‘Wrestle to be the man philosophy wished to make you’: Marcus Aurelius, reflective practitioner. Reflective Practice. 10.4 (2009): 429-436. Part 2

As outlined above, many of the sections of each book are epigrammatic and abstract. This is frustrating for the historian, for the personal diary of a Roman Emperor is, one would imagine, a priceless primary source. It also makes it difficult to identify which, if any, specific incidents may have inspired ‘awareness of unsettling thoughts’, and the subsequent critical analysis as outlined in Raw et al.’s (2005) model. Many of the sections are general moral reflections, exhortations to the self to live up to one’s own standards. Phrases such as ‘always remember’ recur some 40 times over the course of the text.
Some sections deal directly with his role as ruler:

Take heed not to be transformed into a Caesar, not to be dipped in the purple dye, for it does happen. Keep yourself therefore, simple, good, pure, grave, unaffected, the friend of justice, religious, kind, affectionate, strong for your proper work. Wrestle to be the man philosophy wished to make you. Reverence the gods, save men. Life is brief; there is but one harvest of earthly existence, a holy disposition and neighborly acts. In all things like a pupil of Antoninus; his energy on behalf of what was done in accord with reason, his equability everywhere, his serene expression, his sweetness, his disdain of glory, his ambition to grasp affairs. (Book VI, Section 30)
This section is full of imperatives – ‘take heed’, ‘keep yourself’, ‘wrestle to be the man’, ‘reverence’ – before returning to the example of his foster father and imperial predecessor. This recurs often in the Meditations. As outlined above, the first book of the Meditations is different in tone and structure from the others, being a catalogue of people to whom Marcus is grateful, and what he is grateful for. By some distance the longest of these sections is on Antoninus. Thus it could be considered that Antoninus became for Marcus an ideal Emperor to be emulated, as close as one could get to the Stoic ‘sage.’ The section quoted immediately above continues:

Also, how he let nothing at all pass without first looking well into it and understanding it clearly; how he would suffer those who blamed him unjustly, not blaming them in return; how he refused to entertain slander; how exactly he scrutinised men’s characters and actions, was not given to reproach, not alarmed by rumour, not suspicious, not affecting to be wise; how he was content with little, in lodging, in his bed, in dress, in food, in service, how he loved work and was long‐suffering.
Thus Antoninus reflected the Stoic conception of virtue. As a reflective practitioner, Marcus returned the examples of Antonius and of the virtue of ‘philosophy’ as touchstones. One could consider that they provide the framework for critical analysis of the situations Marcus was faced with that provoked reflective thought. Not surprisingly, another repeated theme is that it is possible to live a philosophical life as an Emperor. It was often felt that philosophy and the eminence that went with being Emperor were diametrically opposed. Some of this attitude derived from philosophers – it was the view of the Epicureans that involvement in public affairs inevitably brought pain. Political actors, too, were often disdainful of philosophy – the view of Agrippina, Nero’s mother, as reported in Suetonius, was that philosophy was a hindrance to a future ruler (cited in Rutherford, 1989b, p. 178).
Marcus often returns to this topic:

As are your repeated imaginations so will your soul be, for the soul is dyed by its imaginations. Dye it, then, in a succession of imaginations like these: for instance, where it is possible to live, there also it is possible to live well: but it is possible to live in a palace, therefore it is also possible to live well in a palace. (Book V, Section 16)
This tension was obviously one of the main preoccupations of Marcus. As outlined above, self‐improvement was key to Stoic practice, and as Emperor clearly the pressures of affairs seemed to militate against this. Marcus uses a maternal metaphor to reconcile himself to this tension:
Had you a step‐mother and a mother at the same time, you would wait upon the former but still be continually returning to your mother. This is now what the palace and your philosophy are to you. Return to her again and again, and set up your rest in her, on whose account that other life appears tolerable to you and you tolerable in it. (Book VI, Section 12)
It is noteworthy that at the end of this section Marcus accuses himself – looking beyond difficulty in the court to difficulties in his inner self. Immersion in his ‘mother’, philosophy, will make him ‘tolerable’ in the world of the court. Therefore we see Marcus repeatedly reflecting on his role as Emperor, and trying to see beyond his immediate reactions and frustrations.
Another saying is also significant, as it sees Marcus going beyond this tension to identify his role as being ideally suited for philosophical practice:

How vividly it strikes you that no other calling in life is so fitted for the practice of philosophy as this in which you now find yourself. (Book XI, Section 7)
To return to Tight’s (1998) concern with the potential of imposed reflective practice to become a stale chore, within the professions it is important not only that reflective practice occur, but that it be seen to occur. Reflective diaries that can be read and scrutinised, supervision sessions that can be counted and minuted – all ultimately for the sake of proving that reflection exists. Marcus Aurelius wrote what would later become known as his Meditations without any external compulsion. There was no authority demanding evidence of reflective practice.
Furthermore, some of the pressures that Marcus describes of sheer busy‐ness leading to a tension between the workaday world of administrating the empire and the reflective work of philosophy are obviously familiar to practitioners today. While reflective practice is increasingly popular amongst medical professionals, it is still viewed with a certain amount of reserve by many. The tendency is to see it as a luxury, at best an optional extra, at worst a distraction from ‘real work.’ Marcus’Meditations show that this tension has always been with us, and that Marcus himself drew strength and support from philosophical practice.
It will strike some readers as ironic that I am using a Roman Emperor as an example and exemplar of a reflective practitioner. Marcus presided over mass slavery and the persecution of Christians. He was not simply an imperialist – he was Empire. It may seem ludicrous to describe being Emperor as a profession in the same sense we use it when discussing contemporary reflective practice in health care or in other areas. Whatever the power of the professions, few professionals have anything like the power of a Marcus Aurelius.
Marcus himself, however, reminds us repeatedly of his humanity and our common humanity with him. He does not refer to even the most virtuous emperors as divine, writing that:

In the first place, be not troubled, for all things are according to Universal Nature, and in a little while you will be no one and nowhere, even as Hadrian and Augustus are no more. (Book VIII, Section 5)
The Marcus that emerges is not saintly or otherworldly – as Rutherford remarks in the introduction to his edition of theMeditations, ‘from his own words we can deduce that he often found it hard to restrain his temper, and hence that the many references to anger in the Meditations are not merely conventional’ (Rutherford, 1989b, p. xvii). Many of the values that were universally held in his society are repugnant to us today. Nevertheless, he emerges from the Meditations as a man reflecting on his work and striving to improve it and himself – a model of the reflective practitioner.
One could identify certain characteristics of his writings that may be useful to other reflective practitioners. For instance, he uses Antoninus as a role model and returns repeatedly to his example. Thus, modelling effective practitioners, often suggested as a framework for professional reflective practice, has a precedent. He also demonstrates great personal commitment to his reflective practice, and works within the framework of his overall philosophical approach to life. He also manages to identify the tensions between his imperial role and philosophical inclinations and, while acknowledging them, comes to see how these roles are complementary.

REFERENCES

  • 1. Brunt, P.A. 1974. Marcus Aurelius in his Meditations. Journal of Roman Studies, 64: 1–20.
  • 2. Epictetus. 1928. The discourses as reported by Arrian, the manual, and fragments, Edited by: Oldfather, W.A. Harvard, MA: Loeb Classics.
  • 3. Foucault, M. 1984. The history of sexuality: Volume 3 – The care of the self, London: Penguin Books.
  • 4. Gibbon, E. 2000. The history of the decline and fall of the Roman Empire, Edited by: Wormesley, D. Harmondsworth, , UK: Penguin.
  • 5. Hadot, P. 1990. Forms of life and forms of discourse in ancient philosophy. Critical Inquiry, 16(3): 483–505.
  • 6. Hadot, P. 1995. Philosophy as a way of life, Oxford: Blackwell.
  • 7. Hadot, P. 2001. The inner citadel: The Meditations of Marcus Aurelius, Cambridge, MA: Harvard University Press.
  • 8. Machiavelli, N. 1983. Discourses on the first decade of Titus Livy, Edited by: Walker, L.J., Richardson, B. and Crick, B. Harmondsworth, , UK: Penguin.
  • 9. Nordenfelt, L. 1997. The stoic conception of mental disorder: The case of Cicero. Philosophy, Psychiatry and Psychology, 4: 285–291.
  • 10. Raw, J., Brigden, D. and Gupta, R. 2005. Reflective diaries in medical practice. Reflective Practice, 6(1): 165–169.
  • 11. Rutherford, R.B. 1989a. The Meditations of Marcus Aurelius Antoninus: A study, Oxford: Oxford University Press.
  • 12. Rutherford, R.B. and Farquharson, A.S.L., eds. 1989b. The Meditations of Marcus Aurelius Antoninus, Oxford: Oxford University Press.
  • 13. Schön, D. 1987. The reflective practitioner: How professionals think in action, New York: Basic Books.
  • 14. Sellars, J. 1996. Stoicism, Chesham, , UK: Acumen.
  • 15. Tight, M. 1998. Lifelong learning: Opportunity or compulsion?. British Journal of Educational Studies, 46(3): 251–263.[Taylor & Francis Online], [Web of Science ®]

‘Wrestle to be the man philosophy wished to make you’: Marcus Aurelius, reflective practitioner. Reflective Practice. 10.4 (2009): 429-436. Part 1

Re-reading this I am struck with my anachronistic hubris in trying to claim Marcus Aurelius as a some kind of trainee emperor scribbling away his reflections. Mary Beard had a piece in the LRB pouring scorn on the idea of the “philosopher-emperor” and I am pretty sure would disapprove of this piece. And my respect for the profession of history is such I cringe at my no doubt many errors.
However, one of the wonders of literature is that it allows a dialogue with the dead and perhaps the connections are not so forced as all that.  I also find the tension between a regulatory demand for reflection and the actual practice of reflection an even more germane one at this stage in my career. Regulators are increasingly demanding what sound like benign, motherhood-and-apple-pie type textual interventions, which in practice turn into form filling chores, much resented.

The original paper is here

Abstract

The Meditations of the Roman Emperor Marcus Aurelius Antoninus have been read by historians, philosophers and general readers as a text of Stoic philosophy and an insight into the mind of an imperial ruler. In this paper the author discusses aspects of theMeditations from the point of view of reflective practice, positing that Marcus Aurelius is in some ways an exemplar of reflective practice. He discusses his own professional background and concerns within it about reflective practice being a compulsory or imposed part of training. A description of Stoic philosophy follows, with an emphasis on its ethical and moral teachings. The work of Pierre Hadot and Michel Foucault on ‘the care of the self’ and the importance of practice in Ancient Philosophy is discussed. Extracts from the Meditations which can be read as reflective work by Marcus Aurelius on his ‘professional’ role as Emperor are presented and discussed. Finally the relevance of Marcus Aurelius today, and his possible role as an exemplar of reflective practice freely undertaken for its own sake, are discussed.
The Roman Emperor Marcus Aurelius, named at birth Marcus Annius Verus, is now remembered primarily as the author of what have become known as the Meditations. These reflections were written on campaign in the later years of Marcus’ life. The title Meditations is a later addition – the title on the manuscripts that survive is Tά εỉς έαυτόν, transliterated to Ta eis heauton (‘to himself’). In this paper, I will examine the Meditations and Marcus’ reflections on his role as Emperor as an exemplar of reflective practice. This is in the context of Stoic philosophy, and a wider concern in the ancient world with self‐cultivation by means of reflection and diary keeping – I also wish to provide a historical context for reflective practice work. I will use this to reflect on practices in my own profession of medicine and suggest that Marcus Aurelius is a useful role model for reflective practice.
Before discussing the Meditations as a prototypical reflective practice text, I will discuss reflective practice from my own perspective. I am from a medical background, at time of writing a Special Lecturer and Senior Registrar in Psychiatry. Reflective practice has become popular within the professions; one could argue that reflective practice is something that has always been implicit in them, as an extension of the duty to ‘keep up to date.’ Another view would see it as being imposed by regulatory and other agencies, representing a public distrust of professional authority.
A key text in reflective practice in its modern incarnation is Schön’s 1987 book Educating the Reflective Practitioner. In the book, Schön quotes the sociologist Everett Hughes:

In return for access to their [the professions’] extraordinary knowledge in matters of great human importance, society has granted them a mandate for social control in their fields of specialization, a high degree of autonomy in their practice, and a license to determine who shall assume the mantle of professional authority. But in the current climate of criticism, controversy, and dissatisfaction, the bargain is coming unstuck. When the professions’ claim to extraordinary knowledge is so much in question, why should we continue to grant them extraordinary rights and privileges? (Schön, 1987, p.7)
The power of the professions and the power of the academy are continually questioned in modern society. Medicine in particular has lost much of its privileged status. Scandals such as the Bristol, Alder Hey and Shipman cases in the UK, the Michael Neary case in the Republic of Ireland, and contaminated blood products in a number of jurisdictions, have led to a much greater public expectation of external scrutiny of medical authority. Reflective practice may offer an answer to Hughes’ question.
Various models of reflective practice are influential in biomedicine. One is that described by Raw, Brigden, and Gupta (2005) consisting of:
an awareness of unsettling thoughts/feelings about an event or events;

critical analysis of the situation; and

the development of a new perspective on the situation.

This approach has been incorporated within professional education in the establishment of formal mentoring and supervision schemes, and the formal use of reflective practice diaries. Reflective practices are increasingly built into both undergraduate medical education and postgraduate training. This reflects a concern in medical education with fostering deeper, lifelong learning patterns. Medical students were, traditionally, seen as particularly prone to exam‐focused, ‘just in time’ learning.
Concern has arisen within medical educational research about the possible effects of embedding reflective practice in work and the framework of regulatory supervision. This concern is well articulated by Tight (1998). Can this lead to a joylessness and rote approach to reflection, a sense that rather than being something that can lead to professional and personal growth and development, it is simply a means of control by external agencies? With this question in mind, I wish to return to discussing the philosophical background to the Meditations.
Cicero, the Roman orator and political figure of the first century BC, whose philosophical writings are sympathetic to Stoicism, described philosophy in his Tusculan Disputations as animi medicina, or ‘medicine for the soul’ (Nordenfelt, 1997). Ancient Philosophers saw their role as discerning and teaching the right way to live, in a way that modern academic philosophy, ethics apart, does not.
The Meditations are often described as a text of Stoic philosophy. ‘Stoic’ in modern contemporary usage is synonymous with ‘repressed’ and has pejorative connotations. This was very different from what the Stoics actually taught. Zeno of Citium (334 BC–262 BC) started the Stoic school of philosophy around 301 BC, teaching in the stoa poikile or ‘painted porch’ of his house in Athens, from whence the word ‘Stoic’ derived. Stoic thought (Sellars, 1996) provided a holistic, unified worldview, with a threefold approach of formal logic, materialist physics and naturalistic ethics. It is for their ethical writings and teachings that the Stoics are now primarily remembered, but an equal emphasis was placed in Stoic teaching on a view of logic which held that certainty in knowledge could be achieved through the use of reason, and a cosmology which posited the universe as a material substance capable of reason and known as ‘God’ or ‘Nature.’
As mentioned above, it is in the ethical field that the Stoics are most remembered and most misunderstood. Rather than encouraging an emotion‐free approach to life, enduring for the sake of enduring, they proposed an approach based on απαθεια (apatheia) which is generally translated as ‘apathy’ – something very different from modern use of the word.Apatheia implies clarity of thought and judgement rather than indifference. They argued that we should attempt to focus on what is under our control, and what is not under our control is ‘indifferent.’ It is possible to have ‘preferred indifferents’, things not under our control but desirable, such as health or good reputation. Stoic thought postulated an ideal ‘sage’ to which we could aspire, although no one had actually achieved that level of apatheia and indifference to indifferents.
The Meditations are not straightforwardly ‘Stoic’, and incorporate elements of Platonism and Epicureanism as well. They generally avoid technical discussion of Stoic or other approaches to questions such as the nature of being. They have been divided, traditionally, into 12 ‘books’, although the structure of the original manuscript is considerably looser. The first of these books is quite different from the rest, consisting of a catalogue of significant people in Marcus’ life and what he has learned or derived from each. The other books compile his own reflections in various ‘sections’, not organised with any evident over‐riding scheme or argument. They are generalised, rather than dealing with specific instances. Many allude to quotations and historical incidents, some of which are unknown to us.
The Meditations, I argue, reflect a key argument of Stoic thought – that apatheia, the characteristic of the wise man or sage, could be cultivated and developed. The Ancient Greeks had a concept of meditation or practice from early in their cultural history. The original Muses (female personifications of various attributes) were three – Mneme (memory), Aoite (song) and Melete (meditation/practice) – before later becoming the more familiar nine. The first identifiable philosophers of Ancient Greece, the Pre‐Socratices and the Sophists, also discussed the importance of practice and reflection. The Sophist Isocrates stated that the exercise of philosophy (philosophias askesis) is for the soul what medical attention is for the body. The word ‘ascetic’ is derived from askesis, and in a now familiar pattern had a broader meaning than the current sense of the abjuration of physical comfort.
The French philosopher and classicist Pierre Hadot described how Ancient Philosophical traditions distinguished between philosophy as philo Sophia (‘the love of Wisdom’) and discourse about philosophy as practice (Hadot, 1990, 1995, 2001). The Stoics, for Hadot, exemplified the ancient tendency to focus on practice rather than speculation, or debate. Practice leads to the cultivation of wisdom and the development of a spiritual life. Epictetus writes ‘the lecture room of the philosopher is a hospital ward’ (Epictetus, 1928, 3.23.27) and the Stoics, like other Ancient Philosophers, saw their work as being the cure of souls. As mentioned above, the Stoics did have a cosmological and metaphysical system, which loomed as large in their work as the ethical one – but the writings of Stoics such as Seneca, Cicero and Marcus Aurelius (all primarily public figures rather than philosophers) focused on practical ethics.
Another French thinker who particularly attended to Stoic thought (and has been highly influential) was Michel Foucault. In his later works, Foucault explored the creation of ‘a technology of the self’ (Foucault, 1984) and, while his starting point was Socrates’ injunction that one should ‘take care of oneself’, he mainly focused on the Stoics as the Ancient Philosophers who developed techniques for actually doing this. ‘Technology of the self’, discussed in the third volume of Foucault’s unfinished magnum opus The History of Sexuality (Foucault, 1984), referred to the techniques through which human beings constitute themselves. Foucault argues that, as subjects, we are perpetually engaged in defining and producing our own ethical self‐understanding. Foucault discusses at length the υποµνηµα – or Hypomnema – a Greek term that can be translated in many ways – as a reminder, a note, a copy, a public record, and other terms. Foucault uses the word in the sense of a note, and discusses it in the context of Seneca’s discipline of self‐knowledge.
Foucault’s and Hadot’s view of Stoicism as being concerned with ‘practice’ brings us to the actual practices that were involved in developing apatheia. Epictetus advised his adherents ‘to exercise daily to meet the impressions of our senses’ (Epictetus,1928, 3.8.1). In his writings, we find question‐and‐answer pairs that serve to limit the perceived consequences of any particular occurrence. For instance, ‘His ship is lost. What happened? His ship is lost. He was carried off to prison. What happened? He was carried off to prison.’
Meditations (all citations to this text that follow are from the Oxford World’s Classics Edition of Rutherford, 1990) was written as a form of practice of Stoic discipline, with the headings of individual parts of the manuscript indicating that entries were written at particular stages of a military campaign. Rutherford observes that they

are not predominately reflections, pensées, or miniature essays; Marcus tends to be talking to and at himself. The aim of the Meditations is therapeutic: to revive and bring home to himself, in suitably striking and memorable form, the moral truths that the author has accepted in the past. (Rutherford, 1989a, 13)
Who was Marcus Aurelius? Marcus Annius Verus was born in 121 AD. His father, Verus, died when Marcus was young, and he was raised primarily by his grandfather, also Marcus Annius Verus, who was an influential figure related to the Emperor Hadrian. Hadrian punningly nicknamed Marcus verisissimus – ‘the truest’ – and regarded him as something of a favourite, prevailing upon his heir Antoninus Pius to adopt the boy in 138.
On the death of Hadrian, Marcus was betrothed to Antoninus’ daughter (and his own cousin) Faustina. On his accession as Emperor, Marcus requested that the Senate install his adoptive brother Lucius as Co‐Emperor. Lucius took the name Verus as Emperor and would earn a reputation as a playboy in later literature, partly as a rhetorical foil to the serious Marcus. However, Marcus’ diaries and correspondence reveal affection and respect for his Co‐Emperor, who pre‐deceased Marcus in 169.
The five emperors up to and including Marcus became later known as the Five Good Emperors. This phrase is derived from Machiavelli’s Discourses, as an illustration of the superiority of succession by adoption (implying a degree of judgement and merit) over succession purely based on birth (Machiavelli, 1983). Edward Gibbon, in his History of the Decline and Fall of the Roman Empire, wrote that

If a man were called to fix the period in the history of the world during which the condition of the human race was most happy and prosperous, he would, without hesitation, name that which elapsed from the death of Domitianto the accession of Commodus [Marcus’ son and heir]. (Gibbon, 2000, I:70)
During his reign, the Empire was more or less constantly beset by wars. From the 160s, Germanic tribes began launching incursions into Gaul and across the Danube. After Verus’ death, the rest of Marcus’ reign was spent on campaign. The main tribal antagonists of the Romans were the Marcomanni and Quadi, and the term ‘Marcomannic Wars’ has been given to the overall conflict. Although a Roman victory in 176 AD saw a triumph for Marcus, the respite was brief and in 177 AD a second Marcomannic war began. Over the course of this campaign, Marcus Aurelius fell ill with chickenpox and died in Vindobona (modern Vienna) on 17 March 180.
The Meditations were unknown during his lifetime and until the fourth century. Brunt (1974) argues that as the Meditations can often be cryptic and allude to what are presumably personal events, as well as repetitive and unsystematic in their treatment of various themes, it is nearly certain that they were written for Marcus himself rather than an external readership.

Sophistry, the Sophists and modern medical education. Medical Teacher Volume 32, Issue 1, 2010. Part 2.

THE SOPHISTS AND THE PROFESSIONALISATION OF MEDICAL EDUCATION

One of the direct ways in which the Sophists are relevant to today is that they were the first to put a monetary value on education; they were the first professional educators. In Plato’s Hippias Major Socrates remarks that Gorgias ‘by giving exhibitions and associating with the young, he earned and received a great deal of money from the city’ and that Prodicus ‘in his private capacity, by giving exhibitions and associating with the young … received a marvellous sum of money.’
The Sophists’ innovation of seeking payment for tuition is the first appearance of an idea now all pervasive. Today it is taken almost entirely for granted that teachers require payment, and with it in the modern age come sick leave, maternity leave, pensions and other payments.
The professionalisation of education in general is therefore a legacy of the Sophists. The whole apparatus of modern university teaching, for good and ill, has its root in this idea. Despite a long gestation, it is only in recent years that a professionalisation of medical education has taken root, and it still faces cynicism and opposition today even in recent times (Peterson 1999). There has been concern at the standard of clinical teaching in medicine internationally for a number of years (Wall and McAleer 2000). In the United Kingdom, partly under the influence of the National Committee of Inquiry into Higher Education (Dearing 1997), in the number of departments of medical education attached to medical schools has grown, and a proliferation of masters level programmes and postgraduate certificates in medical education (Pugsley et al. 2008). The whole apparatus of modern academic discourse — peer-reviewed journals, associations, national and international conferences and other scholarly paraphernalia — has grown up around the subject. The subtitle of Peterson’s article cited above — Tomorrow’s doctors need informed educators not amateur tutors — gives a flavour of this new emphasis on professionalisation in medical education.

THE SOPHISTS AND TEACHING VIRTUE

The second great sense in which the Sophists are still relevant is their case that virtue was not inborn or innate, but could be taught. Their ‘most revolutionary innovation was, precisely, that, faced with nature, they set up teaching to counteract it and considered that virtue could be learned by attending their classes’ (de Romilly 2002), and the problem of nature versus nurture, as it is invariably dubbed today, is a very old one that troubled the Athenians with a peculiar intensity. We see it in Thucydides, in the comparison between the courage of the Athenians — described by the historian as deriving from reason, from expertise and from experience — and that of the Spartans, portrayed as ‘natural’ and traditional. We see it in Euripides’ play, Hecabe, when Hecabe (wife of King Priam of Troy) learns of the slaughter of her daughter. After a few rather perfunctory expressions of grief she launches into a meditation on this very question:
How strange, that bad soil, if the gods send rain and sun,
Bear a rich crop, while good soil, starved of what it needs,
Is barren, but man’s nature is ingrained—the bad
Is never anything but bad, and the good man
Is good: misfortune cannot warp his character,
His goodness will endure.
          Where lies the difference?
In heredity or upbringing? Being nobly bred
At least instructs a child in goodness; and this lesson,
If well learnt, shows him by that measure what evil is.
(Vellacott 1963, lines 593–603)

Plato’s dialogue Protagoras is devoted to the dispute between Socrates and Protagoras on this particular issue, the teaching of virtue. Although both agree that virtue can be taught, Socrates doubts Protagoras’ self-confidence on the issue. This is an issue that has huge implications not only for education but also for wider political economy. Improved knowledge of genetics in the last hundred years has given the problem a new acuity. Nevertheless, in this as in many fields one can get the impression from contemporary media coverage that all this is a new problem, which only our time has had to face. Nothing could be further from the truth, as the example of the Sophists illustrates.

Whatever ones own beliefs on the issue of nature-nurture, and whatever science may or may not tell us about it, one must concede that the Sophists have, from a practical point of view, won the argument. That education should be available for all is such a commonplace in Western society that to suggest otherwise would be social and (for an elected official) political suicide. Prior to the Sophists, the idea that arete was inborn and therefore unteachable was widely held. Therefore aristocratic birth alone qualified one for rule. If Protagoras’ self-confidence in his ability to teach virtue seemed dubious to Socrates, who was after all sympathetic to the essential point, imagine how shocking it must have been to Athenians more in thrall to notions of aristocratic virtue.
This parallels the reaction medical educators often receive from colleagues. While it is often not directly articulated, the claim that communication skills, for instance, or attitudinal aspects of medical practice, cannot be taught but are innate is frequently encountered. With the exception of ethics teaching (discussed below), medical educators may not consider themselves as teaching ‘virtue’, per se, but overall professionalism and attitudinal aspects of medical practice are explicitly incorporated into curricular design and structure. For instance Harden et al. (1999) describe a concentric circle model of learning outcomes, with an inner core of task focused outcomes defining the technical competency of a doctor, a middle section of ‘approach to practice’ outcomes defining understanding of the context of illness and evidence-based and ethics-based approaches to clinical work, and finally an outer circle of outcomes focused on the overall role of the doctor and ongoing personal development. The term ‘personal development’ itself implies that character can be changed by training.
This debate is particularly relevant to ethics training. A tension has been described (Eckles et al. 2005) between proponents of the view that ethics training should be aimed at the formation of virtuous physicians (for instance, Pellegrino and Thomasina,1993) while others have argued that the moral character of medical students is formed at arrival in medical school (Glick1994). This latter viewpoint is expressed as a belief that the goal of ethics training is to impart of body of ethical knowledge and provide a set of skills for application by medical graduates, whose underlying virtue has been established prior to admission to medical school. Eckles et al. identify this dichotomy as making it ‘difficult to find a consensus regarding the goals of medical ethics education’ and suggest that further theoretical work is needed to delineate the core content, processes and skills relevant to the ethical practice of medicine. The antiquity of this debate is not acknowledged.

INTERLUDE – PROTAGORAS AND EDUCATION

A theme of this article is that what the Sophists really thought, and what their influence on Western thought really was, is very different from the broad caricature often presented. Before discussing the final trend in medical education which is prefigured in Sophist thought, I wish to examine the thought of a specific Sophist figure and link with modern medical education theory. The thought of Protagoras (circa 490-420 BC) described as ‘the first and greatest of the Sophists’ (Waterfield2000) is known from a seven fragments and the reports of others, especially his appearance in the Platonic dialogue Protagoras. Both Socrates and Protagoras believe that virtue can be taught, although to differing degrees (and Plato will later have Socrates definitively oppose this view in the dialogue Meno), but Socrates is sceptical of Protagoras’ confidence on this issue.
The surviving fragments of Protagoras’ thought indicates the seriousness with which he thought about education (Lavery2008). The most famous, ‘man is the measure of all things’, is often cited as a key motif of relativist thought. Debate continues as to whether this was an example of ‘strong’ or ‘weak’ relativism – in other words whether this is a general statement about humanity or is about the individual human being’s ability to accurate perceive the world. However the underlying relativist thrust of this aphorism is not in doubt. Constructivist theories of learning, which are influential in medical education today, are clearly influenced by this approach.
Other Protagorian mottos directly related to education are ‘teaching needs endowment and practice. Learning must begin in youth’ (cited as Fragment 2 in Lavery, 2008). ‘Art without practice, and practice without art, are nothing’ (Fragment in Lavery,2008) and ‘education does not take root in the soul unless one goes deep’ (Fragment 8 in Lavery, 2008). All of these are relevant to medical education – the emphasis on practice and on deep learning, and on lasting attitudinal and behavioural change particularly so. As can be seen, these aphorisms are far in spirit from the caricature of the Sophists as promoting a superficial, purely rhetorical education.

THE SOPHISTS AND BEST EVIDENCE MEDICAL EDUCATION

Another characteristic of contemporary medical education theory prefigured in the thought of the Sophists is an evidence-based approach. The Sophists championed empirical knowledge and direct enquiry, which as well as marking them out as early pioneers of the scientific method, also suggests their place as exemplars of evidence-based practice.
The pre-Socratic philosophers of the centuries before both Socrates and the Sophists are often called both the first philosophers and the first scientists. This, of course, is due to their inquiring minds, and readiness to challenge explanations that depended solely on divine action — thus we have the atomic theory of Democritus, or the postulate of Thales that all matter is water (Waterfield 2000). Nevertheless, a modern reader often finds the Sophists more familiarly ‘scientific’ than the pre-Socratics. This is due to the pre-Socratics’ tendency to expand speculation into explanation, and to engage in metaphysics. The Sophists are more recognisable ancestors of modern scientific method because of their scepticism, their refusal to accept simple explanations, and their pragmatic bent. Defining the scientific method is a hugely problematic enterprise, but an attempt at the unprejudiced search for alternative explanations for any given event or observation is one of its cardinal features.
‘Making the weaker argument the stronger’, a taunt of Aristophanes in The Clouds, is one of the phrases with which the Sophists were most often abused. At first glance, it suggests a sort of confidence trick, a justification for wrongdoing. Yet on reflection, ‘the weaker argument’ may conceal the best answer. The querying approach of the Sophists forces one to examine apparently sound arguments and justifications, and thereby perhaps discover their soundness to be illusory. Richard Feynman described the scientific method as ‘a kind of scientific integrity, a principle of scientific thought that corresponds to a kind of utter honesty–a kind of leaning over backwards. For example, if you’re doing an experiment, you should report everything that you think might make it invalid—not only what you think is right about it: other causes that could possibly explain your results; and things you thought of that you’ve eliminated by some other experiment, and how they worked—to make sure the other fellow can tell they have been eliminated’ (Feynman 1974). So openness to alternative explanations, and a willingness to accept that the ‘weaker argument’ (or initially less persuasive or attractive hypothesis) may be closer to the truth, is a characteristic not of rhetorical chicanery, but of any empirical approach to knowledge and practice.
Best evidence medical education enshrines this empirical approach. Mirroring definitions of evidence-based medical practice, it is defined by Harden and Lilly (2000) as the implementation, by teachers in their practice, of methods and approaches to education based on the best evidence available. This means integrating individual educational expertise with the best available external and internal evidence from systematic research. Best evidence medical education approaches mean that the assumptions of medical educationalists are themselves open to question. Our fondness for a particular innovative means of teaching should be as suspect as the stubborn retention of every aspect of traditional teaching. In Western thought, the Sophists were the great intellectual gadflies, the questioners – pointing out social assumptions and prejudices for what they were. Medical educators owe a debt to these intellectual precursors.
Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.

REFERENCES

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Sophistry, the Sophists and modern medical education. Medical Teacher Volume 32, Issue 1, 2010. Part 1.

I’m sure on a Friday evening what the world is waiting for is the reposting of a paper on  (possibly) unfairly maligned Ancient Greek philosophers and the parallels between their thought and modern medical education theory. I fully expect this one to go viral. Re-reading it I am quietly happy with my discussion of the (mis)use of the term “sophistry” in the educational literature…. less admirably, I barely mention any of the Sophists themselves. Original is here

Sophistry, the Sophists and modern medical education

Abstract

The term ‘sophist’ has become a term of intellectual abuse in both general discourse and that of educational theory. However the actual thought of the fifth century BC Athenian-based philosophers who were the original Sophists was very different from the caricature. In this essay, I draw parallels between trends in modern medical educational practice and the thought of the Sophists. Specific areas discussed are the professionalisation of medical education, the teaching of higher-order characterological attributes such as personal development skills, and evidence-based medical education. Using the specific example of the Sophist Protagoras, it is argued that the Sophists were precursors of philosophical approaches and practices of enquiry underlying modern medical education.

Abstract

The term ‘sophist’ has become a term of intellectual abuse in both general discourse and that of educational theory. However the actual thought of the fifth century BC Athenian-based philosophers who were the original Sophists was very different from the caricature. In this essay, I draw parallels between trends in modern medical educational practice and the thought of the Sophists. Specific areas discussed are the professionalisation of medical education, the teaching of higher-order characterological attributes such as personal development skills, and evidence-based medical education. Using the specific example of the Sophist Protagoras, it is argued that the Sophists were precursors of philosophical approaches and practices of enquiry underlying modern medical education.

The Sophists and Medical Education

J

The Sophists

The Sophists were among the earliest philosophers of the Western world. Their name is now generally used as a term of intellectual abuse. ‘Sophist’ means a clever cheat, a casuist, a spin doctor, an insincere practitioner of misleading rhetoric. This is because what little we know about the Sophists comes from their opponents, especially Plato. Plato portrayed Socrates as a man of truth, seeking wisdom, as opposed to the quick-witted but superficial Sophists. They were also accused of being mercenary as they took payment for their teaching. Modern perceptions of the Sophists derive mostly from Plato’s depiction and Aristophanes’ comedy The Clouds. In this play, an Athenian father sends his son to a parodic academy of unworldly philosophers so he can learn how to win law cases. However ultimately his son questions and overthrows (literally) paternal authority using the rhetorical skills he has learnt. It suggests that young men would be distracted from dutiful, honest dreams of martial glory by a world of, at best, useless speculation and, at worst, logical hair-splitting that would allow them, literally and figuratively, to beat their betters (Sommerstein, 1973). This negative image of the Sophists has passed into both general discourse and educational philosophy. In this article I wish to discuss what the Sophists actually thought, insofar as we can elucidate it, and draw parallels with modern medical education theory and practice. Some of the most fundamental principles of medical education theory have their origins in the work of the Sophists.
There are three main strands of Sophistic thought which find parallels in the modern discourse of medical educationalists. Firstly, the whole idea of education as a professional enterprise requiring structured attention and of monetary recognition. Secondly, the idea that what are often seen as innate qualities can in fact be taught. Thirdly, an empirical, evidence-based approach to receive opinion and practice.

Who were the Sophists? The word is derived from the Ancient Greek sophos meaning ‘wise’, ‘skilful’, ‘clever’. In early Greek literature, a Sophist was a teacher, poet and wise man. This is how ‘Sophist’ is used by Homer and Hesiod in the seventh centuries BC (O’Grady 2008). A laudatory meaning was attached to the word when used by Homer. In the works of Herodotus (c. 490–420 BC), ‘Sophist’ is employed neutrally to mean ‘teacher’. The ‘Sophists’, as a term, now generally refers to philosophers of the fifth and fourth century BC. They were freelancers, mostly non-Athenian, independent teachers who travelled from city to city throughout Ancient Greece, charging for their services and making their living from a demand for education (O’Grady 2008). Kerferd (1981) identified distinguishing attributes of Sophists – they were paid for teaching, they were patronised by the wealthy, were mainly non-Athenian as well as itinerant, claimed to teach political arête (excellence) and how to be a good citizen, and emphasized the art of speaking. It was this focus on the art of speaking, and a delight in rhetorical innovation and, above all, a constantly questioning stance, which earned the Sophists their reputation. Although a later group of philosophers in the second century A.D. were also dubbed Sophists, ‘the Sophists’ generally refers to these fifth century B.C. intellectuals.
The Sophists brought tremendous intellectual excitement to Athens. This excitement brought with it anxiety, as is evident in The Clouds. All was up for grabs for the Sophists, from the nature of reality itself to the nature of the good to the existence of gods. For traditionally minded Athenians, this was a threatening stance.
The history of ideas is sometimes seen as a series of reactions and counter reactions — Reformation and Counter-Reformation, Romanticism and Neo Classicism, Postmodernism versus modernism. In educational theory, we see parallel dichotomies of behaviourist and constructivist paradigms. The Socratic movement and the Sophists can be seen as being in a similar opposition. Of course, all these developments derive from the other and each depends upon the other. Socrates and the Sophists were not mutually exclusive camps. Aristophanes’ portrayal of Socrates in The Clouds, for instance, is very clearly of a Sophist. And the intellectual excitement which the Sophists kindled in Athens surely had much to do with Socrates setting himself up as a philosopher, and with Plato, at later date, writing his dialogues.
Later generations have been harsh to the Sophists. They were described by the classicist Henry Sidgwick in 1872 as ‘a set of charlatans who appeared in Greece in the fifth century, and earned an ample livelihood by imposing on public credulity; professing to teach virtue, they really taught the art of fallacious discourse, and meanwhile propagated immoral practical doctrines’ (Sidgwick 1872). Right up to the present day, ‘Sophist’ carries this meaning, as can be seen in the words of the contemporary Catholic apologist Peter Kreeft: ‘Socrates made a point that he never took a fee for his teaching. (Neither did Jesus.) This proved that he was not one of the Sophists, who sold their minds as a prostitute sells her body’ (Kreeft 2002).

‘Sophistry’ in modern educational theory

In educational theory and philosophy, similar views prevail – Socratic and Sophistic approaches to education are often contrasted, usually unfavourably to Sophistic ones. For instance Furedy and Furedy (1982) propose a Socratic-Sophistic continuum, positing that Socratic approaches are characterised by enquiry while the Sophistic approach is characterised by persuasion and a focus on rhetoric. Elsewhere, the same authors (1986) argue that Socratic approaches are conterminous with critical enquiry and that Sophistic influences have been mainly implicit and manifested in tendency towards instrumentalism and affective learning as well as in the choice of curricula and curricula development. The title of this latter paper — On Strengthening the Socratic Strain in Higher Education — strongly suggests where the authors’ sympathies lie. As Furedy and Furedy acknowledge, the Sophistic–Socratic dichotomy, like all dichotomies, is overly simplistic, and in this ariticle I will argue that when we look at what the Sophists themselves thought and taught, we find a strong commitment to critical enquiry and the questioning of assumptions.
Boyles (1996), writing from the perspective of teacher training, collapses the Socratic–Sophistic dichotomy in his analysis of the Socratic dialogue Meno – but in a way unfavourable to both schools. He argues that Socratic dialogue is an example of coercive Sophistic rhetoric rather than disinterested enquiry. Hall (1996) in his commentary on Boyles’ paper takes the view that ‘sophistry is deficient insofar as it panders to the desire of the unwise, untutored, and unreflective for quick acquisition of knowledge. If one had enough money, one could with great speed acquire knowledge about, for example, political affairs together with the ability to speak persuasively on virtually any subject’ (Hall 1996) This statement, coming as it does within a sophisticated discussion of a Socratic dialogue, summarises the dominant view of the Sophists within educational philosophy. Stabile (2007), in his analysis of the clash between ‘virtue’ and ‘Sophist’ trends in education, depicts Sophist approaches as synonymous with utilitarian ones. In educational discourse, ‘Sophist’ has become a pejorative term in a more specific way then the general pejorative usage. These negative views are counterbalanced by a modern awareness of the importance of the Sophists, and awareness that their thought was more subtle and less focused on persuasion by any means necessary than their critics wrote.

#TRIALSYM15

The original purpose of this blog was as an entirely personal, reflective project. In the last few weeks (not that the blog has a history before this) it has become a forum for my reflections on events I have attended of a general medical innovation bent -the AMEE Hackathon and a CCIO meeting.  And now it is the turn of the inaugural Clinical Trials Methodology Symposium of the HRB’s brand new Trials Methodology Research Network. I only attended day 1 of this event which is a pity. The hashtag #trialsym15 is being used on Twitter so proceedings can be followed there. I won’t try and summarise proceedings here as it would be a little too much “he said… she said…” but give some reflective thoughts, especially following on from my prior posts.

As a full time clinician with an aspirational interest in research (ie a desire to take part in it that is often foiled) I find the concept of a network very appealing, and having an interest in conceptual issues in mental health and illness the methodology element is also fascinating.   It is rather invidious to select highlights; one was Sir Iain Chalmers , a founder of the Cochrane Collaboration (the logo of which incorporates a metaanalysis performed by an Irish doctor, Patricia Crowley ) who in a fascinating talk showed how, contrary to what is often taught, the randomised controlled trial did not emerge in 1948 from statistical theory but from a much longer history of clinical researchers engaging in fair trials of treatment.

Another was NUI Galway’s John Newell who gave the most engaging talk by a statistician I have ever heard

(his NUIG bio photo is also pleasingly Action Man-y)  john_newell

Newell gave a really honest and inspirational talk on translational statistics, and conveying statistical concepts to non-statistician audiences. I also learned about an egregious misuse of statistics by no less a moral authority than Fintan O’Toole … in a rather self-righteous article decrying the misuse of statistics. “The most entertaining talk I ever heard by a statistician” probably sounds like a set-up for a joke, but actually statisticians in my experience tend to be a wry lot. Newell’s talk really was the most entertaining talk I ever heard by a statistician.

I also enjoyed the total absence of the words “transform” or “revolutionise.” This was a particularly evident absence in Prof Craig Ramsay’s  witty, optimistic-yet-realistic presentation on  implementation science or knowledge transfer or (insert current description of this field here) . I had to pop out for a call towards the end (see the passing comment on not having time to do research above!) and, lurking at the door afterwards, was interested to hear him discuss developing research teams integrated into clinical settings. This chimed with some of my thoughts on the technology-health interface discussed towards the end of my Glasgow Hackathon post

The dynamic between technology and healthcare (and technology and education) is becoming one of the themes of these blog posts. My Glasgow experience made me wonder if the dynamic is, almost irretrievably, biased towards the tech being in the driving seat. I was more reassured by the CCIO meeting and even more impressed today by the amount of thought going into methodology by the likes of Prof Ramsay and the COMET Initiative .

Another highlight was Prof Peter Sandercock’s at times harrowing account of the travails of the International Stroke Trial and an illustration of the downside of social media and healthcare’s interaction. A questioner asked him about his current thoughts on pharma and drug trials. To paraphrase his reply, he said that he worried less about pharma influence, which is now highly scrutinised and regulated, than the medical device industry, which is not to anything like the same degree.

This got me thinking again about the deification of tech, or rather a certain kind of tech. Big Pharma is now a regular movie villain, whereas medical devices are Good Tech and therefore only criticised by fogeys. As it happened, during the day I came across a blog post by my  friend Phil Lawton  which, in dealing with the recent move of the Web Summit from Dublin, captured many of my own thoughts not only about the uncritical adoration of tech, but also about Dublin itself – especially as a Dublin native now happily domiciled a long long way away in Tipperary.

What makes “a new mental illness”?: The cases of solastalgia and hubris syndrome. Cosmos and History, 2009. Part 3

Solastalgia and hubris syndrome considered through the prism of the contesting definitions of mental illness

Analogies can be drawn between solastalgia and post-traumatic stress disorder. Post traumatic stress disorder is a contested diagnosis within psychiatry. Many argue that it is simply a new name for a condition described by Homer (Shay 1995) and recognised by military physicians and psychiatrists under a variety of names (Shepherd 1994). Others argue that is has been “invented” for political reasons (Summerfield 1999) and reflects the subjugation of psychiatry to socio-political imperatives. Uniquely among conditions described in both DSM-IV and ICD, in its definition the cause is specified.Solastalgia would share this quality. Indeed, online commentators from the environmental movement have criticised Albrecht for the perceived narrowness of the focus and his adoption of a medical model of harm induced by environmental change.

It is of course invidious to try and predict what individual thinkers might “make of” solastalgia and Albrecht’s contention that it is a “new mental illness, ” or of Owen’s identification of hubris syndrome as potentially causing more death and disability than any other illness worldwide. However, it seems reasonable to assume that Thomas Szasz would dismiss the idea of both being “new mental illnesses” because he views mental illness itself as a myth. The problem of adjusting to an environment made strange around one is a “problem of living”, and the problem of leaders growing out of control is a political one. The use of the concept of disease in these two settings is simply an error.

Using Boorse’s framework to analyse these entities also leads to interesting considerations. One of Boorse’s initial arguments in his 1975 paper is that what gives rise to ambiguity and difficulty with mental illness is the “territorial ambitions” it has. Psychiatry is laying claim to more of life’s problems, leading to a “medicalisation of morals.” This,rather than basic definitional issues of what is a mental illness, leads to problems. In a sense Boorse partly agrees with Szasz about “problems of living” being the root of at least some “mental illnesses”—the difference being that Szasz would deem all mental mental illnesses so. This would suggest that Boorse would be sympathetic to the view that the concept of solastalgia and hubris syndrome represents medicalisation of the moral fault of man-made environmental change and of overweening power. Boorse’s 1975 argument came in two parts—by positing disease as dysfunction, it preserved a value-free status for medical and psychiatric practice and decision making, while by describing the social components of illness, it acknowledged the degree to which social practices and behaviours within a social context define illness. In the case of solastalgia, what “dysfunction” may be said to underlie the “disease process?” It is not clear, although perhaps the development of psychological assessments of Environmental Distress may aim at identifying specific thought processes. It is noteworthy that Albrecht and colleagues do not propose a “treatment” for solastalgia, but propose further research. It is not suggested that the interviewees reactions are in any way pathological, or that other reactions and emotions are more appropriate or more “functional.”

Canguilhemian notions of illness as a loss of normativity, a loss of the ability to adapt, are consonant with solastalgia’s emphasis on the distress caused by change. Canguilhem’s other emphasis on an understanding of disease that must move beyond the laboratory and detached “scientific” considerations to the setting where distress is experienced is also echoed in the solastalgia literature. Yet the use of a rating scale, with the inevitable emphasis on scores and purported norms, suggests an approach ultimately very different from that of Canguilhem.

Using Fulford’s “full field” model of mental illness, which incorporates both a “value-laden” pole of failure-of-action/illness and a “value free” or “factual” failure-of-function/disease pole, we again hit the difficulty of which, if any, failure of function is being described.There is a similarity between the approaches of Locker and Albrecht in terms of their use of interviews to discover themes in subjective experience. Using the four features identified by Locker, clearly the experiences described by Albrecht’s interviewees are negatively evaluated. They have an ongoing duration and intensity. The experience is not “done by the person experiencing it.” The “sense of injustice and powerlessness” described by Albrecht et al in their paper as characteristic of solastalgia reinforces this. However, one could observe that that the experience could be said to be due to the actions of another—for instance the mining companies. Using this approach, solastalgia describes distress rather than disease.

As for hubris syndrome, Owen suggests neurochemical imbalances that may underly the phenomenon. These are very much suggestions, however, without any definite suggestions as to what neurological circuitry is involved, for instance. Owen also writes that

Hubris syndrome is not yet a diagnostic category of accepted mental illness but it probably stems from a set of genetically codetermined predisposed personality traits. To the psychiatrist any potential new syndrome is likely to be an interaction between genes and environment or nature and nurture. Early biology and upbringing provide the basis of personality which can then be expressed, or not, depends on constraints or opportunities. (Owen, 2008b, p. 431)

While this statement is accurate, it is also extremely generalised and does not point to which aspects of “early biology and upbringing” might contribute to later hubris syndrome.

Owen locates hubris syndrome as stemming from personality traits. The implications of Canguilhem’s thinking on the normal and the pathological for the diagnosis of personality disorders has been discussed by Buchanan (2007), in particular intolerance of “the inconsistencies of the environment.” Buchanan suggests that “one testable hypothesis arising from Canguilhem’s work is that a failure actively to adapt to one’s surroundings represents the final common pathway by which narcissistic, borderline, schizoid, or other traits prevent someone from achieving his or her potential in a range of social and occupational spheres.” Owen describes a rigidity and unwillingness to reverse decisions as being among the criteria for hubris syndrome.

The distress experienced by Albrecht’s interview subjects is real. Is what they are having a “new mental illness”? While there is clearly some journalistic hyperbole at play here, and in their published papers Albrecht and his co-authors are careful to emphasise the preliminary nature of their work, solastalgia serves as a good example of how the concept of “mental illness” is discussed in the public domain. Albrecht is describing a psychological phenomenon and making a link with environmental change.

From the philosophical point of view, solastalgia is extremely broadly defined and seems synonymous with distress due to environmental changes. Albrecht et al powerfully illustrate the distress of their interviewees, but have not shown this is distress to be a mental illness. The weakness of Robins and Guze’s model of defining mental illness is illustrated by this. Essentially it depends on consensus and the acceptance of a phenomenon as an illness by the body of psychiatrists. Solastalgia, especially since the creation of a relevant and reliable rating scale, may in fact suit this definition more readily that any definition rooted in more philosophical rigour.

Similarly Owen provides a checklist of “symptoms” of hubris syndrome. Unlike what is the case with solastalgia, there is no evidence that the individuals purportedly “suffering from” hubris syndrome are experiencing any distress. The threat is more to society in general. Using Locker’s framework, the experience is not negatively evaluated by the person, or experienced as necessarily inflicted from outside on the person. Furthermore there a sense of powerlessness is not (though possibly one of injustice is) associated with the experience. Overall, then, what Owen is described is not pathological for individual but for wider society.

Conclusions

One could surmise that one of the motivations for developing the concept of solastalgia is to try and quantify the immediate health costs due to environmental change and further influence the arguments about environmental policy (a particular issue in Australia, which has a strong mining lobby) in the context of often rancorous debate, rather than to identify a new mental illness per se. Similarly, Owen’s identification of hubris syndrome can be seen as a plea for rule by cabinet and parliament rather than individuals, for oversight over leaders and for mechanisms to avoid the isolation and insularity that can accompany great power.

The language of psychiatry, as seen with Robins and Guze’s approach to defining schizophrenia as an entity, tends to circularity. Mental illness is treated by psychiatrists, and who are psychiatrists? They treat mental illness. This allows the language of psychiatry to be adopted as a form of rhetoric. What both Albrecht and Owen have identified are serious social problems, ones which in different ways can affect the continuance of human life on this planet. Both raise issues that are worthy of consideration by any thinking person. The rhetoric of mental illness, which of course is related to the rhetoric of illness and disease overall, is a powerful tool to raise awareness and to agitate for change. However we should be cautious of identifying new mental illnesses based purely on the laudable motivations of those who expound them.

Special Lecturer and Senior Registrar in Psychiatry
at the Department of Psychiatry and Mental Health Research,
St Vincent’s University Hospital/University College Dublin,
Elm Park, Dublin 4, Ireland.
Email: seamus.macsuibhne@ucd.ie

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What makes “a new mental illness”?: The cases of solastalgia and hubris syndrome. Cosmos and History, 2009. Part 2

The concept of mental illness: psychiatrists and philosophers

Defining what psychiatry is and what mental illnesses are can often seem a circular process. One indisputable fact is that psychiatry, as it is currently constituted, is a branch of medicine. While contemporary psychiatrists tend to aspire to practice using a “biopsychosocial approach” (Clare, 1999, p. 109), their training and the structure of the vast majority of psychiatric practice fits a medical model. People present with symptoms and exhibit signs which are examined. If these symptoms and signs are deemed to provide evidence of pathology, they lead to a diagnosis of an illness. Investigations and treatments are ordered. Medications and other interventions are prescribed to treat the illness. The cessation of the symptoms and signs marks recovery from the illness. This is, on the surface, similar to how an ophthalmologist would approach cataract, or a respiratory physician chronic obstructive pulmonary disease. Dictionary definitions of psychiatry describe it as the medical specialty concerned with mental illness (Oxford English Dictionary, 2007) Psychiatry textbooks too generally gloss over the actual meaning of mental illness but assume it has a readily understood and commonly accepted meaning.

A key paper from within the psychiatric establishment on the definition of mental illness is Robins and Guze (1970) on the establishment of diagnostic validity in psychiatric illness, with regard to schizophrenia. This paper’s approach has had a strong influence on the development of DSM-IV, the American Psychiatric Associations classification of mental illnesses which is used in clinical practice (although it was developed primarily to enable researchers to communicate with each other rather than as a clinical tool) for diagnostic purposes.Robins and Guze describe a five step method for achieving diagnostic validity in psychiatric illness is described, consisting of five phases: clinical description, laboratory study, exclusion of other disorders, follow-up study, and family study. The method was applied in this paper to patients with the diagnosis of schizophrenia, and it was shown by follow-up and family studies that poor prognosis cases can be validly separated clinically from good prognosis cases. The authors conclude that good prognosis “schizophrenia” is not mild schizophrenia, but a different illness.

“Diagnostic validity” means that a diagnosis of schizophrenia is in fact a case of schizophrenia. It differs from a related concept, reliability, which describes how well diagnoses match each other—a reliable diagnosis of schizophrenia means that other clinicians would come up with a diagnosis of schizophrenia given the same case. It is possible for a diagnostic process to be reliable but not valid, although validity implies reliability.It does not, however, address the question of what schizophrenia is.

Validity implies that one is describing an entity whose existence and nature is not disputed. It does not address fundamental questions of what this entity actually is. Solastalgia may well fit the Robins and Guze framework very well. Clinical description has already been carried out. “Laboratory investigation” is mirrored in the development of the Environmental Distress Scale. Exclusion of other disorders could, arguably, involve showing that the distress experienced by the person is due to environmental change and no other factor.

Hubris syndrome also fits this framework very well. Already clinical description and exclusion criteria are provided by Owen. Owen suggests possible avenues for laboratory study, referring to neurotransmitters. Although the rarity of hubris syndrome may make this study and follow-up studies challenging, it may be that analogues to hubris syndrome in less eminent persons will be developed. Family studies would be more problematic, although cases such as the two Bush Presidents and the Nehru-Gandhi dynasty in India would suggest that this could be overcome. Follow-up and family studies, in any case, refer to activities psychiatric researchers undertake, and implicitly assumes that the diagnosis is an entity in itself.

And this points to the essential circularity of mainstream psychiatry’s definitions of mental illness. Robins and Guze’s formulation of mental illness is made up of five steps that refer entirely to medical and psychiatric activity itself. Psychiatry is the medical specialty concerned with mental illness, and mental illnesses are conditions which are the concern of psychiatry.

As outlined in the statement of the Focus & Scope of this journal, a tension between “cosmology, conceiving the cosmos as an immutable, timeless order, and history, concerned with actions, intentions, conflicts and the rise and fall of individuals and communities, has been at the core of virtually all intellectual and political oppositions throughout the history of European civilization.” This tension is particularly germane to psychiatry. Psychiatrists spend much of their time trying to improve the image of psychiatry within medicine by insisting it is a scientific enterprise, characterised by the assumptions of expertise, specialist knowledge and greater objectivity that (it is assumed) are possessed in full by other medical specialties. However psychiatry, as shall be seen, is also intimately concerned with values and the concerns of the humanities. The tension between the worldviews of ethical and political philosophy on the one hand and the traditional scientific view on the other is particularly acute in psychiatry.

Any attempt at any overarching, definitive definition of what philosophy is will be even more contested than that of psychiatry. Just as with medicine and medical practice, there are very many disciplines subsumed within philosophy, and while the medical model described above is generally accepted within most medical specialties, there is no such consensus within philosophy as to what philosophers do, what “the business of philosophy” should be, or how philosophers should approach the problems that come under the heading of “philosophy.” Of the many things that philosophy is, it is perhaps safest to say that philosophy questions assumptions and encourages critical thinking about things taken for granted.

The concept of “mental illness”, which as we can see from the above can be considered an assumption in common usage within the psychiatric profession (and, perhaps, in wider society), has been subjected to a thoroughgoing critique from philosophers, psychiatrists, psychologists, social workers, political scientists, feminists and many other figures. This critique has taken five main approaches:

  • a psychological model, as exemplified by the British psychologist Hans Eysenck, arguing that mental disorders are in fact learned abnormalities of behaviour (Eysenck 1968)

  • a labelling model, as exemplified by the American sociologist Thomas Scheff, who argued that the features of mental disorder are in fact a response to the labelling of an individual as “deviant” (Scheff 1974)

  • a “hidden meaning” model, postulating that the apparently irrational, harmful or meaningless behaviour associated with mental disorder is in fact meaningful. The Scottish psychiatrist R.D. Laing, for instance, argued that “madness” was a sane response to an insane society. (Laing, 1960)

  • an “unconscious mind” model, influenced by psychoanalysis, which postulates that, again, the apparently irrational can be comprehended, this time with reference to the unconscious mind

  • political control models—this critique of psychiatry sees it as a legitimising the social status quo and allowing those who dissent from it to be labelled mentally ill. The practice of psychiatry in the former Soviet Union exemplifies this. Another example is the feminist critiques of post-natal depression, which feminists would argue reflects society’s treatment of mothers rather than being a disease per se. Thus legitimate distress at the unfair structure of society is pejoratively labelled an illness. Similarly, the Franco-Algerian psychiatrist Frantz Fanon argued that psychiatry was a tool of colonial control and part of the hegemonic order of industrial capitalism.

This questioning, much of which has been posed by psychiatrists, has forced psychiatry to scrutinise its own concept of what constitutes mental illness. Many of it is more about the role of various psychological, social and political factors in the development of mental illness, rather than being an attack on the basic concept of mental illness. Other critiques have not so much been of psychiatry as a discipline or practice, but on the cultural significance of a therapeutic ethos, for instance that of Philip Rieff in “The Triumph of the Therapeutic.” (1965) For Rieff, the rise of psychotherapy and the “psychological man”—marked a turning point in human culture, being the death-knell of a Western culture whose ideals had lost their power to deeply pervade the characters of its members. In a therapeutic ethos, truths are contingent and negotiable, and commitments or faiths only survive as therapeutic devices easily discarded in the interests of therapy. For Rieff, this is a symptom of Western cultural decadence and decline.

Much of the “antipsychiatry” critique has been absorbed into mainstream psychiatric thinking and practice. Psychiatry is generally practiced in the community in a multidisciplinary, biopsychosocial fashion, and psychiatrists themselves lobby for extra resources to achieve this. Government policies enshrine the concept of patient-centred care that meets holistic needs and aim for “recovery” that goes beyond the simple alleviation of symptoms (Expert Group on Mental Health, 2006.) Compulsory treatment of those diagnosed as mentally ill is surrounded by tight regulatory control in Western societies.

However, for the most thoroughgoing anti-psychiatrists, this is not enough. They favour not tighter controls on compulsory admission, but the complete abolition of the phenomenon.One of the most influential critiques is that of Szasz (Szasz, 1960). Szasz disclaims the label “antipsychiatrist” and also insists he is not a philosopher, however his work could be seen both as the quintessence of “antipsychiatry” and as having a strong influence on philosophical approaches to mental illness. Throughout his career he has stated emphatically that illness requires the presence of a physical lesion which causes disease. With mental illnesses, there is no identifiable physical lesion. Therefore “mental illness” is a myth. This is not to say that the phenomena described as mental illnesses are not actually happening, but that they are not illness. “Mental illness” involves a value judgement, whereas the diagnosis of bodily illness does not. What has formerly been termed mental illnesses are in fact “problems of living.” This leads Szasz to a radical and continuing critique of psychiatry as a discipline (Schaeler, ed, 2004.) Other critics of psychiatry (for instance Eysenck, 1968) have argued that many, if not most, patients presenting with mental illness are in fact experiencing problems of living, but have generally conceded that some at least are experiencing a biologically based mental illness. Szasz, however, has consistently maintained what could be called a “hard” position denying the validity of mental illness and, from this position, attacking both psychiatric coercion (involuntary admission and treatment) and “psychiatric excuses” (the insanity plea) Szasz has not argued for the abolition of psychiatric practice, but that psychiatric practice should only be between two consenting adults (what he calls “contractual” psychiatry), that psychiatrists should have no powers to compel treatment or admission, and that courts deliver verdicts of either guilty or not guilty with no acceptance that insanity can be a mitigating circumstance. Over the course of his career he has compared “institutional” psychiatry (contrasted to “contractual” psychiatry) to the Inquisition, the slave trade and the Holocaust. (Szasz 2002)

Szasz has never stated that the phenomena described as mental illnesses do not exist—that people who are diagnosed with depression are not suffering from distress, or that people who are diagnosed with paranoid schizophrenia are not reporting persecution without a basis in real events. Szasz simply states that these presentations are not illnesses, and their treatment as such is not simply an intellectual error but has lead to massive violations of human rights on a worldwide scale.

There have been many “pro-psychiatry” counterparts to the work of the antipsychiatrists. Kendell (1975) described the ‘biological disadvantage’ criterion of illness, based on the work of Scadding (1967), a chest physician who described a disease as ‘the sum of the abnormal phenomena displayed by a group of living organisms in association with a specified common characteristic or set of characteristics by which they differ from the norm for the species in such a way as to place them at a biological disadvantage.” Kendell used this criterion of “biological disadvantage” to argue that, in fact, a value-free concept of illness was possible, and also that it applied to mental illness, as it shortened life expectancy and reduced reproductive advantage.Later, Kendell changed his position and came to believe that value judgements were inescapable with regard to any illness (Kendell 2002). Kendell’s original argument was directly intended as a response to Szasz and the other antipsychiatrists. So, where Szasz defined bodily illness as cellular dysfunction, Kendell defined it as a process leading to “biological disadvantage.”

Kendell and Szasz share, however, a view that defining bodily illness is uncomplicated compared to mental illness. Their debate is framed in terms of comparing mental illness to bodily illness, and arguing that mental illness is illness in so far as it is more or less like bodily illness. Many critics of Szasz since have taken the same basic approach—for instance, that there are in fact biological pathologies associated with mental illness, or that as medical science progresses we will identify these pathologies. To which Szasz replies that, if this indeed turns out to be the case, these conditions will become bodily illnesses to be treated by bodily physicians, as Alzheimer’s Disease and General Paralysis of the Insane (tertiary syphilis) did in the late nineteenth century.

Many later respondents to Szasz have argued that his concept of illness is narrow, and that bodily or purely physical illness or disease is not to be defined as simply as he suggests. Szasz himself has continued to hold to his original position, writing that “I use the terms disease and illness interchangeably” (Szasz, 2000, p. 3.) Szasz has continued to insist that bodily illness is an uncomplicated concept and mental illness an unjustifiable extension of that concept. One of his supporting references is the introductory material for pathology textbooks, which (in a way analogous to the simple definitions of mental illness that are used in psychiatry text books) generally simply state that disease is due to cellular damage. Whether the authors of these textbooks, any more than those of psychiatric textbooks, have taken a philosophical approach to the underpinnings of their specialty could perhaps be questioned.

Boorse (1976) has also described the distinction between illness and disease, with disease referring to dysfunction (which, Boorse argues, can be used to describe cognitive and perceptual as well as purely physical domains) and illness referring to the social consequences of disease. “Disease” is a value-free, objective entity—“illness” is a value-laden, socially determined process or consequence of disease. Boorse argues that a disease becomes an illness when it becomes incapacitating for the person experiencing it. In social terms, it must be undesirable for its bearer, “a title to special treatment” and “a valid excuse for normally criticisable behaviour” Boorse argued that the fact that mental illness is value-laden relative to physical illness was not because physical illness was value free—for the whole concept of illness is value-laden. Mental illness is seemingly more value-laden because the sciences that underlie mental illness are not as well developed as those underlying other medical specialties, but this is simply a historical factor which will be rectified over time.

Boorse’s disease/illness distinction—an attempt to retain value-free evaluation of pathology while accepting the value-laden nature of diagnosis, treatment and the sick role—brings us to one of the pivotal work of the French epistemiologist and physician Georges Canguilhem. Canguilhem, author of one of the key texts in the philosophy of medicine, The Normal and the Pathological (Canguilhem, 1989), challenged the dominant “scientific” paradigm of pathology based on statistical norms of supposed immutability, which defined boundaries on a continuum between normal and abnormal. For Canguilhem, health and disease were properties of a total organism, with health being the capacity to withstand change and to establish new norms—the ability to fall sick and recover,  or normativity—and disease the lack of this capacity. Anomalyper se was not abnormality, and a list of symptoms and signs or deviations from a statistical norm did not define disease.

Canguilhem’s work was rooted in an approach to the history of medicine that looked at the evolution of conceptual rather than factual knowledge (Horton, 1995). For Canguilhem, as for many other philosophers of science as the twentieth century progressed, the positivist view of science as based on observations made in language entirely independent of theory was untenable.The dominant positivist view of medicine reflected the influence of  physiologists such as Claude Bernard, who championed an approach to understanding disease based on laboratory experimentation separated from clinical conditions. Against this, Canguilhem argues that a purely “scientific”, lab-based understanding of illness divorced from clinical experience or understanding the conditions of disease is impossible—“it is first and foremost because men feel sick that a medicine exists. It is only secondarily that men know, because medicine exists, in what way they are sick.” (Canguilhem, 1989, p. 229)

A futher key of Canguilhem’s approach was that the history of medicine had shown a gradual movement from concepts of health and disease as qualitatively different entities, to one in which there is only a quantitative difference. For Canguilhem, the pathological state is qualitatively different from health because of its implications for the organism’s survival and ability to flourish. It is this factor that  purely positivist accounts of sickness cannot account for, but cannot ignore. The implications of Canguilhem’s writing for mental illness have been discussed by Magree. (Magree, 2002)

Arguments continue about definitions of mental illness. As outlined above, Szasz has kept very strongly to his original position over the years, in the face of all critics. However the debate has moved on to other terms. Christopher Megone, for instance, describes illness both bodily and mental as incapacitating failure of bodily or mental capacities to fulfil their functions (Megone, 2000). He traces this concept of functional impairment back to Aristotle.Fulford, meanwhile, focuses on the actual experience of illness as a basis for thinking about illness (Fulford, 1993). This is influenced by the work of the philosopher J L Austin and the sociologist David Locker (Austin, 1961 and Locker, 1981). Austin was a philosopher associated with the Linguistic Analytic move in philosophy, which emphasised examining how a concept is used in ordinary usage as a way of finding out its is meaning. One of the approaches to “doing philosophy” which was seen traditionally as leading to clear thinking was to “define your terms.” In other writings Fulford has discussed how the assumption that “defining your terms” is a necessary condition for clinical utility has become so prevalent within medicine has lead to the belief that concepts are only clinically useful if they can be so clearly defined (Fulford, 2001). Austin suggested that “philosophical fieldwork”—exploration the use of concepts in everyday language and usage—may be a better means of approaching the meaning of concepts, rather than concentrating on definitions per se.

Austin also described the complexity of actions. Philosophers had previously tended to focus on particular aspects of action—intention, voluntariness and so on—and to unpick them by defining them. Austin focused on “the machinery of action” which involves a wide range of processes and activities—“we have to pay (some) attention to what we are doing and to take (some) care to guard against (likely) dangers; we may need to use judgement or tact; we must exercise sufficient control over our bodily parts; and so on.” (Austin, 1961)Fulford utilises this as a way of approaching the medical concept of illness, as “action-failure.” “The machinery of action” has a wide range of elements, and this breadth gives Fulford a wide range of approaches to understanding illness experiences, both physical and mental.

The work of  Locker on those features of experiences that people identify as marking out these experiences as illnesses helped suggest this approach.Four relevant features were identified—the experience is negatively evaluated,  has a certain intensity and duration,  is not “done to or happens to” the person undergoing it, and  is not “done by the person” themselves.

Fulford has built on Austin and Locker’s work to describe the importance of “action failure” in defining illness. At first sight, “action failure” does not seem too different from the “dysfunction” of Boorse’s thought. Action and function are closely related, but are also more distinctthan one might think. Individual people (as agents) perform actions; particular physiological systems or body parts function. Fulford uses this distinction to draw a parallel with the distinction between the patient’s experience of illness and a doctor’s knowledge of illness. Fulford has described a “full field” model of mental illness. Going beyond purely medical models, focusing on disease and failure of function, it combines the social, value-based concept of illness with corresponding failure of action.

To the objection that unpleasant experiences such as pain or psychological distress are often involved in illness experiences (and that these do not immediately obviously fit into the concept of action failure, Fulford replies that pain is integral to “the machinery of action”, as is psychological distress, and therefore action-failure analysis can be applied.