But if the narrative presupposes psychological states, then that will surely, illicitly, presuppose a concept of self of whom the psychological states are states [15]. My purpose in raising these questions is not (here) to suggest that there is no hope for such a narrative theory of self. But it is to suggest that, because such a theory is at least contentious, the idea of a narrative formulation within psychiatric assessment is best not tied to any such substantive theory of the self. In the face of these two initial questions – deciding the specific style of narrative and its necessary or otherwise relation to self-hood – I propose a modest account of narrative understanding. I will take it to be the kind of understanding that connects together beliefs, desires, intentions and so forth in rational patterns. It deploys a framework of propositional attitudes whether this is thought of as codified in an implicit ‘theory of mind’ or more directly applied in response to behavioural expressions or through empathy. It is thus broader and narrower than a particular literary style: narrower, in that it is restricted to the understanding of rational agents rather than just any sequences of worldly events; but broader, in that it is presupposed by any particular story of rational agents. Indeed, Wilfrid Sellars argues that it runs deeper than that. The central role of this approach to understanding other people stems from the fact that that it employs the very same form of reasoning necessary for being a rational agent oneself. ‘The ‘manifest’ image of man-in-the-world … is … the framework in terms of which man came to be aware of himself as manin-the-world … [A]nything which can properly be called conceptual thinking can occur only within a framework of conceptual thinking in terms of which it can be criticized, supported, refuted, in short, evaluated. To be able to think is to be able to measure one’s thoughts by standards of correctness, of relevance, of evidence’ [16, p. 6].

Sellars’ idea seems to be this. Just as to be capable of thought – of rational or conceptual thought – requires an ability to assess one’s reasons for belief and action, so that same ability is what forms the basis of ascription of mental states to others. This is not the same as saying that selves are constituted by narratives. It is a weaker claim that rational agents, who may or may not be the same as selves, are describable by narratives in the sense described here. This is enough, however, to mark an important distinction from criteriological or nomological explanation. Thornton

Narrative judgement contrasts with nomological or law-like understanding or explanation not because – like idiographic judgement – it aims at one-off events but because it is normative. The appropriate contrast is not between the generality of nomothetic approaches and individualised judgement of particulars but rather between non-normative and normative descriptions. Narrative judgements thus answer to a different kind of internal logic to non-normative nomological accounts. In the vocabulary John McDowell has developed from Sellars, they belong to the ‘space of reasons’ rather than the ‘realm of law’ [17]. Why are narrative judgements, so understood, normative? Three considerations support this claim. Firstly, those individual elements within narrative accounts of subjects that correspond to propositional attitudes are normative. An expectation, for example, defines the event that would satisfy it; a belief defines the state that would make it true. In forming such an attitude, a subject adopts a normatively characterised stance to how the world is or will be. Secondly, the connections between elements of a narrative description of a subject reflect how a subject ought to think and act. They answer, in Donald Davidson’s phrase, to the ‘constitutive ideal of rationality’ which has ‘no echo in physical theory’ [18, pp. 223, 231]. They are, as Jaspers says of empathic understanding, ideally typically meaningful connections. A subject is compared to an ideal of good thinking. This contrasts with subsumption of events under natural laws in which that normative dimension of what ought to happen is missing. Tailored to an understanding of persons, the elements of a narrative are mental states described in a rational pattern of propositional attitudes. ‘The concepts of the propositional attitudes have their proper home in explanations of a special sort: explanations in which things are made intelligible by being revealed to be, or to approximate to being, as they rationally ought to be. This is to be contrasted with a style of explanation in which one makes things intelligible by representing their coming into being as a particular instance of how things generally tend to happen’ [19, p. 389].

Thirdly, as that quotation suggests, anomalies are differently accounted for in normative and non-normative forms of understanding. If an explanation by subsumption under a natural law fails because observations of what has happened fail to fit the law, then so much the worse either for the accuracy of observations or for the supposed natural law. But this is not the case for narrative accounts where deviations from the standards of good reasoning can be accommodated as occasional lapses of Idiographic versus Narrative Approaches to Assessment

judgement, perhaps explained by other aspects of the pattern which do accord with the standards. (One can, for example, form a mistaken belief for a good reason.) This feature gives narrative understanding in practice a particularly open-ended structure. Just about any surprising belief, desire or expectation can be accommodated through suitable adjustment to the rest of the system. That is to say, a subject may hold just about any surprising belief providing that he or she also holds corresponding supporting beliefs. These differences substantiate a key and underlying difference between narrative formulation and criteriological diagnosis. The former aims at making sense of the experiences and behaviour of subjects within a normative pattern rather than subsuming symptoms under kinds which fit into law-like patterns of disease aetiology and prognosis. Despite this difference, narrative accounts are nevertheless couched in general terms and consequently there is no necessary tension between adding such elements to a model of comprehensive assessment or diagnosis and aiming for its validity. This is because narrative accounts are conceptually structured and, according to a very plausible principle, concept mastery is an essentially general ability. The most famous statement of this is the philosopher Gareth Evans’ Generality Constraint. ‘It seems to me that there must be a sense in which thoughts are structured … I should prefer to explain the sense in which thoughts are structured, not in terms of their being composed of several distinct elements, but in terms of their being a complex of the exercise of several distinct conceptual abilities … Thus, if a subject can be credited with the thought that a is F, then he must have the conceptual resources for entertaining the thought that a is G, for every property of being G of which he has a conception’ [20, pp. 100–104].

Because narrative understanding of others rides piggy back on conceptual thought in general, it inherits the latter’s essential generality. The validity of narrative understanding might be thought to be put under threat by a second factor, however. Unlike subsuming chemical substances under the categories of the Periodic Table and their associated natural laws, describing individual human subjects in the normative terms of rationalising narratives can seem inevitable. Whilst one way of rationalising an action might be put aside in favour of another as new information about a person’s motives is presented, the broader patterns of rationality that are used to weave the elements together seem to have to be presupposed by any particular narrative account. But if there are no alternative ways of setting Psychopathology 2010;43:252–261

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about narrative understanding available, what sense is there that the structure used is valid? The solution to this is to recognise that a normative standard can operate even though it can only operate from within a stance taken to the world. To amend a quotation from the contemporary philosopher John McDowell: ‘Like any thinking, [narrative] thinking is under a standing obligation to reflect about and criticise the standards by which, at any time, it takes itself to be governed ... Now it is a key point that for such reflective criticism, the appropriate image is Neurath’s, in which a sailor overhauls his ship while it is afloat. This does not mean such reflection cannot be radical. One can find oneself called on to jettison parts of one’s inherited ways of thinking; and, though this is harder to place in Neurath’s image, weaknesses that reflection discloses in inherited ways of thinking can dictate the formation of new concepts and conceptions. But the essential thing is one can reflect only from the midst of the way of thinking one is reflecting about’ [17, p. 81].

This is the standing obligation that appears to be in abeyance in the examples from medieval accounts of the lives of the saints and why I argued that only particular narrative styles are suitable models for narrative understanding within psychiatric assessment. By recognising that narratives are based on general elements – both concepts in general and a structure of propositional attitudes more specifically – which can be assessed, even if not from a perspective external to them, one can reconcile including narrative formulations within diagnosis and still aiming at validity. Thus, if the supposedly idiographic elements that, in addition to general criteriological or nomological elements, make up comprehensive diagnosis are really narrative in this sense, then they do add something genuinely distinct without necessary risk to validity. (Of course, a spurious narrative will not be valid.) They add a rational, normative form of understanding that has a different underlying logic to explanation by subsumption under natural laws. But whilst they help to outline individual human subjectivity by furnishing accounts that can be tailored to individual subjects, this is not to deny their implicit generality. The concepts that form narrative accounts can be applied in different ways to different subjects providing that the narratives so formed are shaped in recognisable rational patterns.

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Conclusions

In recent discussion of psychiatric assessment, a key aim has been to replace a narrow conception of criteriological diagnosis with a broader model aimed at a truly person-centred approach to mental health care. As part of that, there has been a call for an idiographic element to complement the existing nomothetic approach implicit in criteriological diagnosis. At the same time, this has also been equated with a narrative formulation. I have argued that there is need for some care here. First, although the term ‘idiographic’ has a settled use in psychological research to refer to small-scale qualitative studies, that use does not explain how an idiographic element would be a genuine complement to criteriological diagnosis in psychiatry. Thus I examined the origins of the term in Windelband’s rectoral address. On his account, an idiographic judgement is aimed at a particular case but, further, seems to be a special kind of individualised, general-concept-avoiding judgement. Such a conception, however, falls prey to an argument against the Myth of the Given. Idiographic judgement, construed as individualised judgement, is incoherent. But the other suggestion to capture the nature of individuals in a broader model of psychiatric assessment seems more plausible. Narrative judgements, once distinguished from doubtful constitutive theories of the self and a too close assimilation to the idea of stories, are a plausible tool for mental health care. Understood as an aspect of the everyday self-critical and rational structure of concept-using agents, their underlying generality heads off a priori worries about their validity. But they have their own open-ended normative structure, distinct from the nomological structure that characterises claims about the aetiology and prognosis of diseases elsewhere in psychiatry.

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