Constructed Worlds, Forms of Life and Intellectual Disabilities

In his ‘Philosophical Investigations[1]’ Ludwig Wittgenstein discussed simple language games as a way of exploring the nature of our own language. One of the themes discussed early in the PI was ostensive definitions and how they could be used to teach that a word refers to number, shape, colour, a whole object: e.g. Slab, or whether a word is being used as a demonstrative; this and that. Wittgenstein’s discussion reveals a kind of poverty of stimulus in learning a word through ostension. So if a person points to something and says ‘Blickiri’ it is unclear purely by ostension whether the person is referring to a colour, a shape, an object, a number etc. Wittgenstein notes that we could limit possible interpretations of ‘Blickiri’ if it was prefixed by ‘Is a colour’, ‘Is a number’ etc. However, obviously if the person we are trying to teach by ostensive definitions already understands predicates of our language like ‘Is a colour’, ‘Is a number’ etc they would already understand complex aspects of our language and hence are not being taught from scratch by ostension.

On the picture sketched by the later Wittgenstein we learn our language through our shared form of social life with our peers. Throughout the PI Wittgenstein analyses how words get their meaning; and shows that supposed bearers of linguistic meaning such as private mental images, are not sufficient to the task of providing linguistic meaning. His emphasis on the social determination of meaning, shared practices, and actual linguistic use broke philosophy away from its traditional a priori methodologies. Instead of arguing that concepts MUST have a certain structure, or that we MUST be following certain determinate rules when reasoning, Wittgenstein asked us to look at our practices. This approach if adopted makes philosophy more pragmatic and interested in our actual interactions with the world as opposed to a purely speculative or armchair discipline.

Martin Heidegger’s dense prose and profound sounding claims about the nature of ‘Being’, ‘Language’ and ‘Concealment’, ‘Technology’ etc at a first glance seem to be far removed from the pragmatic spirit of the latter Wittgenstein’s philosophy[2] Furthermore Heidegger’s later philosophy is no more compatible with pragmatism than is the philosophy the early Wittgenstein espoused in his ‘Tractatus’. However, it has often been noted that aspects of ‘Being and Time’ with its focus on everyday life and our concernful engagement with the world, and the role of implicit awareness, and embodied engagement with the world is also subject to a pragmatic interpretation.

While Heidegger argued against a psychological interpretation of his work it has nonetheless been used a great deal in both psychology and psychoanalysis. Robert Stolorow and George Atwood are excellent scholars of Heidegger and psychoanalysts who have managed to combine Heidegger with Freud. Their work has greatly enriched some Freudian concepts and has helped in understanding the lived world of people suffering from psychosis. Clinical psychologist Louis Sass has also managed to combine the insights of the later Wittgenstein and Heidegger’s ‘Being and Time’ as a way of understanding the lived experience of people with Schizophrenia.

In this blog-post I want to discuss the social world that is partially constructed for people with severe intellectual disabilities. My aim is not provide a scholarly discussion of the philosophy of either Wittgenstein or Heidegger, rather I will use some of their concepts to help me elucidate the world of people with severe intellectual disabilities is partially socially constructed. In an earlier Blog-post ‘Radical Interpretation and Intellectual disability: The principle of Charity and The Typical Mind Fallacy’ I tried to explore some of the challenges of interpreting how people with various forms of intellectual disability experience the world. In that work I called for more descriptive work similar to the work Oliver Sacks has done on people with neurological disorders to help health care workers understand the subjective world of the people they care for. The emphasis in that blog post was on the subjective world of people with intellectual disabilities and the challenges of interpreting it. In a later blog-post ‘Some Behavioural Techniques and The Idea of a Blank Slate’ I briefly discussed some behavioural techniques that are useful for dealing with people with intellectual disabilities who engage in challenging behaviour. Here the focus was on objective features of the environment and behavioural techniques that reduce the probability of a particular behaviour occurring. In this blog-post I aim to discuss an intermediate state: the lived world of people with intellectual disabilities. Here my focus will be on intersubjective communication, and the social world that people with intellectual disabilities sometimes live in.

In the 1960s when a child was discovered to have an intellectual disability a lot of the time the child would be immediately abandoned to state care. Things now a days are much different, people in general have a greater grasp of what having a child with intellectual disabilities actually entails. The stigma once associated with having a child with intellectual disabilities has now been greatly eroded. Furthermore there is much greater social support for the parents of a child with intellectual disabilities than was previously available. This isn’t to imply that things are perfect, this is obviously far from the case, many challenges still exist. My point is merely that things have to a small degree improved.

When discussing the social world of a child with severe intellectual disabilities my focus will be on their social world in the institute they live in. As I mentioned earlier children are not automatically placed in care when they have severe intellectual disabilities[3]. There is a great emphasis the importance of the child staying with his family and being included in the wider community. Nonetheless caring for a child with severe intellectual disabilities, while perhaps caring for other children, is an extremely difficult job emotionally. To help parents to provide the best care possible respite services are offered to them where their child with severe intellectual disabilities can be cared for by community house which specialises in respite care.

Depending on level of care required by the child and the family circumstances respite care can begin at any age but it is typically provided for children as they get older and harder to manage. On average people will enter respite care from the age of 5 or 6. Like all children a child with intellectual disabilities is thrown into a pre-prepared world upon birth. A child is born into a family drama[4]; the parents give the child his name and typically have a room ready for the child along with fantasies about who the child will become. The child upon birth is immediately situated in a narrative created by the parents about the nature of the family and its relation to the external world. Wittgenstein correctly notes that to come to speak a language is to be immersed in a particular form of life. Different communities, societies and families have different forms of life. The new born child who is thrown into the world has to try and learn the various criss-crossing language games of the family or society they are born into. Parents of a child with intellectual disabilities often talk about a process of mourning that they undergo when they realise that the child they had imagined will never exist. They need to undergo this process of mourning their idealised child in order to get to know their actual child with his various impairments. Parents claim that eventually they just see their child as person and don’t see the intellectual disability after a while.  However there is a period where the child is not living up to the unconscious fantasy that the parents had created of him. It is difficult to speak in general about the experiences of children with intellectual disabilities as different disorders such as Williams Syndrome, Downs Syndrome, etc will result different difficulties in processing emotions, communicating etc. Furthermore, even people with particular syndromes will differ in their abilities and temperaments. So there is no one fit all criterion we can provide which will describe the challenges they will face growing up within their family these matters will have to be evaluated on a case by case basis. But while it is essential to take note of the child’s intellectual disability and particular temperament, it is just as important to note the form of life that one is to some degree imposing on the child and whether that form of life is suitable for the particular competencies of the child in question.

When the child is brought into respite care for the first time he will again be entering a prepared world where the staff working there will have a working theory of who the child is. Some of the staff (typically the nurse in charge) will have met the family to discuss the child and will be introduced to the child. The family will typically try to prepare the child for respite by telling him where he is going, showing him pictures of where he is going to respite, and bringing the child to visit the respite unit before his respite begins. The staff will prepare by reading files from psychologists, social workers, GP, reports from the child’s school and reports from the child’s parents/guardians etc.

Human nature being what it is; staff will have formed a picture of the child before he arrives. Evidence from the files and reports will help the staff form a picture of the child who is coming into respite. Staff upon hearing the nature of the disability, and facts about the child’s behaviour may view the child in comparison to various other people with intellectual disabilities they have looked after. Preparations for the child’s arrival will take place in various ways. One key issue will be what children is the child suitable to be placed with? Various social factors will have to be considered, if the child is prone to imitative behaviour placing him with other children who can be violent or engage in self injurious behaviour is not a good idea. Likewise if the child is finds noise intolerable then placing him with children who like to make loud vocalisations may not be a good idea.

When the child arrives into respite care for the first time, just like when he is brought home from the hospital, or his first day in school he is arriving at a drama prepared for him. The child is being cared for by nurses and care staff with fixed roles, the staff will have an idea of who the child is and how he will behave, and have prepared activities and environment accordingly.

Occupational Therapists have long recognised that a huge part of what makes us who we are is what we do. Our daily activities are a large part of who we are. We are not disembodied Cartesian egos, on the contrary we are embodied creatures immersed in and engaged with our world. Because of Heidegger’s focus on ‘Being-in-the World’ and his detailed phenomenological analysis of our behaviour as we engage with our lived daily experience a lot of occupational therapists and nurses incorporate aspects of Heidegger’s phenomenology in their research[5]. The importance of understanding everyday activities and how people find them meaningful in their daily activities lives cannot be stressed too much when considering the child entering respite care.

As we have already noted the child enters his new world with a place prepared for him by staff. Some children are verbal and some are non-verbal nonetheless it is important for staff and the new child to establish functional communication. If the child is non-verbal he will indicate what he wants by his behaviour, he will try to take what he wants, will get upset and may engage in self injurious behaviour if he cannot obtain what he wants. Even with children with severe intellectual disabilities can be taught to use at least some degree of symbolic communication. The PECS (Picture Exchange Communication System) which involves the child being given a book full of pictures placed on a page with Velcro is a useful system in this sense. Children who may not be able to use PECS to form actual sentences can still learn to use the pictures to communicate what they want. Lamh which is a simple form of sign language which lacks the complex syntax of ordinary sign language is also an effective way of communicating with others. However if children cannot master these devices to any degree staff will need to interpret the behaviour of the child e.g. crying is a form of communication that something is wrong. And the staff has to use whatever background knowledge he has of the child to discover what the child is.

The phenomenological approach I have sketched involves treating the child with intellectual disabilities as an intentional agent who engaged in his world and is trying to find meaning in a social world partly created by those who care for him. This approach recommends that those whose responsibility it is to look after these children with ensuring that the social environment is structured in such a manner that it is as easy as possible for the child to immerse himself in the shared form of life of his peers.

There has been some regrettable disputes about the importance of phenomenological research in occupational therapy and nursing. Some proponents of its use have claimed that the phenomenological approach is an alternative to scientific third-person accounts. This has lead to a backlash where some theorists[6] have attacked phenomenological approaches to explore the lived world of people who are ill or have a severe intellectual disability.

The approach of treating phenomenology as an alternative to scientific approaches is radically wrong-headed. When we are trying to understand the lived world of a person with intellectual disabilities we are adopting personal level explanations of their behaviour. This is how we interact with people in ordinary lived experience.  When I arrange to meet a friend for a coffee, I will use this personal level mode of explanation. Thus I will use propositional attitude level type reasoning. I will assume that because my friend knows I will be in a particular coffee shop at a particular time, and he wants to meet me, has agreed to meet me at said time, and knows how to get to the shop, he will therefore meet me unless something happens to prevent him from meeting me. We use this personal level type explanation all of the time in our interactions with others and it works quite well[7]. When dealing with children who have an intellectual disability we are dealing with persons some of whom are perfectly healthy aside from whatever developmental delay they have. Personal level interpretations are both appropriate and useful. Adopting a phenomenological approach is to interpret the behaviour of the child interms of personal level ascriptions though careful phenomenological analysis will sometimes reveal a more detailed picture than our ordinary folk intuitions do. This is not an alternative to scientific analysis of behaviour. It is just an approach which is useful and humane.

If we are trying to teach a child better functional communication a lot of the time behavioural techniques which occur at the sub-personal levels are superior to personal level techniques. Likewise if we are dealing with severe challenging behaviour, a combination of medical treatment and behavioural analysis usually works much better than any treatment at the personal level. But all of this is true of people who do not suffer from intellectual disabilities. A person with no intellectual disabilities may suffer a bout of depression and treatment interms of medicine may work better than personal level psychotherapy. Here we are using a sub-personal level explanation to help the person. The same will be true if a person with or without Intellectual disabilities gets sick with MS or any other disorder.

Personal level ways of interpreting people with intellectual disabilities are not an alternative to scientific explanations they are just standard ways of understanding how a person finds meaning in the world and particular socio-linguistic community they find themselves in. As always we can shift our levels of explanation as pragmatically needed. And leave the question of whether propositional level explanations will eventually be eliminated to future science to decide.

[1] Hence forth ‘Philosophical Investigations’ will be referred to as PI.

[2] Richard Rorty discusses the relation between the early Heidegger and the later Wittgenstein in his ‘Wittgenstein, Heidegger, and the reification of language’ (1991)

[3] Here my comments on care are restricted to practices in present day Ireland. Different countries have different procedures and practices and it would be a mistake to generalise my comments too widely without doing a lot of comparative research.

[4] Lacan whom I disagree with a lot is actually quiet good at emphasising the nature of family dramas a child is thrown into at birth.

[5] See for example Wilding and Whiteford ‘Phenomenological Research: An Exploration of Conceptual, Theoretical, and Practical Issues (2003), and Clarke (2005) ‘An Introduction to Phenomenological Analysis: A Useful Approach for Occupational Therapy Research’, as well as Crotty (1996) ‘Phenomenology and Nursing Research’.

[6] For criticisms of the phenomenological approach in nursing see John Paley ‘Phenomenology as Rhetoric’.

[7] In his 1981 paper ‘Eliminative Materialism and Propositional Attitudes’ Paul Churchland argued that we may end up eliminating propositional attitude level explanations of behaviour as we learn more about neuroscience. He may be correct on this point but at the present time we are nowhere near this point, and there is little reason to deny ourselves the tool of personal level ascriptions.

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