Tuesday, 27 July 2021

Ethics, Law & Natural Hazards

In today's blog, Lauren Traczykowski (Aston University) presents her new book: Ethics, Law & Natural Hazards: The Moral Imperative for Intervention Post-Disaster (Routledge 2021).




Some of the first official feedback I received on my research was that it was morbid. Well, yes, I guess; I am interested in post-natural hazard response. I study the ethical what should happen when we have mass casualties, large scale homelessness or even physical insecurity after say, an earthquake, volcanic eruption, tsunami, hurricane, etc. and a national government is either unable or unwilling to help its people. 
Governments usually try to help their people if for no other reason than that they have a sovereign responsibility to do so. Even if their attempts are feeble or full of mistakes, a government recognizing that it is unable to fulfil its duties shows willing. 

Take the US Government response to Hurricane Katrina. There are a lot of notable failings; but the government was acting to support its people and it definitely had the resources and personnel to adequately respond. Likewise, when international assistance was offered, it was (eventually) accepted. In this way, I would argue that the US Government was both able and willing to respond to the needs of those affected by Hurricane Katrina.

 

But what I’m worried about is when a government is either unable or unwilling to support its people. Beyond any sovereign responsibility to help your people it is our duty to help other humans. In this monograph I explain that we have a duty or responsibility to help other humans because humans have (moral) human rights; they matter.

 

Specifically, I focus on the human right to welfare. When we consider any human right to welfare in the aftermath of a natural hazard, I’m talking about the minimum, basic provision necessary for human survival: objective goods that people need to live a life with a high level of welfare including a life sustaining amount of food, water, shelter and security. Humans cannot pursue their concept of a good life if they don’t have certain basic elements necessary for survival.

 

If we can agree that humans have a right to life-saving, life-sustaining goods, then we should be able to likewise agree that there must be a duty holder. When a state, the primary duty holder, has not acted on their duties to save or sustain life, the duty doesn’t just disappear. Instead, we, other humans, are still duty holders, and have a moral obligation to act.

 

There are only rare occasions when governments can’t or don’t act on behalf of their people in the aftermath of a natural hazard. The most contentious case of this was in the aftermath of Cyclone Nargis in Myanmar in 2008. Mass homelessness, destroyed buildings, and thousands killed. Myanmar did not request any international assistance in the immediate aftermath of the storm. Worryingly, though, the Government also restricted the movement of foreign aid workers already in-country. One could argue that aid workers were being prevented from doing their jobs. Foreign aid was also not allowed into the country. I would suggest that Myanmar, at this point, was unwilling to do what was necessary for its people.

 

Let’s quickly consider when a country can’t provide life-saving assistance to its people. For example, imagine that every person in the Myanmar Government was killed by the cyclone (you can see a bit of the morbid-ness critics were talking about). The international community is legally prevented from providing assistance to the people of Myanmar without a specific request/consent from the Government of Myanmar. But they can’t give that consent if they are no longer alive. There is no mechanism in international law for the international community to act in this kind of scenario. This is ethically problematic as the international community has second-order duties to provide for the welfare of those affected.

 

Lauren Traczykowski
 


When a government won’t act on behalf of its people, we have a bigger ethical problem. In 1999, Hasner argued that ‘preventing people from being saved’ is an act of allowing harm. Whilst doing harm is, ethically, more blameworthy, preventing someone from being saved is, still a ‘lethal’ harm and hence carries moral blameworthiness. The international community needs some sort of mechanism in which we recognize this moral blame and are empowered to act for the welfare of those affected.

When assistance was not accepted or requested, and diplomacy was not budging the Myanmar government, the international community started having political discussions amongst themselves. Some argued that the Responsibility to Protect (R2P) doctrine should be triggered and with that military force should be used to ‘protect’ those being prevented from being saved.

 

But death caused by natural hazards are not one of the triggers for initiating the R2P doctrine. R2P can only be triggered through international agreement and in response to a genocide, war crimes, ethnic cleansing and crimes against humanity. So, there is no legal or practical way to use R2P in the aftermath of a natural hazard. Similarly, it is argued, that if we (the international community) tried to use any military force, we would be violating the sovereignty of the country as well as possibly triggering a domino effect of social, political, and economic issues resulting in mass causalities (within and around the affected country).

Hence, the ethical issue: there is no formal mechanism for when a government is unable or unwilling to help its people in the aftermath of a natural hazard. This is despite the international community having a moral obligation to provide the goods associated with basic survival for those humans affected. To that end, in the monograph I suggest a possible way of developing international policy based on Just War criteria which account for our ethical requirements whilst addressing the possible legal and political hurdles that stand in the way of saving lives.

 

So, yes, there is a lot of death and destruction in my research. But don’t mistake the morbid-ness of what I research for anything other than hope. I work to make ethical justifications for international community action in ways that mean that those in life threatening situations in the aftermath of a natural hazard are properly valued as being worthy of being saved. The type of emergency should never undermine our duties to other humans.

 

Tuesday, 20 July 2021

Dementia and Identity

Today’s post is by Giovanni Boniolo, Professor of Philosophy of Science and Medical Humanities in the Department of Neuroscience and Rehabilitation at the University of Ferrara, Italy.


Giovanni Boniolo


Since 2018, I have been appointed as Scientific Director of the Civitas Vitae Research Centre (CVRC). This is a new department of the Fondazione OIC onlus (Padova, Italy) devoted to seeking, implementing and disseminating sociological and ethical innovative procedures and strategies aimed to improve the quality of life of people who are vulnerable and fragile due to age or disability. 

The Fondazione OIC onlus is an innovative nursing home with about 1500 guests (from about 65 to about 100 years old) and 1700 operators, where the values of longevity as a resource, intergenerationality, positive culture of the limit, and fragility are intended as opportunities for social networking.

Since its establishment, the CVRC has been realizing several initiatives and research programs. In 2019, we organized a workshop on Rethinking Aging from the point of view of a philosophy of science interbreed with ethics and sociology (the contributions are published in History and Philosophy of the Life Sciences). On that occasion, I presented a talk on identity and dementia that has been published in the collection just mentioned.

This paper (“Demented patients and the quandaries of identity: setting the problem, advancing a proposal”) was intended to enter the vivid debate concerning the impression that dementia brings loss of the self, or loss of identity, or loss of personhood. This loss is alleged to occur since dementia negatively affects, step-by-step, the proper functioning of the main higher mental functions (memory and decision-making capacity). 

This decline, especially in the middle and late stages, could lead to the idea that the self, or the identity, or the personhood, has completely changed and is replaced by a different one. Further on, that decline could lead also to the idea that demented individuals would no longer have moral status, since they would no longer be persons. 

However, what do ‘self’, ‘identity’ and ‘personhood’ mean? Before addressing the problem of whether a demented individual has a loss of self, identity, or personhood, and then provide a judgment about his or her moral status, we should have a clear idea of what we mean by those terms. In my paper, first, I have provided some clues to clarify the meaning of the terms. 

Next, without using vague or ambiguous term like “self” and “personhood,” I have proposed an empirical (more precisely, biological) perspective on identity, based on the notion of ‘whole phenotype’ (I call it the Whole Phenotype Account, or WPA), which has allowed me to argue that the demented individuals maintain their identity, in particular their whole phenotype identity. Moreover, I have advanced some remarks on how it is possible to use the WPA to cope with the questions related to demented individuals’ loss of the capacity to make moral decisions.

On the basis of the WPA, the conceptual analysis I proposed resulted in showing that there are no strong reasons to claim that a demented individual is a different individual compared to whom they were before the disease. Claiming that they are different means starting from very partial accounts of identity where, many times, vague concepts (as self), or ambiguous concept (as personhood) are introduced. We do not need this kind of accounts when we are in the unlucky position of being forced to consider the dementia of our relatives. 

We need an open mind to understand that the demented individual in front of us is not a different individual from what they were before: they are the same, as the WPA allows to argue. Unfortunately, they have a terrible pathology and we have to help them and take care of them as far we can and until we can. We have to respect them and their choices and decisions as long as they are capable of choosing and deciding. Then, when this capacity has vanished, we have to continue respecting not only them, but also the choices and decisions they made.

Tuesday, 13 July 2021

Philosophy of Psychology: An Introduction

Our (Kengo Miyazono and Lisa Bortolotti's) new Philosophy of Psychology textbook is out! Today it is the worldwide publication date for the book but in the UK it has been available since 14th May. 

If you want to participate in the book launch, please visit this page and enjoy two conversations on the themes of the book, one with Nevia Dolcini and Jules Holroyd on rationality, self-knowledge, and implicit bias; and one with Katrina Sifferd and Pablo López-Silva on autism, psychopathy, delusion, and confabulation.

In the book, we defend a particular view of human cognition and agency as imperfect. In this post, we say a little more about the sense in which human agents fail to meet ideal standards of cognition and agency, such as criteria for rationality and self-knowledge. 



 

Rosa wants to pass her ballet exam tomorrow and she knows that she needs to rehearse the opening routine to make sure she remembers all the steps. Passing the exam is important to her, and she would be very disappointed if she failed. Yet she sits on the sofa to watch a movie instead of practising her routine. Given Rosa's goal (passing the ballet exam tomorrow), her behaviour (watching a movie instead of practising) may be considered irrational since she does not take the appropriate steps to fulfil her goal (see chapter 1 on rationality).

Giorgio describes himself as an exceptionally generous child, always willing to support his friends. However, that is not how his friends describe him. On a number of occasions, they have observed that Giorgio has put his own needs before theirs and has refrained from sharing snacks or helping them with their homework. They think of him as mean and selfish. If Giorgio’s friends are right, then we can say that Giorgio does not have an accurate representation of himself. In particular, he attributes to himself qualities (such as generosity) that he does not have (see chapter 2 on self-knowledge).

Elsa, a white US citizen, thinks of herself as a very egalitarian person who respects everybody and considers them all equal, independently of ethnic origin or skin colour. However, when she goes to work, she avoids sitting next to Asian passengers on the bus and, when she talks to her colleagues at work, she tends to ignore her Nigerian secretary. Elsa does not have explicit beliefs that are prejudiced against people who look different from her but behaves in ways that are inconsistent with her explicit beliefs and values. She is vulnerable to implicit biases for which she may or may not be responsible (see both chapter 3 on duality and chapter 6 on free will and responsibility).

You may have experienced similar failures of rationality and self-knowledge and have encountered biases in yourselves and others, especially when considering beliefs and choices that have morally relevant implications (see chapters 4 and 5 on moral judgement and motivation). Indeed, the view that human cognition and agency are imperfect is not new. However, our book does not just claim that human cognition and agency are limited; on the basis of relevant psychological studies, it also makes some potentially surprising and controversial claims about the extent to which human cognition and agency are limited.

Human cognition and agency can be ‘imperfect’ in another sense; i.e. they are vulnerable to impairments and behavioural anomalies. Our book discusses delusion and confabulation (in chapter 7) and autism and psychopathy (in chapter 8). Thinking about unusual behaviours helps us understand how cognition works and how vulnerability to disorders of the mind relates to the failure to meet ideal standards.

 

Overall, we are not committed to a pessimistic conception of human cognition and agency. Rather, we advocate a realistic conception that is informed by psychological findings and is defended by philosophical arguments. We resist two extreme views of human cognition and agency. On the one hand, we resist an overly optimistic view according to which human cognition and agency are perfect (or near-perfect) with respect to ideal standards such as rationality, self-knowledge, and free and responsible agency. 

Kengo Miyazono

Lisa Bortolotti


On the other hand, we resist an overly pessimistic view according to which human cognition and agency are hopeless with respect to these ideal standards. By learning about the nature and the extent of their limitations, human agents can improve their performance. That is one of the reasons why philosophy of psychology matters. It does not simply provide information about what we can or cannot do. It offers us the resources to enhance our performance (in reasoning, decision-making, problem-solving, etc.) so that we can get closer to our ideal standards.

Tuesday, 6 July 2021

Philosophy Labs

This post is by Joe Vukov, Assistant Professor and Graduate Program Director in the Philosophy Department at Loyola University Chicago. The post discusses ideas presented in his recent paper, “Philosophy Labs: Bringing Pedagogy and Research Together,” co-authored with Kit Rempala, PhD student at Loyola Chicago, and Katrina Sifferd, Professor of Philosophy at Elmhurst College.

 

Joe Vukov

 

In STEM fields, collaboration is the norm. Go visit the biology or engineering building on campus, and you’ll notice undergraduates consenting participants for an experiment, graduate students crunching statistics in the hallways, post-docs writing articles in their offices, and faculty guiding the process. 

The experience provides a pedagogically-rich experience for those being apprenticed into their fields. It also produces a wealth of research. Take a look at the CV of a mid-career chemist or neuroscientist, and the list of publications far outpaces that of a mid-career philosopher. The lesson? Collaborative research not only provides a path for training those new to a discipline; it can also foster the efficient production of high-impact research. 

Philosophers don’t typically take advantage of this model. Sure, philosophers sometimes co-author articles or book chapters. This process, however, often consists in little more than the formal documentation of a series of happy-hour conversations. There’s nothing wrong with this -- we all do our fair share of co-authoring of this kind. But genuine collaborative research in philosophy--the pursuit of long-term projects between scholars at various stages in their careers--is rare. 

Need things be this way? We think not, and propose one model for conducting philosophical research in collaborative contexts: the philosophy lab. The philosophy lab is modeled on the STEM lab, and uses collaboration to pursue professional-level funding, presentations, and publications. Pedagogically, philosophy labs take their cues from group learning models such as Positive Interdependence Theory (PIT). 

In a new article, we argue that PIT, when deployed in the context of a philosophy lab, provides four central guidelines: 
  1. the careful selection of small, heterogeneous groups of collaborators 
  2. facilitators who foster individual autonomy among all participants
  3. an emphasis on open-ended taskwork
  4. a careful balancing of individual and group rewards. 

These tenets are broad, and applying them will be an art, not a science. After all, institutional contexts differ, and what works in one won’t work in another. Launching and maintaining a philosophy lab must therefore take on-the-ground conditions into account. The academic interests of faculty leaders; the presence of a graduate program; funding for undergraduate research: all of these should influence the precise form a philosophy lab takes. Just like a STEM lab, we believe there is no one form philosophy labs should take. 

But the proof is in the pudding. Do philosophy labs get results? In our experience, the answer is a resounding ‘yes,’ on whatever metric you’d like to measure success: consistent professional publications and presentations; funding for lab activities and individual students; placement of undergraduate students into choice graduate programs. Philosophy labs not only provide a rich learning experience for collaborators. They also further the careers of those involved in them. 

Do we want the hallways of philosophy departments to one day resemble those of a STEM building? No. Philosophy is not a STEM field, and we are confident that lonely-armchair-style philosophy will and should continue. There has always been a place for that kind of philosophy, and we see no reason to abandon it. 

But at the same time, we’d like to challenge our discipline to reflect carefully on new, more collaborative ways to engage in philosophical research. Collaboration is good for ourselves, for our students, and for the work we produce. There will, no doubt, be a plurality of methodologies that can serve these ends. We believe philosophy labs are one of them.

Tuesday, 29 June 2021

Ignorance, Misconceptions and Critical Thinking

This post is by Sara Dellantonio and Luigi Pastore. They discuss the theme of a recent paper, "Ignorance, misconception and critical thinking", appeared in Synthese.


Sara Dellantonio

Beliefs such as “Tiny specks of matter don’t weigh anything”, “Most people only use 10% of their brains”, “People with severe mental illness are prone to violence” or “Autism has become an epidemic” are usually defined as misconceptions, i.e., as beliefs that are considered to be false in the light of current accepted scientific knowledge.

Most studies on misconceptions aim to identify and create lists of the most common misconceptions across scientific fields such as physics, psychology, medicine, etc. In our article “Ignorance, misconceptions and critical thinking” we instead investigate the reasons that such misconceptions are endorsed in the first place.

It turns out that many of our misconceptions are not isolated errors that occur against the background of a correct explanatory framework. Instead, they constitute an integral part of and are the products of pseudo-explanations.

It is widely acknowledged that misconceptions are dangerous and detrimental. In everyday reasoning and decision-making, we rely on our beliefs. If these beliefs contradict current scientific knowledge, they are most probably erroneous and misleading; they will lead us to conclusions and actions that are not aligned with a scientific understanding of the world.

According to a widely accepted view, (one of) the most effective ways to eradicate misconceptions is to intervene directly: identify the specific misconceptions, inform people that these positions are wrong, and provide them with the correct facts.


Luigi Pastore

However, if our misconceptions are deeply rooted in our belief system and closely tied to pseudo-explanations for phenomena, this approach is ineffective: it does not alter the pseudo-explanations these misconceptions rely on and result from. The only truly incisive way to address such misconceptions is to tackle the explanation that supports them and adjust the system of inferences that gives rise to them. By doing so, we can act on all the interconnected false beliefs people hold on the topic, offer good reasons to embrace new beliefs, and provide means to make further well-grounded and congruent inferences on related phenomena – i.e., to develop new insights into this content.

In order for such changes in belief systems to occur, we not only need to acquire new disciplinary knowledge but also to develop adequate reasoning skills. The discipline that appears most promising to develop these skills is critical thinking. At its very basis, critical thinking aims to improve people’s analytic and evaluative attitudes toward knowledge; it consists in training individuals to reason in a disciplined manner, adhering to clear intellectual standards.

The definition of critical thinking goes back to John Dewey. In Dewey’s view, critical thinking consists in an active form of knowledge acquisition in which immediate intuitions are weakened and put under scrutiny and in which the acquisition of new information is accompanied by an adequate comprehension of how this knowledge should be organized and how its various components relate to form a system. Critical thinking appears to be key to developing integrated and coherent belief systems that are continuously examined from the point of view of the evidence they rely on and that are continuously re-evalutated to ensure all components remain mutually consistent and plausible.

Tuesday, 22 June 2021

Striving for Perfection

In this post, Rie Iizuka (Kansai University) reports on a held three-day workshop on epistemic paternalism and enhancement, entitled "Striving for perfection". This workshop was held online in February 2021, organised by Rie, as a part of her research on epistemic paternalism funded by the Japan Society for the Promotion of Science. 


Day 1-Epistemic Nudging

As an epistemic analogue of libertarian paternalism, Kengo Miyazono (Hokkaido University) introduced epistemic libertarian paternalism; epistemic nudges are placed in such a way people would judge in desirable ways, while no inquiries are blocked.  Epistemic nudging only changes our epistemic choice architectures but not our choice sets. This position may look modest initially. However, some believe epistemic nudging is an inherently contested concept (one of which claims nudging is irrational). He argues that such irrationality is contingent: some nudging can be rational, especially where nudges neutralize our biases.

Bart Engelen (Tilburg University) introduced the ways in which we can put exemplars to the fore in our moral education. He argues that nudging strategies could enhance effective exemplar narratives by increasing the perceived importance of exemplars through their vivid embodiment. In other words, reminding moral exemplars would help us reconceptualize the ethical demands by motivating us to imagine exemplar's perspectives.


Day2-Epistemic Paternalism

According to Daniella Meehan (Glasgow University), there is an inherent tension between virtue epistemology and epistemic nudging. Some might think nudging can help us cure intellectual vices, i.e., epistemically damaging characters that need systematic treatment. However, a systematic epistemic nudging involves a potential risk of harming our reflective epistemic autonomy, in the worst scenario, leading to creating yet another epistemic vice (such as laziness). A few ways to avoid this conflict were proposed: allowing some violations of epistemic autonomy for the greater good, nudging to enhance our deliberative capacity, and defending the view of characters fostered by nudging is not a genuine vice.

How shall we combat fake news? Shane Ryan (Nazarbayev University) believes an educational approach is key. Having compared three different ideas surrounding epistemic interventions: paternalism, benevolence, and laissez-faire, he concludes that making public media education a requirement for releasing contents on social media site may be permissible based on his formulation of epistemic paternalism: regardless of what S believes Y's wish, if S acts because of a positive epistemic standing that X may improve Y's epistemic welfare, S acts epistemically paternalistically.  

  

Day3-Enhancement

Rie Iizuka (Kansai University) takes virtues to be beautiful into serious consideration. Unlike familiar cautionary tales in enhancement debate in general (e.g., the argument from giftedness), people are eager to enhance their beauty standards by using various methods. Our narratives surrounding beauty practices are dominantly positive, choice-oriented, and techno-progressive. While we may rightfully attribute some virtues (such as tenacity or courage) to those who engage in such practices, she left some cautionary remarks: beauty practices are driven by consumerism that does not necessarily track beauty ideals. We also need to acknowledge the virtue of humility for appreciating the beauty in others.

Emma Gordon (Glasgow University) has shown a dilemma inherent in pharmacological cognitive enhancement. Her research is conducted in collaboration with Lucy Dunn (Glasgow University Medical School). When one achieves epistemically (e.g., acquiring knowledge) with the help of an enhancement drug, such an achievement seems to be primarily attributed to the drug than ourselves. We can avoid this cheapened achievement problem by claiming that success is ours when enhancement is adequately integrated into our cognitive architectures. On one hand, proper integration requires systematic and long-term use of enhancement drugs in such a way we understand the effect of such medications reliably, but on the other hand, constant use of cognitive enhancement drugs will have severe consequences, such as physiological and psychological dependence. 


Saturday, 19 June 2021

Agency in Youth Mental Health (6): “You’re not crazy, you just need to be shown compassion”

This post is the sixth in a series of posts on a project on agency and youth mental health funded by the Medical Research Council and led by Rose McCabe at City University. Today a member of Young People's Advisory Group writes her reflections about the project and what it means to her. 

The author is Catherine Fadashe, who is currently a third-year student at Birkbeck University studying English Literature and Italian. Her interests within mental health focuses on how to de-stigmatize culturally-influenced perceptions of mental health within Africa.




In 2019, I delivered a TEDx talk speaking on my mental health journey since my suicide attempt when I was 18. Talking about something so personal on a public platform, and being so open and honest about the topic, gave me a huge sense of liberation. So when I came across the opportunity to be on the Young People’s Advisory Group (YPAG) for the McPin Agency project, I jumped at it because it was my chance to turn lemons into a lesson that others suffering can learn from. 

The Agency in Mental Health project is important because it looks at whether the appropriate care and agency is given to young people when they seek out treatment for their mental health. This particularly interested me because I wanted to know if my negative experiences with therapy were abnormal or if they reflected the average experience of most young people. Unfortunately, I quickly realised it was the latter. 




One of the things that has been beneficial in highlighting these issues are the videos we have watched during our meetings which were reflections of some of our personal experiences in the group. Within the videos it showed interactions between mental health practitioners and young people who have been referred to for an assessment or/and ongoing therapy.

What I discovered whilst watching the videos was how grossly outdated the training that is given to mental health professionals is. The approach of many of the practitioners shown was mechanical and prescriptive with little to no compassion shown. As well as evaluating videos, one of the most significant aspects of our role on the YPAG panel is making contributions to the project proposal by suggesting what and how reform can be made in the treatment of mental health patients. Afterall, the long-term goal is that through the research done on the project it can enable better training for mental health practitioners in being able to give sufficient care and agency to young people.

Growing up in a Nigerian household meant that I had to learn to sweep my struggles under the rug. Mental health was not something that was ever discussed in our home. So when things came to a head and I went for my first ever therapy session after my attempt, I found the experience underwhelming. After much reflection, I realised that being from a culture where mental health is stigmatised created barriers in my communication with my therapist due to cultural differences. This caused delays in treatment which inevitably worsened my mental state.

I think one word which accurately sums up the difference between a good experience with a therapist and a bad one is empathy. In our lowest, loneliest and most desperate moments we wanted someone to make us feel like they cared. Like they were seeing us. They were hearing us - loud and clear. Not just blindly diagnosed by a doctor who signs off on a bunch of prescriptions to recalibrate our brain or to activate that little nub inside our heads that is so deeply starved of serotonin.

Put simply, we wanted validation. Validation that we were good enough.

Positive reinforcement goes a long way. Simple things such as saying, “You’re intelligent. You’re valuable. You’re beautiful” can make a world of difference to someone who never hears that. Or even to lower the volume on the negative voices that they hear in their head.

Before there can be valuable and sustainable progress in improving the agency that young people feel over their mental health treatment there needs to be a more robust infrastructure within the health service that can handle the complexities of dealing with such patients. For example, a homeless young person who has been referred for therapy may not feel motivated to attend their sessions as they may not deem it a top priority. Therapy and medications will not fix their predicament. In this case, housing associations and homeless charities would also need to be involved. 



Due to the pandemic and the lockdown that ensued in 2020, the YPAG members have not been able to meet in person. Nevertheless, thanks to the team members at McPin and academics leading the research we have all been able to gel well together during the Zoom meetings. Also, due to all the advisors having relevant lived experience of the topics discussed, we understand the importance of creating a safe space to listen to each other.

I am so glad and grateful to have been able to participate in such a significant project. And I look forward to being a part of more of McPin’s projects to contribute to better care for people struggling with their mental health.




Friday, 18 June 2021

Agency in Youth Mental Health (5): Lisa Bortolotti

This post is the fifth in a series of posts on a project on agency and youth mental health funded by the Medical Research Council and led by Rose McCabe at City University. Today it is my turn (Lisa Bortolotti) to answer four questions about the project. 



I am Professor of Philosophy at the University of Birmingham, affiliated with the Department of Philosophy and the Institute for Mental Health. I am a philosopher of psychology, interested in belief, rationality, self-knowledge, and mental health. 




What interests you about clinical encounters with young people in the mental health context?

The encounter between a mental healthcare practitioner and a young person experiencing a mental health crisis is the paradigmatic case of an interaction characterised by power imbalances: the practitioner is an expert who can assess risks and prescribe treatment, whereas the young person is thought of as a vulnerable and inexperienced person who depends on the practitioner for further support. We would expect epistemic injustice to flourish in this context. Epistemic injustice occurs when a person is discredited as a knower due to negative associations triggered by the person's identity. 

Indeed, in our study we have witnessed practitioners' behaviours that undermine young people's capacity to contribute valuable information to the exchange. A young person seeking support for mental health problems may trigger negative stereotypes (being fickle, attention seeking, unreliable) that may lead to the practitioner dismissing the young person's experiences. Unfortunately, there is a risk that such negative conceptions are internalised because the young person's identity is still developing and the most important relationships in the young person's life which could provide some anchoring are also evolving in the transition from childhood to adulthood.

Why is the focus of agency important in this context?

For the typical human being, the concept of the self involves a concept of agency. We see ourselves as capable of intervening in the surrounding physical and social environment so as to pursue our goals and interests and securing our wellbeing. Ultimately, agency means that we can give some shape to our own lives. 

We tend to think of agency as a power that we can exercise as individuals, but any realistic assessment shows that agency survives in the wriggle room we manage to carve from the constraints of our environment and the pressures of our social world. We are never agents in a void and we are never agents alone. As agents we support and obstruct, cooperate and manipulate one another.

When the young person's shifting sense of self is impacted by interactions with teachers, parents, friends, and mental healthcare practitioners, the young person may feel empowered or helpless, supported or abandoned, understood or dismissed, as a result of those interactions. Interactions of this sort are not the whole story, of course, but may make a difference to whether the young person will seek the help they need to bounce back.

What do your experience and disciplinary background bring to the project?

In this project, I am learning, not leading. I am new to youth mental health, and new to some of the methods used in the study, such as the conversation analysis of clinical encounters. But I have a deep interest in the strengths and limitations of the concept of agency and the role of agency in our identity.

Indirectly, I have worked on agency for the whole of my academic career, first thinking about how we attempt to understand the behaviour of other agents by ascribing beliefs to them; then questioning whether agency depends on the person conforming to standards of rationality; next arguing that poor mental health does not need to translate into compromised or reduced agency; and more recently reflecting on the role of optimistic conceptions of the self in supporting motivation and boosting resilience.




What do you hope to see as an outcome of this project?

I would like for everybody who deals with young people, not just healthcare practitioners, but also parents and educators, to appreciate the damage that unchallenged negative stereotypes can cause in interactions, and how easy it is, often without malice or ill-intent, to communicate in a way that makes young people feel bad about themselves and leaves them unsupported.

We are developing something we have called the agential stance: a set of practices that help us recognise and nurture a sense of agency in young people, without burdening them with the overall responsibility for the situation they find themselves in. I would like that stance to be discussed as part of parental education and the professional development of teachers and healthcare practitioners, together with examples of good and bad practice.

Thursday, 17 June 2021

Agency in Youth Mental Health (4): Michael Larkin

This post is the fourth in a series of posts on a project on agency and youth mental health funded by the Medical Research Council and led by Rose McCabe at City University. The research team members were asked the same four questions and today it is Michael Larkin's turn to answer.


Michael Larkin


Michael is a Reader in Psychology at Aston University. He is interested in related and connectedness and is an expert in the co-production and co-design of psychosocial services. In 2019, he was awarded the Mid-Career Research Prize by the Qualitative Methods Section of the British Psychological Society.



What interests you about clinical encounters with young people in the mental health context?

Over the years I’ve been involved in lots of studies about people’s experiences of mental health services, and of course, read a lot of other’s people’s work in this area too. It’s really striking how frequently certain key themes recur when people are unhappy with services. Off the top of my head, I’d summarise these as: not being listened to, not being understood, not being helped, and a lack of continuity even after some help is provided. There are some more coercive themes too, unfortunately. Generally these are themes are like overarching patterns, but this project presents a really exciting opportunity to ‘zoom in’ at the micro level, and to do that at the point where people are seeking help.

 

Services which are really attuned to not losing out on the opportunity to build a relationship with someone would see these clinical encounters as critical, make-or-break points. But many mental health services are not in that position. They are underfunded, and so they have more requests for help than they can deal with. They are also structured to provide a different kind of support (assess, intervene, discharge) to the kind that many service-users want (continuity of care; and permeable, ongoing access to that care). Instead of working hard to start everyone’s journey well, the organisational pressures may well be about identifying who they absolutely have to take on, so that everyone else can be re-directed elsewhere.

Why is the focus of agency important in this context?

 

It’s a horribly familiar case of an interaction arising from two completely different sets of expectations. The person seeking help wants to be heard, understood, and supported in improving their situation. They want to be told that they have done the right thing, come to the right place, and that now something helpful will happen. This is a reasonable expectation. But to be heard and understood, you need an audience willing and able to deal with complexity, ambiguity and contradiction – the grey areas of human experience.

 

Unfortunately, the person assessing them may well have been directed to decide that things are either one thing (acutely serious and immediately risky) or the other (currently under control or somebody else’s problem). If so, the young person’s agency gets overwritten– their nuanced account is recategorised firmly as either a Problem for this Service, or Not a Problem for this Service.

 

Experienced users of services come to understand that the way to reliably access the little support that is available is by learning the magic words – the things that have to be said to a gatekeeper for them to judge that the problem in front of them is a Problem for this Service. In our project we are seeing young people’s agency quashed, partly because they do not yet know the magic words.

 

We can add to this an unpleasant Catch-22. Young people seeking help are exercising some agency, and this can be turned against them, if someone has a suspicion that what they have brought is Not a Problem for this Service. ‘Too much’ agency can be read as too much functionality, an indicator that a person does not need help. This is especially true if the only help available is urgent help, I think.

What do your experience and disciplinary background bring to the project?

 

I’m writing this in Mental Health Awareness Week. Like a lot of people with a stake in mental health, I find it difficult: awareness is not really what’s lacking. What I’ve been feeling very aware of is a trail of dead family members, friends, colleagues, and friend’s family members. Something came on the radio which prompted this, so I began counting them, naming them. It was overwhelming - I had to stop. These people that I knew, who came to mind, are now dead. I was surprised how many there were. They died prematurely - largely because, as a society we have not been able to organise ourselves, and especially our workplaces and education systems, in ways which accommodate – and do not pass judgement – on the complexities of how life is lived when people experience mental health difficulties. I don’t think that it ought to be so difficult to do this, and I feel very angry about it. So that’s my experience, right now, at the time of writing: I feel angry.

 

One of the few advantages of not being a young person myself anymore (Kurt Vonnegut was right about the knees) is that I could stop there. It would be allowed. But I will try to say something about my disciplinary perspective too. As a psychologist, sometimes it is tempting to overstate the complexity of psychological matters – to say that of course a more concrete problem would be easier to deal with. Unfortunately, if anything, seeing the response to Covid has made me feel even more angry about the situation with mental health. Even with an immediate, universal problem with clear parameters, it has been striking how difficult it is for many of our institutions to imagine organising themselves differently. It’s tempting to throw your hands in the air. But … 




What do you hope to see as an outcome of this project?

The point about our topic is that agency – and mental health – are much more complex. The parameters are less clear. There’s a lot less ‘either/or’ and a lot more ‘both/and’. Young people may, for example provide care to others, and still need care from others too. This shouldn’t be rocket science, but if we build systems which sort helpseekers into two streams (yes, you do or no, you don’t), then researchers need to illuminate this complexity, and to show some different ways of working with it, and responding to it, which are human, and which are helpful. I would hope that this is where a convergence of phenomenological and psychological perspectives can help.

 

The young people working with us on this project – as advisors, co-analysts and co-authors – are a tremendous antidote to the feelings of anger and hopelessness that I associate with the topic generally, and with some of the video recordings we have watched, specifically. It is tremendously valuable to work with collaborators who not only remind you why change is important, but also show you how it is possible. So what I hope is that we can do some work together that will allow others to see that too. One of the things we will do is identify what it looks like when someone is listened to, is understood, and help is provided. I think that can be a positive step, even if it is one component of a systemic problem.

Wednesday, 16 June 2021

Agency in Youth Mental Health (3): Rose McCabe

This post is the third in a series of posts on a project on agency and youth mental health funded by the Medical Research Council and led by Rose McCabe at City University. The research team members were asked the same four questions and today it is Rose McCabe's turn to answer.


Rose McCabe


Rose is a psychologist specialising in professional-patient communication in mental health care. She records professional-patient encounters and micro-analyses verbal and nonverbal communication. She also works on translating these findings into novel interventions to improve communication and patient outcomes in mental healthcare. 




What interests you about clinical encounters with young people in the mental health context?

I am fascinated by communication between people and how it has the potential to impact us in a good or bad way. In a mental health context, when someone is distressed and vulnerable, this becomes even more important. Young people who are distressed may be particularly vulnerable and struggling to understand what is happening and why it is happening to them. 

There is a lot of self-stigma and societal stigma around seeking help for mental health difficulties and young people are putting their trust in people in positions of power to support them. Often these conversations go well but unfortunately sometimes they do not go well. This can have a profound impact and sometimes means young people will not seek help in the future when they may really need it.

Why is the focus on agency important in this context?

As agency is to do with our sense of being in control of our lives and decisions that affect our lives, it is important to think about how this plays out with young people in distress in mental health encounters. When we feel depressed or anxious, hear voices or have intrusive thoughts, this can make us feel like we are not in control. Young people may also be treated as not having agency by adults who think they are immature and not yet able to reliably report on their experiences or make good decisions about their mental health.

What do your experience and disciplinary background bring to the project?

I bring experience of analysing communication and working closely with people with lived experience and professionals to the project. I video record clinical encounters and analyse verbal and non-verbal communication in-depth, looking for obvious and less things that go well and not so well. An example of something obvious might be a professional encouraging someone by saying something like “You have been going through a really difficult time, you did the right thing in coming to see us and we are here to support you”. 

A less obvious, but really important aspect, might be a professional’s tone of voice when they talk to a young person (e.g. a patronising tone) or when a young person disengages nonverbally in the encounter and you can see they are losing trust in the professional. I have worked on communication surrounding self-harm in primary care, sharing a diagnosis of dementia, training to improve communication with people with psychosis, and shared decision making.

What do you hope to see as an outcome of this project?

I have enjoyed working with an advisory group of young people so much on this project and I am hoping that their views, experiences and recommendations will be used in training health professionals (and other people who support young people like teachers) to have better mental health conversations. 

There are some very fundamental and important things that are often missing from these conversations, particularly really listening to understand the young person, acknowledging that they are distressed and validating their decision to seek help. I hope that young people can be directly involved in training people who support them when they have mental health difficulties.




Tuesday, 15 June 2021

Agency in Youth Mental Health (2): Matthew Broome


Matthew Broome

This post is the second in a series of posts on a project on agency and youth mental health funded by the Medical Research Council and led by Rose McCabe at City University. The research team members were asked the same four questions and today it is Matthew Broome's turn to answer.

Matthew is an academic psychiatrist and Director of the Institute for Mental Health at the University of Birmingham. His main research interests lie in the field early psychosis and in the philosophy and ethics of mental health. 




What interests you about clinical encounters with young people in the mental health context?

There were two main drivers to my interest. One is very practical: as a psychiatrist I often see young people with mental health problems and am aware of the difficulties they can face in getting the help and understanding they would like. 

The second driver is more theoretical, but with potential clinical relevance. I became interested in how young people may change their conceptualisation of themselves, of their competence, agency, and responsibility, through the experience of clinical encounters and how the interactions with professionals could themselves shape that self-understanding, positively or negatively. Through studying these encounters, I hope we can improve the positive consequences for young people and lessen the negative impacts.

Why is the focus of agency important in this context?

Agency is important for us in the project as we want to examine how the young person is able to be an agent in the clinical encounter, that is, have their own views, opinions, and choices recognised and valued, and how we can improve these clinical meetings to further support agency. 

We’re aware that too much freedom and choice can itself be overwhelming, particularly when young people may be experiencing mental distress, but conversely, it’s important for young people not to be treated passively and not to have their views ignored. The agency of young people, both in terms of being a conveyor of knowledge and of being responsible for clinical and moral choices, is a key theme for us in the project and one that we see as being dynamic, and being in part connected with the interpersonal experience of the clinical encounter.

What do your experience and disciplinary background bring to the project?

I hope I have been able to bring my experience and background is as a medical doctor and clinical psychiatrist where I have worked with many young people with predominantly psychotic illnesses. In parallel, I have supported a close family member, who has had times of poor mental health, in their clinical consultations with professionals. In addition, I hope I have been able to bring a wider experience of how NHS services and professionals work, and how we train clinicians. 

In addition to clinical experience, I hope I have also brought an interest in philosophy and ethics of mental health care. Specifically, the ideas of the philosopher Miranda Fricker on epistemic injustice and how that can be experienced by young people with mental health problems, and themes from German Idealist philosophy, that run into twentieth century phenomenological-existentialism, namely, how the self is in some sense constituted by its relation with the Other.

What do you hope to see as an outcome of this project?

The main outcome I hope for is to take what we can learn from the clinical encounters and use it to help professionals in various settings (for examples, primary and secondary care, education) improve how clinical consultations are conducted, such that the mental health of young people is improved, and they are given support to enhance their agency in relation to their care and the choices they can make.

Monday, 14 June 2021

Agency in Youth Mental Health (1): Rachel Temple

Rachel Temple

This post is first in a series of posts on a project on agency and youth mental health funded by the Medical Research Council and led by Rose McCabe at City University. The research team members were asked the same four questions and today it is Rachel Temple's turn to answer.

Rachel is a Public Involvement & Research Manager at the mental health research charity, The McPin Foundation. At The McPin Foundation, she leads the McPin’s Young People Advisory Group and the wider young people’s network. She is passionate about ensuring meaningful involvement of young people in mental health research in ways that are comfortable, accessible, and engaging; regularly drawing from her social anxiety experiences when facilitating. 




Rachel is responsible for ensuring that no key decisions are made without consulting with the young people on this project; seeking their input on things such as project aims, design, results and presentation of findings. Rachel also identifies as a young person with lived experience of accessing mental health services, as well as a former support worker for young people’s inpatient services. To learn more about Rachel's work, follow the Young People's Network at the McPin Foundation on Twitter or Instagram.

What interests you about clinical encounters with young people in the mental health context?

My interest in this area comes from a lived experience perspective. As a young person with mental health issues myself, I have seen first-hand how instrumental those initial conversations are in installing trust. Feeling validated and like you have been listened to are some of the major things which help to establish that trust. 

Effective communication means absolutely everything in these encounters. For some, they really are ‘make or break’: if handled poorly, they can completely discourage a young person from ever seeking support again. This can cause a young person’s mental health to deteriorate further. As a former support worker for young people with mental health issues, I have seen this happen. I am deeply interested in what we can do to stop this from happening. Ultimately, I am interested in what we can learn about agency to improve these interactions and in turn, ensure that young people with mental health problems feel better supported.

Why is the focus on agency important in this context?

From what we have witnessed, the concept of agency - and the professional’s perception of the young person’s agency - can steer these interactions into a particular direction. We have seen examples whereby a young person is considered to have so much agency that their plea for support is dismissed. 

In some cases, they have even been held responsible for the difficulties that they are experiencing. Or basically just told that they should go ahead and do the things that the professional advises – like take their medication properly. It is important for us to understand why and how these judgments are formed about agency, how they impact mental health interactions - and what we can do about it.

What do your experience and disciplinary background bring to the project?

 

I wear multiple hats on this project: my lived experience expertise, my prior experience as a mental health support worker, and my current role as Young People’s Involvement lead at The McPin Foundation. I do my best to draw from all three where applicable. Above all, my role is to ensure that we are involving young people every step of the way and within every decision we make about the project.


What do you hope to see as an outcome of this project?

Personally, I have learned so much from this project, merely by listening to what other people on the team have to say. I hope for us to share learning with those who will benefit from it the most: mental health professionals and young people. 

If we can hammer home the importance of agency in establishing effective relationships between these groups, I think we could see a real positive shift in these interactions. To do this, I hope we can identify some of the major ingredients for a successful mental health interaction, and then share that knowledge in a meaningful, accessible and engaging way.





Tuesday, 8 June 2021

Social Approaches to Delusions (5): Turning Away from the Social Turn

Here is the fifth post in our series on social approaches to delusions. Today, Phil Corlett raises some concerns about the arguments proposed in favour of a social turn in the previous posts, offering a different perspective.


Phil Corlett


Lots of people I like and respect who think about delusions have recently decided that social processes are relevant to belief formation and maintenance and thence to delusions. I call this the social turn.

The preceding blog posts in this fascinating series suggest:

1) That we give testimony about the quality of other individuals as sources of testimony, and as such, we should define delusions and (given their social contents) delusions arise within individuals, through inherently social processes.

2) That testimonial abnormalities might be domain specific and dissociable from general reasoning abnormalities, and further that the socially specific deficit is one of coalitional cognition – how we form and sustain alliances with conspecifics.

3) That the brain’s statistical algorithms operate in the control centre of a unique primate that evolved to navigate a distinct (social) world of opportunities and risks and as such, any computational account of delusions should honor that social domain specificity

4) That there may be a new learning mechanism, through which jumping to conclusions – a bias widely held to be relevant to delusions - becomes contagious, jumping from individual to individual in a chain of agents drawing conclusions.

These seem like four very good reasons to take the social turn seriously. Other good reasons include the apparently social contents of delusions, as well as empirical data that seem to suggest that a domain specific coalitional mechanism is relevant to delusions [see Raihani and Bell 2018 and Bell et al. 2020].

 

With all due respect to these authors, and in deep appreciation and admiration of their work, I would like to push back today.

I wonder:

1) Whether we need to posit a domain specific mechanism, when perhaps a general learning mechanism might suffice? 

I want to be very clear, I acknowledge that humans are exquisitely social, and that we have specialized mechanisms for social cognition and interaction. We are influenced by the elegant work of Cecilia Heyes, who argues that much of what we call social cognition across species is actually driven by domain-general precision-weighted inference mechanisms [Heyes and Pearce 2015]. Put simply, we learn about other people as if they were cues with a mean expected value, and a reliability [Heyes et al. 2020] (this could be a mechanism through which we give testimony about others testimony). 

Evidence for this type of view is extensive. Some of the most compelling comes from developmental work in humans. Human infants’ domain-general associative learning abilities portend their social cognition and behavior later in life [Reeb-Sutherland et al. 2012]. I would like to suggest that much of social cognition involves ill-posed and recursive inference problems. These are hard problems. They tax the inference machinery extensively. Any insults to that inference machinery will impair social inference (as well as inferences more broadly). This would be consistent with our observations relating paranoia in patients, on the continuum, and perhaps even in rodents, to non-social precision-weighted updating [Reed et al. 2020]. We still need to get from our non-social deficit to an extremely social belief. 

Briefly, after Sullivan and colleagues, I think that having an enemy or persecutor can actually be reassuring. Perceiving that enemy as a source of misfortune increases the sense that the world is predictable and controllable, that risks are not randomly distributed [Sullivan et al. 2010] – blaming enemies might mollify the uncertainty that characterizes high paranoia, delusions, and psychosis more broadly. In settings where a sense of control is reduced, people will compensate by attributing exaggerated influence to an enemy, even when the enemy’s influence is not obviously linked to those hazards.

 

To be clear again, neither I nor Prof. Heyes disavow the presence or importance of domain-specific social mechanisms to human cognition and comportment, or indeed, that there are human-specific, and extremely impactful processes of social exchange (like language, in service of communicating meta-cognitive precision for interlocution and ideally shared belief updating [Heyes et al. 2020]). I would call these social-cognition proper.

I’d like to suggest that those inclined toward the social turn need to show that delusions are particularly related to these specific mechanisms (like theory of mind).

When social and non-social streams of information are available for inference by people who are highly paranoid, it is not clear that they have a specific problem with the social, that is not also present in handling the non-social [Suthaharan et al. 2021, Rossi-Goldthorpe et al. 2021].

In a recent meta-analysis of all functional magnetic resonance imaging studies of prediction error [Corlett et al. 2021], my colleagues and I found that there are regions (including the striatum, midbrain, and insula) that carry prediction errors across domains (like primary rewards, perception, and social variables). However, we also found some more domain-specific prediction errors, for example we saw prediction errors climbing the visual hierarchy during visual perception. 

Crucially, we found a social domain-specific prediction error in the dorsomedial prefrontal cortex (though – in something of a replication of what was found recently with direct recordings [Jamali et al. 2021]) this signal was present in non-social tasks, albeit less so). Perhaps one way that we might adjudicate between domain-general and social-specific accounts would be to show that delusions are more related to one or the other of these circuits, and the behaviors that they underwrite.

2) How well a coalitional cognition mechanism can explain the contents of all delusions? 

To be fair, this is also a problem for domain general theories, but, since the social turn is supposed to solve that problem for us, it is important to evaluate whether the social turn achieves its ends. I think it works best to explain paranoia, and, indeed the data so far have largely focused on the continuum of paranoia, rather than persecutory delusions. 

Commonly, the next delusional theme mentioned by social turn takers is grandiosity. The idea here is that grandiosity serves to protect low self-esteem through the coaltional mechanism, by convincing others of one’s power and insights. I am not sure the available data really support this inflationary account of grandiosity.

I remain curious, how might coalitional threat explain misidentification delusions? What subprocesses of coalition would we need to delineate and dissociate so that someone could get Capgras delusion rather than Fregoil delusion (again, I know a domain general account struggles here too). What is the coalitional explanation of Cotard delusion? The social coalitional turn honors the power dynamics implicit in passivity delusions, but what links between coalitional cognition, action, intention, and proprioception would need to exist for the social turn to work?

 

3) If the extant data regarding social cognition and social contagion in people with schizophrenia are consistent with the coalitional cognition failure? 

Sometimes people with delusions (or paranoia) rely excessively on others’ testimony [Rossi-Goldthorpe et al. 2021], sometimes they respond less to others’ suggestions [Hertz et al. 2021], and they can be overconfident in their own advice [Rossi-Goldthorpe et al. 2021, Hertz et al. 2020]. 

No doubt that people with schizophrenia have deficits in social cognition, and perhaps the tasks that have probed these challenges have failed to engage the underlying coalitional deficit, however, one would imagine that a foundational deficit would come readily to the fore, and explain more of the variability in delusions and/or hallucinations. The associations that have been reported are often specific to paranoia, rather than delusions or positive symptoms more broadly, and they are complex – dependent on IQ and negative symptoms [Bliksted et al. 2017] – and sometimes counterintuitive; mild to moderately impairments to social cognition are associated with fewer positive symptoms, but more paranoia [Nelson et al. 2007].

When the authors across previous posts talk about an evolved mechanism dedicated to social information, it brings to mind a module – though I know many reject that term. One could imagine a 2-factor account wherein the belief evaluation deficit (factor 2) was one of coalitional cognition. The 2-factor explanation of paranoia actually invokes rather domain-general mechanisms (of sensory or cognitive loss) as Factor 1 [Langdon et al. 2008]. 

These raise uncertainty and demand belief updating. Ironically, this places the 2-factor explanation closer to my own – though of course I reject a strict separation between perceptual uncertainty and belief updating. Consider the elaborate visual hallucinations of Charles Bonnet Syndrome. The person experiencing these may, over time, come to question and reject their veracity despite their vividness and persistence. Here the abnormal experience does not usually generate paranoia though it can do, see for example [Makarewich 2011]).

The relevance of the jumping to conclusions bias to delusions is by no means certain [Tripoli et al. 2021], and, its unclear whether contagion of such jumping should be increased or decreased in people with delusions. However, the elegant paradigm outlined by Sulik and colleagues could be extremely relevant to folie a deux (wherein a non-psychotic person ‘catches’ a delusional belief from a close conspecific) and perhaps to the online radicalization toward conspiracy theorizing we have observed over the past year (folie a internet?). Such contagion (or lack thereof) may even be an empirical basis to distinguish delusions from other odd delusion-like beliefs.

I thank the previous authors for giving much food for thought. In my lab, we’ve taken their ideas very seriously. Based on our data, their data, and others, I am not quite ready to take the social turn, but I’ve learned a lot by considering it.