Papers and Commentaries in Peer Reviewed Journals by Michael A Schwartz
Comprehensive Psychiatry, 1984
The Perspectives of Psychiatry impressively paves the way towards the comprehensive practice of p... more The Perspectives of Psychiatry impressively paves the way towards the comprehensive practice of psychiatry by helping the reader structure the bewildering disarray of concepts and approaches which characterize the field. Intentionally written for beginners, the book is clear and accessible. Yet at the same time, it exhibits a remarkable sophistication and thoroughness. The authors present basic principles in psychiatry by probing fundamental questions of methodology: How do we know what we know? Why do we reason in this way rather than another? How might an opinion be challenged or disproven? The goal of this questioning is a critical examination of the diverse facets of psychiatry that highlights strengths, reveals limitations, and delineates applicability. This slender volume succeeds admirably in achieving its goal. The authors assert that two fundamentally different methods of explanation apply in psychiatry and that at least four major constructs or perspectives exist that make clinical observations intelligible. Taken together, the methods of explanation and the clinical perspectives give order to the discipline. There are two basic methods of explanation-the analysis of form and the analysis of function-because the individual patient is always both an object/organism as well as a subject/agent. As a result, mental experience "can be assessed as forms appearing among other forms in consciousness and judged normal or abnormal by their defined characteristics, frequency, temporal appearance, and associations; or they can be evaluated as the products and functions of an individual who ultimately reveals through them his intentions and his individuality." Understanding the difference between these two methods, the practitioner can use both of them, each within its proper place. In a similar manner, the authors maintain that there are at least four major clinical constructs or perspectives which make sense of the clinical situation of patients: the concepts of disease, of dimensions, of behaviors, and of the life story. The disease concept involves a search for disease entities, initially by identifying characteristic clinical syndromes and pathological entities. This approach, which is essentially an analysis of form, encompasses syndromes such as delirium, dementia, schizophrenia and manic-depressive illness. The dimension concept relies upon the fact that people differ in psychological as well as physical characteristics. The authors note, "What is most apparent is not a stereotyped set of symptoms with a relentless course indicative of some class of disorder (i.e., a disease) but a troubled person expressing natural feelings and complaining that they are excessive and distressing." Identifiable dimensions include intelligence as well as various personality traits. While these traits can be identified as forms, they also operate functionally as the potential for actions in susceptible individuals in response to provoking life situations. The concept of behaviors constitutes the third major clinical construct identified by Drs. McHugh and Slavney. Behaviors are defined in terms of their consequences and their goals. Thus, more than a measure of mere activity, "behavior is a construct that makes sense out of activity and activity's regularities." For example, eating is a behavior the consequence of which is food consumption. Behavioral disorders in psychiatry cover a wide field including alcoholism, suicide, anorexia nervosa, sexual disorders and drug abuse, among many others. They can be formally identified and functionally analyzed. The final clinical perspective developed is the concept of the life story. Here the patient is clearly a subject/agent and every action is associated with an intention and a consequence. In this construct, we explain in terms of function as we ask ourselves why the patient acted as he did. As in the case of the other clinical perspectives, Drs. McHugh and Slavney invoke the concept of the life story critically, evaluating it in terms of its
Existenz, 2020
This essay engages critically with Mattias Desmet's book The Psychology of Totalitarianism. I arg... more This essay engages critically with Mattias Desmet's book The Psychology of Totalitarianism. I argue that Desmet's notion of "mass formation" has some validity, yet it needs to be refined, differentiated, and complemented with further aspects that contribute to the emergence of a totalitarian mindset. By doing so-alluding to present COVID-19 vaccination issues-I also explore how to advance public health in the United States so that people can maintain faith in the system and trust its decisions that infringe upon liberty. An honest and respectful discussion is needed in order to overcome polarization of individual positions in these matters.
This paper argues that intuition plays a role in the diagnosis of schizophrenia and presents its ... more This paper argues that intuition plays a role in the diagnosis of schizophrenia and presents its phenomenological rationale. A discussion of self-assessment questionnaires and empirical studies in the clinical setting provides evidence that despite the prevalence of operational diagnosis, the intuitive judgment of schizophrenia continues to take place. Two related notions of intuitive diagnosis are presented: Minkowski's diagnostic by penetration and Rümke's praecox feeling. Further on, the paper explores and clarifies the phenome-nology behind the praecox feeling. First, it is argued, intuitive diagnosis is neither a feeling nor an experience, but a typification operating at an implicit level. Second, it is not simply subjective as spatially it takes place in the in-between of the clinical interaction. Finally, it is not just momentary, but temporally extended, and, hence, partly reflective. The paper suggests that intuitive diagnosis requires critical testing on the side of the psychiatrist to either confirm or falsify it through reflective operations. In conclusion, the merits and shortcomings of intuitive vs. operational diagnosis are presented.
This paper argues in favor of two related theses. First, due to a fundamental, biologically groun... more This paper argues in favor of two related theses. First, due to a fundamental, biologically grounded world-openness, human culture is a biological imperative. As both biology and culture evolve historically, cultures rise and fall and the diversity of the human species develops. Second, in this historical process of rise and fall, abnormality plays a crucial role. From the perspective of a broader context traditionally addressed by speculative philosophies of history, the so-called mental disorders may be seen as entailing particular functional advantages, and thus have a great impact on the course of human history. Nowadays, however, we live under a threat of cultural uniformity. While the diversity of the human species is cherished at the political level, it is being slowly eradicated through medical means. This paradox is a dangerous feature of contemporary globalized society that can lead to highly problematic consequences.
The paper examines both the phenomenology of the manic self as well as critical aspects of manic ... more The paper examines both the phenomenology of the manic self as well as critical aspects of manic neurobiology, focusing, with respect to both domains, on manic temporality. We argue that the distortions of lived time in mania exceed mere acceleration and are fundamental for manic affectivity. Mania involves radical acceleration and radical asynchronicity, which result in an instantaneous existence. People with mania rebel against the facticity of reality and suffer from an existential leap towards the future, in which the self abandons normal temporal boundaries. Excerpts from the interviews with persons with mania who experienced psychosis illustrate this phenomenon. Commenting upon disrupted circadian rhythms in mania and the role of lithium in its treatment the paper posits manic temporality as the link through which manic phenomenology and manic neurobiology intertwine.
December 2015 and March 2016 issues of the American Journal of Psychiatry contain a debate focusi... more December 2015 and March 2016 issues of the American Journal of Psychiatry contain a debate focusing on the legacy of Emil Kraepelin, widely considered one of the founders if not the iconic founder of modern scientific psychiatry. The authors, Eric J. Engstrom and Kenneth S. Kendler, challenge the so-called neo-Kraepelinian view of Kraepelin and argue that the true, historical Kraepelin was far more inclined towards scientific psychology, less reductionist and brain-centric, and more skeptical nosologically than his later followers apparently believe. Commenting upon this paper, Rael D. Strous, Annette A. Opler, and Lewis A. Opler do not question these claims per se, but rather recall and emphasize historical facts that the paper regrettably omitted: Kraepelin's avid promotion of degeneration theory, eugenics, racism, and anti-Semitism as well as his mentoring of several of the most prominent Nazi-collaborating psychiatrists. Strous, Opler and Opler go on to suggest that it is now time for psychiatry to unburden itself of any iconic indebtedness to Kraepelin. The authors of the current paper agree, and propose to replace Kraepelin with the psychiatrist Karl Jaspers, MD (1883-1969) as the proper iconic founder of present-day and future psychiatry. Acknowledging our debt to Jaspers can usher in a fully humanistic and scientific psychiatric practice that can flourish as a medical discipline that is respectful of and of service to patients, beneficial for research, multiperspectival and methodologically pluralistic.
A Spanish translation of "Karl Jaspers - the Icon of Modern Psychiatry".
Israel Journal of Psychiatry and Related Sciences, 2017
December 2015 and March 2016 issues of the American Journal of Psychiatry contain a debate focusi... more December 2015 and March 2016 issues of the American Journal of Psychiatry contain a debate focusing on the legacy of Emil Kraepelin, widely considered one of the founders if not the iconic founder of modern scientific psychiatry. The authors, Eric J. Engstrom and Kenneth S. Kendler, challenge the so-called neo-Kraepelinian view of Kraepelin and argue that the true, historical Kraepelin was far more inclined towards scientific psychology, less reductionist and brain-centric, and more skeptical nosologically than his later followers apparently believe. Commenting upon this paper, Rael D. Strous, Annette A. Opler, and Lewis A. Opler do not question these claims per se, but rather recall and emphasize historical facts that the paper regrettably omitted: Kraepelin's avid promotion of degeneration theory, eugenics, racism, and anti-Semitism as well as his mentoring of several of the most prominent Nazi-collaborating psychiatrists. Strous, Opler and Opler go on to suggest that it is now time for psychiatry to unburden itself of any iconic indebtedness to Kraepelin. The authors of the current paper agree, and propose to replace Kraepelin with the psychiatrist Karl Jaspers, MD (1883-1969) as the proper iconic founder of present-day and future psychiatry. Acknowledging our debt to Jaspers can usher in a fully humanistic and scientific psychiatric practice that can flourish as a medical discipline that is respectful of and of service to patients, beneficial for research, multiperspectival and methodologically pluralistic.
https://gladysleandraportuondo.blogspot.com/2018/02/michael-schwartz-marcinmoskalewicz., 2018
Los temas de la Revista Americana de Psiquiatría (American Journal of Psychiatry, nota de la trad... more Los temas de la Revista Americana de Psiquiatría (American Journal of Psychiatry, nota de la traductora) de diciembre de 2015 y marzo de 2016 contienen un debate que se centra en el legado de Emil Kraepelin, ampliamente considerado como uno de los fundadores, si no como el icónico fundador de la psiquiatría científica moderna. Los autores, Eric J. Engstrom y Kenneth S. Kendler, retan a la llamada concepción neo-kraepeliana de Kraepelin y afirman que el Kraepelin verdadero, histórico, se encontraba mucho más inclinado hacia la psicología científica, era menos reduccionista, estaba menos centrado en el cerebro y era gnoseológicamente más escéptico que lo que aparentemente creen sus seguidores posteriores. Al comentar este artículo, Rael D. Strous, Annette A. Opler y Lewis A. Opler no cuestionan estas pretensionesper se, sino que más bien rememoran y enfatizan hechos históricos que el artículo omitió de modo lamentable: la ansiosa promoción por parte de Kraepelin de la teoría de la degeneración, de la eugenesia, del racismo y del anti-semitismo, así como su tutoría de algunos de los más prominentes psiquiatras que colaboraron con los nazis. Strous, Opler y Opler continúan sugiriendo que ha llegado el momento de que la psiquiatría se alivie de cualquier endeudamiento icónico con Kraepelin. Los autores del presente artículo están de acuerdo y proponen sustituir a Kraepelin con el psiquiatra Karl Jaspers, MD (1883-1969) como el fundador icónico apropiado de la psiquiatría presente y futura. Reconocer nuestra deuda con Jaspers puede marcar el comienzo de una práctica psiquiátrica completamente humanista y científica que puede florecer como disciplina científica, respetuosa y al servicio de los pacientes, beneficiosa para la investigación, multiuperspectivista y metodológicamente pluralista.
European Psychiatry, 2017
Disturbances of temporality in mania, underemphasized in present-day accounts, are nonetheless co... more Disturbances of temporality in mania, underemphasized in present-day accounts, are nonetheless core to understanding both the phenomenology and the neurobiology of the disorder:
– phenomenology: already in 1954, Binswanger had articulated that persons with mania live almost exclusively in the present and hardly at all into the future. Especially in the larger scheme of things, their future is already here. There is no “advancing, developing or maturing,” anticipations have already been achieved, and all that I strive for is basically present if you will just get out of my way! A half century ago, Binswanger summed up the consequence of manic temporality: the manic self, not living into the future, “is not… an existential self.” This presentation will further describe phenomenological characteristics of such a self in mania;
– findings from contemporary neuroscience correlate remarkably well with the above phenomenology, importantly clarifying present and future therapeutic interventions. Of critical importance in mania, clocks in our brains afford receptor sites for the lithium ion. Once bound to the receptor, lithium potently inhibits the circadian rhythm regulator glycogen synthase kinase 3 (GSK3) and profoundly alters the biological cascade that it initiates. In this presentation, by taking a close look, step-by-step, we will clarify how lithium disrupts mania rhythm dysregulation and restores a more “normalized” temporality. The consequence is no less than the return of the existential self. We will also briefly glance, in this presentation, at the window that lithium cellular efficacy offers for treatment options “after lithium.”
Comments on Mohammed Abouelleil Rashed’s “A Critical perspective on Second-Order Empathy in Understanding Psychopathology: Phenomenology and Ethics”, Mar 29, 2015
Understanding the mental life of persons with psychosis/schizophrenia has been the crucial challe... more Understanding the mental life of persons with psychosis/schizophrenia has been the crucial challenge of psychiatry since its origins, both for scientific models as well as for every therapeutic encounter between persons with and without psychosis/schizophrenia. Nonetheless, a preliminary understanding is always the first step for phenomenological as well as other qualitative research methods addressing persons with psychotic experiences in their life-world. In contrast to Rashed’s assertions, in order to achieve such understanding, phenomenological psychopathologists need not adopt the transcendental-phenomenological attitude, which, however, is often required when performing phenomenological philosophy. Additionally, in the course of these (non-philosophical) scientific endeavors, differences between persons with psychosis/schizophrenia and so-called “normal” people seem to have a methodological function and value driving the scientist in her enterprise. Yet, these differences do not extend to ethical dimensions, and therefore, do not by any means touch ethical equality.
A Time for Action on Health Inequities: Foundations of the 2014 Geneva Declaration on Person- and People-centered Integrated Health Care for All, 2014
Global inequalities contribute to marked disparities in health and wellness of human populations.... more Global inequalities contribute to marked disparities in health and wellness of human populations. Many opportunities now exist to provide health care to all people in a person- and people-centered way that is effective, equitable, and sustainable. We review these opportunities and the scientific, historical, and philosophical considerations that form the basis for the International College of Person-centered Medicine’s 2014 Geneva Declaration on Person- and People-centered Integrated Health Care for All. Using consistent time-series data, we critically examine examples of universal healthcare systems in Chile, Spain, and Cuba.
In a person-centered approach to public health, people are recognized to have intrinsic dignity and are treated with respect to encourage their developing health and happiness. A person-centered approach supports the freedom and the responsibility to develop one’s life in ways that are personally meaningful and that are respectful of others and the environment in which we live together. Evidence suggests that health care organizations function well when they operate in a person-and people-centered way because that stimulates better coordination, cooperation, and social trust.
Health care coverage must be integrated at several interconnected levels in order to be effective, efficient, and fair. To reduce the burden of disease, integration is needed between the people seeking and delivering care, within the social network of each person, across the trajectory of each person’s life, among primary caregivers and specialists, and across multiple sectors of society. For integration to succeed across all these levels, it must foster common values and a shared vision of the future.
Self-disturbances in Schizophrenia: history, phenomenology, and relevant Findings From research on Metacognition, Dec 2013
With a tradition of examining self-disturbances (ichstörungen) in schizophrenia, phenomenological... more With a tradition of examining self-disturbances (ichstörungen) in schizophrenia, phenomenological psychiatry studies the person's subjective experience without imposing theoretical agenda on what is reported. although this tradition offers promising interface with current neu-robiological models of schizophrenia, both the concept of ichstörung and its history are not well understood. in this article, we discuss the meaning of ichstörung, the role it played in the development of the concept of schizophrenia, and recent research on metacognition that allows for the quantitative study of the link between self-disturbance and outcome in schizophrenia. phenomenological psychiatrists such as Blankenburg, Binswanger, and conrad interpreted the ichstörung as disturbed relationship to self and others , thus challenging recent efforts to interpret self-disturbance as diminished pure passive self-affection, which putatively " explains " schizophrenia and its various symptoms. narrative is a reflective, embodied process, which requires a dynamic shifting of perspectives which, when compromised, may reflect disrupted binding of the components of self-experience. The Metacognition assessment Scale — abbreviated as MAS-A — suggests that persons with schizophrenia tend to produce narratives with reductions in the binding processes required to produce an integrated , embodied self within narrated life stories, and in interactive relationships with others.
Jaspers' Critique of Essentialist Theories of Schizophrenia and the Phenomenological Response, Aug 7, 2013
Abstract: This contribution reviews the fin de siècle and immediately following efforts (Berze, G... more Abstract: This contribution reviews the fin de siècle and immediately following efforts (Berze, Gross, Jung, Stransky, Weygandt, and others) to find a fundamental psychological disturbance (psychologische Grundstörung) underlying the symptoms of dementia praecox, later renamed schizophrenia by Bleuler (1908, 1911). In his General Psychopathology (1913), Jaspers brings order into the field by bringing to psychopathology a scientific basis coupled with phenomenological rigor. He was critical of theories that proposed an essence of schizophrenia, which is merely asserted verbally. This imperative is reiterated by other members of the Heidelberg School (Gruhle, Mayer-Gross, and K. Schneider). Gruhle (1929) contended that the primary symptoms of schizophrenia, indicating an underlying but still unknown neurobiological disease process, are independent from one another. They cannot be brought under a single, current theoretical model. That is, schizophrenia cannot be explained in terms of a ‘catchword', which is only thought but not empirically studied. Sobered but also inspired by Jaspers' rigor, phenomenological psychiatrists (Binswanger, Blankenburg, Conrad, Ey, and others) proposed more tempered models, which could be studied empirically or tested scientifically. This historical progression may be viewed as a dialectical process: First, bold, merely verbal assertions without method were made, then Jaspers followed with a sobering critique, and finally, the existential-phenomenological clinicians/researchers responded by producing fine-grained, rigorous phenomenological models, tempered by humility and self-critique, which led to hypotheses that could be tested in current clinical neuroscience.
In later editions of his General Psychopathology, Karl Jaspers prescribes many different methods ... more In later editions of his General Psychopathology, Karl Jaspers prescribes many different methods and theoretical points of view for psychopathologists to utilize. Each of these perspectives on the subject matter of psychopathology, however, gives the investigator access to only one dimension of the patient's being. Hence, Jaspers insists that several different perspectives must be employed in order to avoid a one-sided and partial comprehension of the patient and his or her problem. He advocates a multiperspectival approach in psychopathology. Nevertheless, Jaspers remains aware that the patient is a unified whole. This unified whole, however, is not knowable as such, but can rather be approached only under the guidance of an 'idea' of the whole. Jaspers takes the basic notion of 'idea' (Idee) from Kant, but he modifies and uses it for his own purposes. Jaspers' multiperspectivalism may seem to invite charges of relativism because it leaves the psychopathologist to 'pick and choose' any method or theory he or she prefers. This charge is addressed by admitting that there does exist a certain relativism in Jaspers' position in that any one perspective does provide only one approach to the reality of the patient and that other equally useful perspectives could have been chosen. However, each perspective itself can be subjected to test by evidence, and in such tests, claims made from that perspective can be found to be true or false. Helen Longino's theory of scientific knowledge helps support such a thesis.
We offer here a framework for the understanding of being in recovery from schizophrenia as an int... more We offer here a framework for the understanding of being in recovery from schizophrenia as an interpersonal process. We draw upon in-depth phenomenological descriptions of the fundamental changes taking place in an individual’s mental life when they are suffering from schizophrenia. There is a loss of commonsensical habituality and interpersonal capabilities, usually most prominently expressed as an impaired intersubjective resonance. People with schizophrenia cannot as easily automatically and coherently display their own emotion via their facial expressions or perceive those of others, as do ‘normal’ people. This implies that interpersonal resonance between interacting individuals is not automatic, as is often taken for granted. The need to actively rebuild interpersonal resonance also holds true for the interacting ‘normal’ person, but would be an unfamiliar and unexpected task. These difficulties in empathizing provoke a mismatch in interpersonal resonance, often leading to the intuition that the person having schizophrenia lacks (explicit) self-awareness. We conclude that there is a mismatch in the form and scope of the social cover extended to the social role opportunities available in trans-Atlantic cultural settings for people with schizophrenia. Typically, these social roles imply that people with schizophrenia are unaware of themselves; however, while they often lack insight or may not consider their symptoms as signs of a mental disorder, they are usually not ‘confused’ or ‘distracted’ in the sense of no longer being aware of themselves. We discuss various options for adequate social cover achievable for people with schizophrenia, demonstrating their impact on the recovery process.
In face of the multiple controversies surrounding the DSM process in general and the development ... more In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM-whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.
In face of the multiple controversies surrounding the DSM process in general and the development ... more In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM – whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.
In face of the multiple controversies surrounding the DSM process in general and the development ... more In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM – whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.
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Papers and Commentaries in Peer Reviewed Journals by Michael A Schwartz
– phenomenology: already in 1954, Binswanger had articulated that persons with mania live almost exclusively in the present and hardly at all into the future. Especially in the larger scheme of things, their future is already here. There is no “advancing, developing or maturing,” anticipations have already been achieved, and all that I strive for is basically present if you will just get out of my way! A half century ago, Binswanger summed up the consequence of manic temporality: the manic self, not living into the future, “is not… an existential self.” This presentation will further describe phenomenological characteristics of such a self in mania;
– findings from contemporary neuroscience correlate remarkably well with the above phenomenology, importantly clarifying present and future therapeutic interventions. Of critical importance in mania, clocks in our brains afford receptor sites for the lithium ion. Once bound to the receptor, lithium potently inhibits the circadian rhythm regulator glycogen synthase kinase 3 (GSK3) and profoundly alters the biological cascade that it initiates. In this presentation, by taking a close look, step-by-step, we will clarify how lithium disrupts mania rhythm dysregulation and restores a more “normalized” temporality. The consequence is no less than the return of the existential self. We will also briefly glance, in this presentation, at the window that lithium cellular efficacy offers for treatment options “after lithium.”
In a person-centered approach to public health, people are recognized to have intrinsic dignity and are treated with respect to encourage their developing health and happiness. A person-centered approach supports the freedom and the responsibility to develop one’s life in ways that are personally meaningful and that are respectful of others and the environment in which we live together. Evidence suggests that health care organizations function well when they operate in a person-and people-centered way because that stimulates better coordination, cooperation, and social trust.
Health care coverage must be integrated at several interconnected levels in order to be effective, efficient, and fair. To reduce the burden of disease, integration is needed between the people seeking and delivering care, within the social network of each person, across the trajectory of each person’s life, among primary caregivers and specialists, and across multiple sectors of society. For integration to succeed across all these levels, it must foster common values and a shared vision of the future.
– phenomenology: already in 1954, Binswanger had articulated that persons with mania live almost exclusively in the present and hardly at all into the future. Especially in the larger scheme of things, their future is already here. There is no “advancing, developing or maturing,” anticipations have already been achieved, and all that I strive for is basically present if you will just get out of my way! A half century ago, Binswanger summed up the consequence of manic temporality: the manic self, not living into the future, “is not… an existential self.” This presentation will further describe phenomenological characteristics of such a self in mania;
– findings from contemporary neuroscience correlate remarkably well with the above phenomenology, importantly clarifying present and future therapeutic interventions. Of critical importance in mania, clocks in our brains afford receptor sites for the lithium ion. Once bound to the receptor, lithium potently inhibits the circadian rhythm regulator glycogen synthase kinase 3 (GSK3) and profoundly alters the biological cascade that it initiates. In this presentation, by taking a close look, step-by-step, we will clarify how lithium disrupts mania rhythm dysregulation and restores a more “normalized” temporality. The consequence is no less than the return of the existential self. We will also briefly glance, in this presentation, at the window that lithium cellular efficacy offers for treatment options “after lithium.”
In a person-centered approach to public health, people are recognized to have intrinsic dignity and are treated with respect to encourage their developing health and happiness. A person-centered approach supports the freedom and the responsibility to develop one’s life in ways that are personally meaningful and that are respectful of others and the environment in which we live together. Evidence suggests that health care organizations function well when they operate in a person-and people-centered way because that stimulates better coordination, cooperation, and social trust.
Health care coverage must be integrated at several interconnected levels in order to be effective, efficient, and fair. To reduce the burden of disease, integration is needed between the people seeking and delivering care, within the social network of each person, across the trajectory of each person’s life, among primary caregivers and specialists, and across multiple sectors of society. For integration to succeed across all these levels, it must foster common values and a shared vision of the future.
Thus, I somehow conjoin from moment to moment, the historical or autobiographical past, how I have been up to the present, with my experience of self as embodied in the present. This self somehow remains with me even as I sleep. Or at least, I am able to return to myself in the morning no matter if I am groggy, no matter if I dream about being different bodies, selves or other transformations during the night. Invariably, I find myself to be there again in the morning, waiting, loyally, as it were, to resume the business of being myself as every other day, even this being a self somehow seems to change unnoticeably over time. But what if this were not the case? What happens if one morning I awoke and – or one day I discovered that - my self had become so transformed that I could never find my way back to the person I was before. As is well-known, this happens in Kafka’s story, “Metaphorphosis” and, in perhaps a not quite so dramatically in his novel, ‘The Trial.” In a different way, this radical transformation of self and inability to return to whom one was before also occurs in acute psychosis of schizophrenia (Mishara and Fusar-Poli, 2014).
In what follows, we draw both from Kafka’s writings and from the accounts of patients with schizophrenia - for very different reasons as we will see - to examine how neuroscience and our experience of existence may throw light on one another, but from very different perspectives. As argued elsewhere: “Literature documents and records cognitive and neural processes of self with an intimacy that may be otherwise unavailable to neuroscience.” (Mishara, 2010a). Importantly, we do not at any point suggest a diagnosis of Kafka. Rather, we point to how Kafka, in a sleep-deprived state, records his own hypnagogic imagery in his writings. Moreover, this hypnagogic imagery (i.e., the dream-like imagery that spontaneously arises just as we are falling asleep)
appears to refer back to the self and its current concerns. We then examine whether the existential model of self reflected in these writings and the hypnagogic state he records may tell us something about the phenomenology and neurobiology of psychosis and the passivity symptoms and thought disturbances associated with the so-called disturbances of self in schizophrenia.
Conversely, the study of schizophrenia may be helpful in furthering our understanding of the self because the continuity and coherence of self-experience may be impacted by illness in what members of the Heidelberg school of phenomenological psychiatry called the self-disturbances (Ichstörungen) (Mishara, Lysaker, Schwartz, 2014; Mishara and Schwartz, 2013). Now there are a number of everyday activities, which we do for the most part automatically, without much thought, what neuroscientists call unconscious, procedural learning. Such activities include the rapid and automatic perceiving and identifying of objects and people in our environment, routine but also skilled movements, goal-processing, speaking, even thinking - many of our thoughts are rather habitual “self- talk” - or even the moment to moment continuity of experiences. That is, these are things which we take as matter of course, without requiring too much effort or conscious thought. Nevertheless, we believe these automatic processes to be under the influence of our conscious will in that we may choose to steer them in a certain way or stop them at will.
Now what if these automatic processes which seem to arise mysteriously from our own bodies were suddenly alien to us, no longer experienced as under our conscious control or related to the self in any way, controlled rather by some outside source or agency? This is what happens in the self-disturbances of schizophrenia.
Psychopathology is no longer the robust discipline it previously was in the field of psychiatry. By “psychopathology” we mean the scientific study of abnormal psychological processes. If we take psychopathology in this sense, however, we must recognize that today this discipline has been replaced by lists of the signs and symptoms of mental disorders, such as we find in the DSM-V published by the American Psychiatric Association. Psychopathology has been replaced by these lists of syndromes because they are more useful for the practical purposes of uniform diagnosis, both for therapy and research. Utilizing such lists is said to provide a more “reliable” diagnosis than one based on detailed descriptions of abnormal mental states. And once reliability has been firmly achieved through the progressive perfecting of the lists, psychiatry can move on to seeking “validity” in diagnosis and eventually even in the specification of underlying causes. We see then that there is a longer-term project guiding the substitution of lists of syndromes for what was previously the thriving discipline of psychopathology. This project has gone by the name of “the medicalization of psychiatry.” Psychiatry seeks to show that it can progress in basically the same manner that medicine in general has been able to progress in its reliable procedures of diagnosis and its evidence-based research into the etiologies of diseases. From such progress in medicine, as we know, have proceeded treatments and therapies that could hardly have been conceived only half a century ago.
Underlying this substitution is also a skepticism regarding the very possibility of psychopathology as a science. The skepticism consists in the profound doubt that the abnormal mental processes that psychopathology seeks to describe are accessible to a truly scientific cognition. In other words, it is the conviction that abnormal mental states cannot really be studied by scientific methods capable of yielding the intersubjective confirmation of findings and claims. The skepticism, then, is directed toward the scientific status of the method of psychopathology. This essay is devoted to addressing this problem of a scientific method for psychopathology.
Hans Jonas has broken new ground in the history of Gnosticism and modernity, medical ethics, and philosophical biology. He has been embraced by people on the political left and others on the political right. Our presentation draws on his interpretation of modernity and his attempt in his philosophical biology to provide a new path out of some of the dead-ends of modernity. As Jonas knew, these concerns have a direct bearing on how we think about medicine.
Modern medicine has enjoyed much success by drawing on those sciences which study the most elementary components of living beings, namely, the sciences of physics, chemistry, genetics, and others. There can be no doubt that these basic sciences do and will play large roles in helping to explain and treat diseases and injuries of various kinds. However, such sciences fall far short in providing for medical practitioners, especially clinicians, a conception of the patient as a living human self that is needed for the practical purposes of healthcare.
Approaches to this Puzzle
In its approach this chapter is divided into two main sections: historical background and conditions for life. The two sections are continuous with one another by drawing on the philosophy of living beings developed by Hans Jonas.
In historical background , we shall briefly sketch the history of modern conceptions of human life which lead to our present-day puzzlement. This sketch will lead to the recognition of the mind/body problem as the persistent intellectual framework from which we still have not succeeded in escaping. As the new sciences of nature emerged in the 17th and 18th centuries, a philosophical framework for trying to unify the ever-expanding multiplicity of theories and concepts took shape. This framework consisted in a hierarchy of the sciences, each higher level science being theoretically dependent upon the concepts and laws of sciences of the lower levels. This hierarchy of the sciences, however, gave rise to an attempt to simplify them all by proposing an all-encompassing naturalism, the philosophy that all the sciences would (and must) someday be reduced to physics. Reductionistic naturalism has never proven to fully satisfy the modern mind, however; and consequently the mind/body dualism persisted to thwart attempts to see living beings – human beings in particular – as unified wholes. Present-day efforts in medicine to make overall sense of the patient as a person thus encounters road blocks.
In this second part of the chapter, we seek to lay out conditions for being alive that are found in both the mental and the more physical dimensions of life. These conditions are the following: (1) the necessity for living individuals to constantly act in order to sustain their ongoing existence; (2) the separateness of the individual living being from its environment while at the same time maintaining an openness to the environment and engaging in transactions with it; (3) the necessity for the organism to undergo constant change while always making a sameness of self throughout this change; (4) the directedness of the organism’s activity toward its own future being, hence the teleological orientation of organic processes; (5) the origin of feelings in higher life forms. These five conditions of life can serve as a framework within a unified conception of the person which for the purposes of medicine includes both the more physical and the more mental dimensions of patients.
Here we shall not examine the creativity that may – albeit rarely – issue from schizophrenic mental life. We shall rather analyze the more common forms of schizophrenia, forms that bring on only severe suffering and hardship without the compensation of greater originality. We shall approach these more common components from the point of view of phenomenological-anthropological psychiatry. We shall first provide a brief introduction to the phenomenological-anthropological perspective. This introduction will paint the background for our own explication of basic phenomenological concepts, namely, intentionality, synthesis, constitution, automatic and active mental life, and the ego. We shall then address schizophrenic mental life as a whole, claiming that the transformation of experience that it entails affects even the most basic ontological constituents of the world, namely, space, time, causality, and the nature of objects. This phenomenological discussion will allow us to adapt a set of concepts from philosophical anthropology and apply it to schizophrenia, namely, the concept of “world openness” and the need to reduce that openness. We shall focus on one of the more puzzling aspects of schizophrenia, what psychiatrists call “thought insertion." We shall then all-too-briefly indicate the difference between an early stage of schizophrenia and a later one.
personality and the type that H. Tellenbach and A. Kraus call typus melancholicus. Changes in social environments greatly alter what can be termed the "pathology" of these personality
types.
We conclude by invoking Erwin Straus on the differences between norm and pathology of I-world relationships.
relationships.
It will be our contention that there are certain types of persons who are so constituted that living in a community is extremely difficult and uncomfortable for them. These people do much better and can even thrive in modern societies. Moreover, there are other individuals who thrive precisely as members of communities. These people find life in society stressful if not unendurable; they may even fall into depression and attempt suicide. A corollary of these contentions is that modern society – with its inherent powerful tendency to erode communities -- presents grave difficulties for persons of the latter type while it affords unprecedented opportunities for individuals of the former type. The advocates of community are not entirely mistaken, however, when they imagine a kind of person who can benefit from both life in communities and a simultaneous life in society. Many such people do exist. We simply wish to prevent this kind of person from being seen as Human Nature writ large: the person who lives a “well rounded” and happier life by participating in both communities and society is only one type of person. There are other types of people, and we need to appreciate what fates they can expect in a mass society like ours in which communities are disappearing.
Psychiatry is moving through a period in which its basic subject matter, namely, the experiential world of its patients, seems inaccessible and unknowable. Contemporary psychiatry does claim that there are certain aspects of mental disorders that we can know. Indeed, psychiatry is experiencing a time of steady growth of knowledge in particular areas. Neurobiology and psychopharmacology seem to be based on firm scientific foundations, and these important fields constitute a considerable part of the picture of psychiatric understanding and treatment. Moreover, psychiatry has developed manuals of diagnostic categories, the Diagnostic and Statistical Manual of Mental Disorders and ICD-10, which are highly regarded for the rigorous procedures by which they have been constructed and revised.
It is inevitable, then, that traditional psychiatric concerns like psychopathology and psychotherapy would fall within the shadow cast by these steadily advancing fields. What is not inevitable, we think, is that in comparison with these other fields psychopathology and psychotherapy would fall into the disrepute into which they have in fact fallen. This disrepute is not due to the intrinsic merits of psychopathology and psychotherapy. We believe that, for a large part, it is due to political and economic forces that today powerfully shape the reality of psychiatry. Economic forces impose limitations on the time psychiatrists can spend with patients, and political pressures enforce these limitations by dictating treatments that take no longer than the little time allowed (Schwartz et al, 2002).
Aiding the economic and political forces, however, is a particular view of psychiatric " science. " It is assumed in many quarters – even in those quarters unhappy with the assumption – that the methodology used in drug trials on large populations of subjects along with the methodology employed in neurobiology are the sole scientific methodologies. Or, if the field of scientific proof is admitted to reach further, the natural sciences – sometimes called " the hard sciences " – still define the paradigm. Since it is impossible to adapt these methodologies so that they can be applied in psychopathology and psychotherapy, the latter two fields are assumed to be doomed to unscientific stagnation.
Much is lost, however, with the withering away of psychopathology and psychotherapy: namely, a large part of the understanding of mental disorders is forfeited. Moreover, with the loss of this understanding comes a fragmentation and incoherence in psychiatric conceptualization and treatment. Psychiatrists sometimes deal with this incoherence and fragmentation by claiming that they are " pragmatists " : they do " whatever works. " This, of course, is only a direct admission that they have little understanding of what they are doing.
Before, however, we entirely despair of the possibility of placing psychopathology and psychotherapy on respectable foundations, we think it wise to reexamine the subject matters of these areas in order to try to determine how an understanding of them might be attainable.
In Husserl’s The Crisis of European Sciences and Transcendental Phenomenology (1962, 1970) Gurwitsch found the key to an area that he himself had sought to explore: a phenomenology of the intellectual genesis of the sciences. This genesis was partly historical, but it was also partly eidetic. Gurwitsch then borrowed Husserl’s key and further systematized this phenomenology of the relations of the sciences to one another. We shall discuss this topic in the second half of our essay.
This discussion will allow us to pinpoint those limited areas in which “naturalism” can claim legitimacy.
In earlier periods of human history some members of society were certainly seen as mentally disturbed or at least as behaving in remarkably exceptional ways. This persistent, unusual behavior was often interpreted in moral or religious terms: the person was viewed as violating the established morality or as introducing a higher morality, as being demon-possessed or divinely inspired. These extraordinary modes of behavior were thus conceived through schemes of interpretation that were already operative in the society.
Today these modes of behavior would be medically conceived. The person would no longer be morally condemned or subjected to exorcism. He or she would now be seen as suffering from an “illness” somewhat similar to other (i.e., physical) illnesses, with uniform symptomatologies and supposedly uniform etiologies. Since these are medical problems, they must be understood through scientific concepts and treated with scientifically established techniques.
Only in the past two decades have signs appeared that this scientific-medical approach to mental disturbances is on the right track. With the increasing “medicalization” of psychiatry during these decades, psychiatry has sought to model its treatment procedures, theoretical concepts, and research methods on hose of biomedicine. This modeling has produced significant advances. We shall mention only three of the most prominent. (1) The official diagnostic manual published by the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM), has continued to undergo refinement and is more and more viewed as authoritative. This manual hasestablished criteria of diagnosis that have high degrees of reliability, and nowefforts are underway to determine their validity. (2) Proof of the efficacy of several different kinds of pharmacotherapy has given psychiatry chemical tools for alleviating suffering that rival the effective medications of other medical specialties. These advances in psychopharmacology have been accompanied by a growing suspiciousness about the scientific credentials and therapeutic efficacy of Freudian and other forms of psychotherapy. (3) Related to pharmacotherapy have been studies of brain chemistry and structure that spur the hope that the neuromechanisms of mental disorders will be increasingly understood and therefore controlled. Hence neuroscience, with its solid experimental foundation, plays a larger and larger role in the basic conception of mental disorders and in strategies for their treatment. As a result of these recent advances, there are those who think that psychiatry has at last entered upon the sure path of a successful medical specialty. For example, here is how Joseph T. Coyle and Richard Mollica, both of Harvard Medical School, depict the capabilities of present-day psychiatry:
“Psychiatry, fortunately, has developed highly reliable, phenomenologically based diagnostic instruments (DSM-IV and ICD-10) that are easy to apply for the diagnosis of common psychiatric disorders. Furthermore, a new generation of psychotherapeutic drugs has been developed that are more effective and exhibit fewer and less serious side effects than the previous generation of psychotropic drugs. The symptoms of the most common disorders, including depression, posttraumatic stress disorder, anxiety disorders, schizophrenia and bipolar disorder, can be very effectively managed in most patients with psychotropic drugs.” (Coyle et al, p. 494)
These advances have seemed to many, moreover, to confirm the superiority of the scientific approaches that produced them. Hence certain spokespersons for these approaches have boasted that the future of psychiatry lies with them and that the fruitlessness of other approaches will become increasingly apparent. It will be noted that these “successful” approaches – DSM, psychopharmacology, and neuroscience – are ones closely associated with the natural sciences, and this too seems to confirm psychiatry’s close kinship with biomedicine. The approaches toward which a growing skepticism has been directed are the ones akin to the social and psychological disciplines.
Not everyone believes, however, that the “successful” approaches alone will yield a fully adequate understanding of mental disorders and their effective treatment. Many psychiatrists feel that other perspectives too need to be included, but there remains significant confusion about just how they should be included. This confusion is so great that most practitioners are wary of any “comprehensive framework” that might be put forward as the systematic and unified discipline of psychiatry. Any such comprehensive framework, it is rightly said, must be “philosophical,” and widespread suspicion exists regarding the demonstrability of large philosophical frameworks. Otherwise stated, philosophical systems are feared to be too subjective. Nevertheless, the confusion in psychiatry to which we have alluded concerns some basic philosophical problems. Among those problems are the following. First, because of the growth of neuroscience, the mind/body question has re-appeared in a slightly new form: Can mental disorders be conceived exclusively as “diseases of the brain” without bothering with a careful understanding of the psychopathology? And if both neurobiology and psychopathology are to be considered, how does one combine these two? Second, the nature/nurture problem has resurfaced: To what extent should mental disorders be conceived as influenced by social environment and to what extent can they be approached as biologically conditioned, ultimately even genetically conditioned? Third, what sorts of methods are most appropriate for research and what sorts of procedures are most effective in treatment? Also among the philosophical problems are, fourth, the ethical problems: What is the proper ethical treatment of persons with mental disorders?
At present little agreement exists on how to answer these questions. Faced with these apparently unanswerable philosophical questions, therefore, only a few options remain available for psychiatrists to decide how to understand their professional field and daily work.
One option would be that of pure pragmatism: one adopts “what works” without too much worry about why or how it works. One despairs of being able to make comprehensive coherent sense of psychiatric practice and tries simply “to do what’s effective.”
Another option is to settle for one’s own personally satisfying world-view, remaining convinced that nothing more rationally defensible can be attained. This world-view may contain a variety of elements from different domains, neuroscience, diverse psychotherapies, religion, common sense morality, etc. Indeed, this collection of items may even be fitted into a roughly unified whole. But one sees it as one’s personal perspective and therefore incapable of proof – indeed incapable of defense against other contrasting and competing “perspectives.”
Both of the above options are, of course, permeated by skepticism. Rationality is deemed incapable of supplying and grounding psychiatry as a whole, and consequently only a non-rational ground is available. The kind of pragmatism that pervades all of medicine, however, may offer consolation in the midst of this intellectual resignation: you don’t have to understand as long as the patient got better.
Because they are scientifically based and subject to ongoing scientific revision, the categories of the DSM can serve both psychiatric research and clinical practice. They serve research by rendering classifications and selections of populations reliable and uniform. And they serve clinical practice by (l) rendering diagnosis more reliable, (2) sharpening and stabilizing the language of all the mental health fields, and (3) facilitating communication with patients and third parties, such as insurance companies. It is for advantages such as these, we think, that in his chapter in this volume (Pincus and McQueen, 2002) Dr. Pincus repeatedly emphasizes the scientific methodology followed ill designing the DSM-IV. He refers to “data" and "evidence," and he alludes to the "systematic and unbiased recording of observations," "understanding rules of evidence," and "comprehensive and systematic searching, extracting, arraying, documenting, assessing, and integrating of information." The DSM-IV merits its hegemonic role because its scientific credentials are far superior to those of any other classification system presently available in psychiatry. To return to our question, then, why has the DSM achieved its hegemony in psychiatry, the answer we receive is. named in scientific terms: we hear about the careful collection and analysis of data, the unswerving reliance on controlled studies and empirical research, the development of rating scales, etc. Furthermore, because the DSM is firmly based on the best and most extensive evidence available, it furnishes a uniformity of categories with which clinicians, researchers, patients, and third parties can reliably communicate with one another.
One might, on the other hand, claim that the hegemony of the DSM has been achieved by other means. One might use, not scientific, but political terms to explain this hegemony. Political concepts like "power," "authority," "regulation," "control," ”ideology," and even "coercion" come to mind. We might say that the DSM dominates present-day psychiatry because the American Psychiatric Association has endorsed it and consequently given it the highest stamp of legitimate authority in the field. Because of this authority bestowed by the APA, the DSM exercises enormous power over the thoughts, decisions, and practices of clinicians, researchers, and students. Other economic and political forces, like third-party payers and granting agencies, put pressure on psychiatrists to use the DSM categories exclusively.
Now the proponents of the DSM might respond that this political authority and power, while real, have nevertheless been derived from non-political sources, namely, the scientific and clinical success of the DSM. Because the DSM is scientifically convincing and clinically helpful, it has been accepted by these other "forces" and has thereby gained dominance of the field. No one can then legitimately object to the political power exercised by the DSM: this political power is dependent on and always subject to correction by a politically neutral authority, scientific proof and clinical efficacy.
But does the scientific proof currently available really justify the political dominance that is supposedly derived from it? Just how extensive is the scientific support for DSM-IV? Does this scientific evidence truly justify the exclusion of other categories m psychiatric diagnosis, treatment, and research? We maintain that it does not justify such exclusion.
Al, a psychiatrist of international renown, joined AAPP shortly after our association was conceived following a successful panel presentation at the 1989 American Psychiatric Association’s annual meeting in San Francisco. Subsequent to this meeting, Ned Wallace invited a small group of us (1) to Augusta, Georgia to strategize about the development of a philosophy and psychiatry organization.
A follow-up meeting – the launch meeting of AAPP – was scheduled at my home in Westport, Connecticut. But how could we draw in a wider group? How could we develop a viable structure? Launch a journal? Go international? Draw in the luminaries of the field? Who better to ask than Al Freedman – my Departmental Chairman at the time, a psychiatrist deeply interested in the big issues in psychiatry, and a man of exceptional experience and accomplishment. Al and I met for lunch at the faculty club at Cornell Medical College in Manhattan. As we dined, he provided guidance, direction and strategic advice and accepted a place in AAPP’s future Executive Council. A Past President of the American Psychiatric Association (APA), Al straightaway connected me with APA’s then Medical Director, Mel Sabshin, and before the day was done AAPP was on its way to its current status as an APA “Allied Professional Society.” We had “cache” – we were strategically invited to have our AAPP Annual meeting at the time and site of APA’s - and we have so met for more than the past 20 years.
Al can be seen a short time later, at the left end in the first row, in a photo taken on my patio in Westport, Connecticut during AAPP’s first Executive Council meeting in 1990.2
Dr. Alfred M. Freedman, AAPP’s first Life Fellow, graduated from Cornell and the University of Minnesota School of Medicine and began his Residency in Psychiatry at Belleview in 1948. His impact on Psychiatry, and indeed on American culture, would be large. He served as Chair of the Department of Psychiatry at New York Medical College, co-created the Comprehensive Textbook of Psychiatry, and created and led the journal Integrative Psychiatry. The International Society of Political Psychology has an annual Alfred M. Freedman Award honoring his contributions to that group. Al was a Past-President of the American Psychopathological Association (1971-2) and of the American Psychiatric Association (1972-3).
Al’s term of leadership in the American Psychiatric Association merits further description. Prior to Dr. Freedman, APA Presidents ran unopposed in an organization that could well be described as an “old boys network.” In this setting, Al was the first to petition his way on to the ballot and into office. And, as President during a time of social upheaval, he played a critical role in APA’s removal of homosexuality from the list of psychiatric disorders and in APA’s declaration that homosexuality was no longer to be stigmatized by psychiatrists as a mental illness. This action has been properly regarded as one of the 100 most important US achievements in the 20th century. Al’s Presidency of APA was also the time of Viet Nam, and the stealing of medical records from of the office of Daniel Ellsberg’s psychiatrist by the Watergate burglars occurred during Al’s tenure.
Subsequently, Al’s passionate and powerful commitment to medical privacy led to his constituting and leading the broad and effective National Council on the Confidentiality of Medical Records and the consequent reform and improvement of medical privacy laws.
Al was a lifelong human rights activist, ceaselessly and effectively campaigning for the rights of all but especially of those whose human rights have been violated. Concerned about the care and education of underserved children, he participated in the development of Project Head Start. During his term as Chair of New York Medical College, then based in East Harlem, he established a narcotics treatment program as well as psychiatric wards at the Metropolitan Hospital. His advocacy for human rights during his tenure as APA President is described above. Subsequently, exposing systematic abusive psychiatric practices in the Soviet Union, he led an international delegation to a Soviet meeting of the World Psychiatric Association which resulted in a withdrawal of the Soviets from WPA from 1983 until improvements were documented in 1989. In recent years, Al Freedman continued effective campaigning against psychiatric abuse in the interrogation of prisoners and against any role for psychiatrists in executions. In 2008, 60 years after beginning as a Psychiatrist, Al Freedman was named as the recipient of the Human Rights Award of the American Psychiatric Association.
What a privilege for all of us in Association for the Advancement of Philosophy and Psychiatry to have been mentored and guided by Alfred Freedman.
Even Gerald Klerman, “the highest-ranking psychiatrist in the federal government at the time,” who had at first appraised the movement from the DSM-I and II to the DSM-III as a “victory for science,” later revised his view that DSM-III was largely “a political document” (cited by Mayes and Horwitz (2005). That is, by adopting Hempel’s logical empirical approach to science, the neo-Kraeplinians’ presumable “revolution” in conceptualizing and classifying mental disorders actually pre-empted alternative approaches, which were philosophically informed, but in a manner different than Hempel, that is, the German tradition of philosophic phenomenology. In fact, the German phenomenological psychiatrist, Jaspers (1963) had written that to the extent that psychiatry ignores philosophy, it is inevitable undone by it in one way or another.
By appealing to phenomenological psychiatrists such as Jaspers, Conrad or Ey, we are not referring to the idiographic-nomothetic opposition which comes precisely with the realist assumptions of the nomologic approach. Rather, as in our previous contribution, we paraphrased Husserl (founder of the phenomenological approach), the perceived individual (whether object or person) is already perceived in terms of a type which subsumes the perception as a meaningful unit. More recent experimental findings have demonstrated the rapidity and automaticity of these processes in decision-making and everyday social cognition.
Method: Pluralogue.
Results: Methodological pluralism must become standard practice in a psychiatry that aspires to stature as a scientific and humanistic discipline. The boundaries of such pluralism are constrained in ways that were first elaborated by Karl Jaspers and can be re-elaborated today. Jaspers already clarified that the methods of psychiatry are perspectival. Emerging from a particular vantage, each method reveals its evidence and at the same time conceals other evidence. Methods clash, complement, are mutually affirmative or disjunctive. Furthermore, the numerous methods of psychiatry are expressed within time – within a temporal horizon – leading us to ask if any is a priori divorced from history. Can we claim that what is compelling today will not be illusory tomorrow? A scientific and humanistic psychiatry always deals with this challenge.
This extraordinary and unprecedented event at the institute will be held on Saturday, October 8, in the Grande Ballroom of the Sheraton San Diego Hotel and Marina. The free, four-hour celebration will feature music, games, inspirational talks, dancing, food, and information booths.
Celebration Recovery is being presented by the Irwin Foundation in collaboration with APA. The Irwin Foundation, which receives sponsorship from a wide array of private, public, and voluntary entities, develops programs to further the vision of recovery from psychiatric illness and develops recovery-focused workshops and symposia.
Celebration Recovery highlights an emerging concept in psychiatry that emphasizes person-centeredness, respect, responsibility, hope, choice, quality of life, consumer and family agency and empowerment, self-help, partnership, diversity, and community inclusiveness.
Recovery from mental disorders should be an expectation, yet the reality of recovery is too often contradicted by stigma, disempowerment, diminished expectations, custodial care instead of active treatment, and pervasive pessimism.
The recovery vision is increasingly informing mainstream psychiatric initiatives. The 2003 report of the President's New Freedom Commission on Mental Health called for a recovery-focused, consumer- and family-driven transformation of mental health care in America, such that “adults with serious mental illness and children with severe emotional disturbance [can] live, work, learn, and participate fully in their communities.”
The vision of recovery has been adopted by most public mental health authorities. In December 2004, more than 100 leaders, including mental health and addiction recovery experts, consumers and families, advocates, community and state officials, national association staff, and public officials, joined forces at the consensus conference “Mental Health Recovery and Systems Transformation,” sponsored by the Substance Abuse and Mental Health Services Administration. Its goal was to define recovery, reach a consensus on its key principles and elements, and identify recovery implementation strategies that work.
In line with these developments and reflecting its leadership role, APA has chosen “Recovery and the Community” as the theme for the 2005 institute. The institute will offer three plenary sessions and numerous workshops and symposia on the theme.
The Irwin Foundation was created in honor of Irwin B., who had a severe mental illness. While he eventually benefited from treatment advances, enabling him to end a relentless cycle of hospitalizations, he continued to struggle with stigma and nonacceptance. The foundation is designed to commemorate his courage and determination to eliminate stigma and to create a better future for those recovering from mental illness.
Since 2001, the Irwin Foundation has held Celebration Recovery events across the country, including most recently at the 2005 convention of the National Alliance for the Mentally Ill in Austin.
Phenomenology is a very broad term that refers to all experience, normal and abnormal. In contrast, the term that should be used to refer to pathologic experience alone, as is obviously the intention in this supplement, is psychopathology.
For example, in the "Introduction," the editors plainly begin, "Aggression is a dimensional symptom." Already, on line 1, from a phenomenologic vantage, there are two major problems with this supplement: (1) the claim that aggression is a dimension and (2) the claim that aggression is a symptom.
The claim that aggression is a dimension is not descriptive (phenomenological), but is rather a theory about aggression. For example, "the increased activity and agitation" (editors' terms) that we see in the aggression of a cat in a cat fight is qualitatively different from the calm, deliberate, and quiet aggression of a cat stalking its prey. Indeed, a single "dimension" of aggression cannot encompass these two very different forms of aggressive behavior. (I could go on - there are more than two qualitatively different forms of aggression - but I will not; then I would be performing a phenomenology of aggression, rather beyond the scope of this letter.) Theories ignore features of phenomena in order to focus on other aspects of the same phenomena. My point is that the editors have clearly chosen a theoretical path in this supplement and not a phenomenological one.
The claim that aggression is a symptom is also a theory and a very bad one at that. Aggression is much more than a symptom. Obviously, soldiers should be aggressive and so should trial lawyers, venture capitalists, and academic psychiatrists who are trying to get grants and publish. When we begin with the idea that aggression is a symptom, we are guilty of pathologizing the normal, something we psychiatrists should vigorously avoid doing.
Another problem follows from the above two. The supplement editors claim to cover the spectrum of aggression from one end, "activity and agitation," to the other, "violent criminal behavior." However, concerning aggression, this is not "one end to the other," no matter how we construe it. For example, one end of a spectrum of aggression could begin with diminished aggression, "the meek and the mild"; on the other end, we would go on to "the violent," etc. Or one end could begin with healthy aggression, perhaps with concepts such as assertiveness, and the other would go on to unhealthy forms of aggression, such as violent, rageful murder.
The editors chose to avoid all of these problems with their reductionistic approach. Fine. Just don't call it phenomenology. It is not.
Finally, in fact this is the Journal's problem and not that of the editors of this particular supplement. Again and again, the editors of the Journal seem to prefer the term phenomenology when psychopathology is more appropriate. Editorial policy is wanting here and should be corrected. Yours is a wonderful journal, and you don't need to gussy up your papers with high-sounding language when more ordinary words will do (and even do a better job).
If, in this condition of excitement and joy, my body were connected to a monitor and tested, it would register certain physiological patterns that might be identical to those of an anxiety attack. So, from one point of view, my anticipation of a thrilling ski adventure could be mistaken for an anxiety attack. This point of view would, of course, have to disregard my subjective experiences, which are those of a person filled with joyful excitement.
Granted, in colloquial English we say, "I am anxious," but in this case it is meant in the sense of "I am anxious to meet my son." This anxiety is of joyful expectation, just the opposite of morbid anxiety. Indeed, if the only categories at one's disposal were pathological categories, my organic condition would have to be classified as an anxiety attack.
Therefore, in order to misinterpret my condition as an anxiety attack: 1) my condition must be decontextualized, i.e., my personal situation - that of a man traveling to go skiing with his son - would have to be disregarded and my organic condition alone considered; and 2) the decontextualized organic condition must be viewed as falling under some pathological classification system. If taken, these two steps would categorize my state as an anxiety attack.
In the modern climate of thought, the first step - ignoring the person's subjective experiences - is easy enough to take. Indeed, this would be viewed as required for a strictly scientific test. Science itself demands that subjective experience be disregarded and organic reality alone examined. Only in this
way, the modern mind assumes, is a truly objective result reached.
The second step does not appear to follow as easily from the proclivities of the modern mind, however. But it does easily follow the modern specialization of the sciences. As they more precisely isolate specific provinces of reality, some sciences have focused on pathological conditions, leaving the study
of healthy states to other disciplines. For example, American psychiatry has become determined to define mental disorders as thoroughly as possible, and it has indeed made some progress in this regard. But American psychiatrists rarely study mentally healthy people.
Traditionally, the term obsession refers to besiegement. In the Middle Ages, for example, agents of the Inquisition attempted to distinguish between individuals possessed by demons and these merely obsessed by them. With respect to obsession (2), the devils and demons vexed, hovered about, and harassed the victim, but they did not possess him, which means that they did not enter into his body and soul and totally overcome him. Possession was somehow resisted (2). In psychiatry, the distinction between obsession and possession is replaced with a distinction between obsession and delusion. The one must be understood in contradistinction to the other.
The term compulsion has equally old usage and refers to the condition of being compelled, constrained, obliged or coerced. By this usage, actions and behaviors can be compelled but so can thoughts, moods, and even obsessions. An obsessive-compulsive patient is compelled to think obsessive thoughts and to behave in congruence with them or in response to them.
Finally, pleasureful preoccupations (that is to say, “overvalued ideas”) are not obsessive-compulsive since they are not besetting and onerous but are instead motivated by self-indulgence and attraction.
Additional difficulties may ensue from the ambiguity that is so characteristic of current-day treatment. In our present era, treatment recommendations are by no means uniform, and the same patient may be offered quite different treatments by different clinicians. Or caretakers may appear to constantly and arbitrarily change medication. Or patients may be poorly informed about the side effects of a medication, or even about the treatment effects. Or patients may simply not want to take medication, in the absence of compelling reasons to the contrary. Given that the need for medication in so many cases is long lasting, and that the medication effect is often delicate and subtle, such problems in communication and understanding can drastically undermine the total treatment effort. Tragically, patients can come to feel more and more like " guinea pigs " and wrongly decide to avoid medications that might otherwise be of obvious benefit. In such a climate, patients and their loved ones have an especially strong need to know the actual " facts of life' about psychoactive medications.
And then there are the street drugs and some remarkable paradoxes to mull over. Such as the fact that many mentally ill individuals shun prescribed medications at the same time that they actively seek and use illicit and presumably dangerous street drugs. This is perhaps another phenomena of our pharmacological era. As a corollary, many clinical and treatment facilities are presently overcrowded with " dual diagnosis " patients – patients with mental illness who simultaneously suffer from alcoholism and/or drug abuse. While it is often unclear which problem began first, it is always clear that each illness complicates the other and confounds overall treatment planning. But precisely how these drugs are dangerous, and exactly what do mentally ill people expect to gain from them if and when they seek them out?
All of these issues are clearly and concisely covered in Jean Bouricius' " Psychoactive Drugs and Their Effects on Mentally Ill Persons " , an outstanding contribution to the mentally ill and to those who care for them and about them.
But let us return to the dictionary for another look. Skeat’s “Etymological Dictionary” traces both “client” and “patient” back to Roman antiquity and earlier. According to Skeat, “client” is derived originally from the Indo-Germanic root “kleu,” to hear, and takes independent form as the Latin “clientum,” “a dependent on a patron.” On the other hand, “patient” is traced back to the Latin “pati,” to suffer, as in “bearing pain, enduring long suffering.” Skeat also relates “patient” to “passion,” defined as “strong agitation of the mind, suffering,” and further relates it to “com-passion.”
These critical distinctions persist in modern times. For example, the authoritative Oxford English Dictionary defines “client” as “1. Rom. Antig. A plebian under the patronage of a patrician…… 2. One who is under the protection of patronage of another, a dependent …… a ‘hanger-on’ ….. vassals or retainers ..... an adherent of follower of a master. 3. One who employs the services of a legal advisor in matters of law. 4. A person who employs the services of a professional or business man in any branch of business, or for whom the latter acts in his professional capacity; a customer".
On the other hand, the Oxford Dictionary defines patient as “A.1. Bearing of enduring (pain, affliction, trouble, or evil of any kind) with composure ….. long suffering, forebearing …. 2. Enduring or able to endure …. 3. Undergoing the action of another…… B.1. A sufferer … esp. One who suffers from bodily disease; a sick person. 2. One who is under medical treatment for the cure of some disease or wound; one of the sick persons whom a medical man attends…
Within psychiatry, Jaspers is widely acknowledged as a seminal thinker, the father of phenomenology, the leading methodologist and a preeminent psychopathologist. But his vast contributions to our field are a mere preface to his other contributions to the general culture – his philosophy of existence and his many books and essays on truth, communication, human nature, science, politics and religion. In these writings, his reflections and insights are wide-ranging in scope, profound in wisdom, audacious in originality and liberating in effect. Can there ever be another psychiatrist such as this? How fortunate are we, then, to have this single volume of critical selections from the entire Jasper corpus freshly translated and generously commented upon by leading Jaspers scholars of the present day.
The book contains seventy-our selections, all excerpts, organized systematically in seven parts with each part and selection preceded by an editor’s guide and commentary. There is also a complete bibliography of Jasper’s books and monographs as well as of writings about Jaspers. Forty per cent of the book is translated for the first time, and most of the selections from previous translations have been retranslated, including a selection from Jaspers’ General Psychopathology.
Fortunately, Hempel himself was once invited by the American Psychopathological Association to criticize psychiatric classification (in 1959, midway between DSM-I and DSM-II). Hempel’s masterful presentation is a classic in the philosophical literature (1, 2). Today we can note that it reads like a manifesto for DSM-III, with its advocacy of a descriptive approach that remains close to observable data, values reliability, and operationalizes terminology.
Hempel’s empiricism, however, is more difficult for Dr. Faust and Dr. Miner to dismiss than Bacon’s. First, these authors claimed that Baconian empiricism has no room for theory and inference. But modern-day logical empiricism certainly welcomes theories and inferences! In fact, Hempel claimed that we can never understand particular things and events scientifically unless we are able to explain or predict them through general laws and theories (1, pp 146-151). Second, since Bacon never anticipated operationalism, Drs. Faust and Miner had nothing to say about this major innovation of DSM-III, but Hempel vigorously promoted operational definitions for psychiatric concepts (1, 2).
How, then, should we judge modern versions of empiricism such as Hempel’s? Here we firmly agree with Dr. Faust and Dr. Miner that there are philosophies of science other than empiricism. Elsewhere, we have tried to show the relevance to psychiatry of these alternatives (3-5), but psychiatry does in general appear to be moving toward an empiricistic monism, as illustrated by the whole project of DSM-III (or by the more recently proposed treatment manual). Past disagreements in psychiatry have thus been over- come by applying an “empiricist” yardstick. But doing so involves ignoring alternative-and equally defensible methodological yardsticks. In actuality, the reigning solution is Procrustean: honest diversity is silenced by an “academy” that dictates “the one true” scientific method.
What is to be done? Thirty years ago, we were wise enough to invite outstanding outsiders such as Hempel to advise us about our methods, but no longer. Now, groups like the DSM-III task force do without advice from the Hempels of the present day. This is an oversight. We have become mired in narrow and outdated views of science. To escape from this predicament, future efforts like DSM-III should involve the broadest consultation with outstanding individuals from philosophy and the social sciences.
Additional difficulties may ensue from the ambiguity that is so characteristic of current-day treatment. In our present era, treatment recommendations are by no means uniform, and the same patient may be offered quite different treatments by different clinicians. Or caretakers may appear to constantly and arbitrarily change medication. Or patients may be poorly informed about the side effects of a medication, or even about the treatment effects. Or patients may simply not want to take medication, in the absence of compelling reasons to the contrary. Given that the need for medication in so many cases is long lasting, and that the medication effect is often delicate and subtle, such problems in communication and understanding can drastically undermine the total treatment effort. Tragically, patients can come to feel more and more like " guinea pigs " and wrongly decide to avoid medications that might otherwise be of obvious benefit. In such a climate, patients and their loved ones have an especially strong need to know the actual " facts of life' about psychoactive medications.
And then there are the street drugs and some remarkable paradoxes to mull over. Such as the fact that many mentally ill individuals shun prescribed medications at the same time that they actively seek and use illicit and presumably dangerous street drugs. This is perhaps another phenomena of our pharmacological era. As a corollary, many clinical and treatment facilities are presently overcrowded with " dual diagnosis " patients – patients with mental illness who simultaneously suffer from alcoholism and/or drug abuse. While it is often unclear which problem began first, it is always clear that each illness complicates the other and confounds overall treatment planning. But precisely how these drugs are dangerous, and exactly what do mentally ill people expect to gain from them if and when they seek them out?
All of these issues are clearly and concisely covered in Jean Bouricius' " Dealing With Drugs. Psychoactive Medications and Street Drugs-Their Good and Bad Effects on the Mentally Ill " , an outstanding contribution to the mentally ill and to those who care for them.
1. The authors dismiss DSM-III criteria for obsessions and compulsions as "nebulous," "particularly the requirement that patients show insight into the nature of, and resistance to, the symptoms." But the DSM-III glossary never requires insight for obsessions and compulsions.
2. DSM-III does properly require that there be "resistance" to obsessions and compulsions. Indeed, the notion of resistance has been intimately connected to the notion of obsessions since at least the Middle Ages, when court inquisitors used the notion of resistance to distinguish between the diabolically possessed and the diabolically obsessed. Within psychiatry, the importance of resistance in obsessions and compulsions has been stressed by all authorities, including Karl Jaspers, Aubrey Lewis, and F. Kraeupl Taylor. The authors could have opposed this long tradition with a forceful argument, but we get no argument, and only one reference to a recent brief paper.
3. The authors' evaluation of current criteria as, again, "nebulous" is simply their opinion. They might have preferred to use more "hard-nosed" contemporary descriptions of obsessions and compulsions such as Taylor's. But putting this aside, no matter what the criteria, it is true that judgments about obsessions, compulsions, overvalued ideas, delusions and so forth are hard to make and require training and the acquisition of skills. Furthermore, some cases remain unclear despite all our efforts, but so it is with all clinical phenomena in medicine.
4. The author's "behavioral" criteria are hardly an improvement. In the first place, it is not at all apparent how criteria such as “indecision/stuckness" are behavioral. Second, one wonders about the ability of different raters to agree about the presence or absence of some of these items. Third, many of the criteria overlap. Won't a patient who is involved with "arranging and rearranging shoes for an hour before bedtime” (criteria 4) also have a "repeated behavior that interferes with daily activities" (criteria 1)? Fourth, the criteria are a psychopathological hodgepodge of possible obsessions, compulsions, rituals, overvalued ideas, delusions, stereotypes, mannerisms, and perseverations that could reflect obsessive-compulsive symptoms, brain injury, or schizophrenia. Fifth, given this hodgepodge, and given the fact that items don't count unless they are present for more than six months, it is certainly not surprising that patients with lots of criteria did less well than did patients with none or one. This hardly says anything about the relationship between obsessive-compulsive phenomena and schizophrenia.
These questions have been long debated in philosophy, outside of the medical context of mental health. Numerous distinctions between different “kinds” of future(s) have been made and explored, such as: determined future (Hempel), unpredictable future (Derrida), future as the Other (Levinas), progressive future (Koselleck), open-ended future (Arendt) or future toward-death (Heidegger). Philosophers have also analyzed problems related to conscious/unconscious horizon of expectation and to the contingency vs. necessity of the future. However, discussions of the deviation from “normality” have remained rare.
At the same time, psychopathological relevance of the varieties of lived time has been discussed within the field of phenomenological psychiatry. Investigating temporality as a pre-reflective structure of all experience and as a reflective attitude towards different dimensions of time, psychiatrists construed future experiences in terms of their abnormality, including phenomena such as: obstructed future (Gebsattel), others-determined future (Binswanger), disconnected future (Straus), uncontrollable future (Melges) or desynchronized future (Fuchs). Regardless of the real, ontological not-yet, future can be lived upon in many different ways, some of them apparently extreme, such as utopian future in addiction, presented future in mania, chaotic future in schizophrenia, fearful future in neurosis, repulsive future in phobias or constricted future in depression.
While it is widely agreed that having no future at all (as in the case of the time of the self coming to a standstill) is truly pathological, the variety of futures actually lived upon makes the question of the boundary between the normal and the pathological difficult to tackle. All the more so since the lived time is a collective phenomenon, subject to quickly changing socio-temporal norms, such as contemporary acceleration, resulting in general uncertainty of the shared future and the concomitant “neurosis” of our times.
The aim of the workshop is to bring together leading specialists in the interdisciplinary field of temporality studies in order to discuss these problems. Its key focus is to demarcate pathological future experiences from its non-pathological, even if unpleasant counterparts, while focusing on underlying, temporal foundations of mental disorders and taking advantage of philosophical notions of the future.
Nonetheless, it can be claimed, as already expressed by Binswanger in 1964, that aberrant temporality is core to the disorder. Persons with mania live almost exclusively in the present and hardly at all into the future. Especially in the larger scheme of things, their future is already here. There is no “advancing, developing or maturing,” Anticipations have already been achieved, all that I strive for is basically present and readily at hand - if you will just get out of my way and be helpful and not an obstacle. A half century ago, Binswanger spelled out this temporal foundation for mania and summed up its consequence. The manic self, not living into the future, “is not, to borrow a word, an existential self.”
In this presentation, the author will further describe phenomenological characteristics of such a self in mania as well as in its attenuated form, hypomania. Subsequently, he will outline findings from contemporary neuroscience that correlate with the above phenomenology. Importantly, these findings complement and clarify rational present and future therapeutic interventions. The ever advancing science of chronobiology can increasingly characterize human biological clocks anatomically, physiologically and functionally. Of critical importance in mania, clocks in our brains afford receptor sites for the lithium ion. Furthermore, It is now well established that lithium is a potent inhibitor of the circadian rhythm regulator glycogen synthase kinase 3 (GSK3). In consequence, lithium will impinge upon and alter the biological cascade that follows. By taking a close look, step by step, we can begin to comprehend implications for mania as well as for its treatment with lithium. We can begin to see how lithium disrupts mania rhythm dysregulation and can restoring a more “normalized” temporality. The consequence is no less than the return of the existential self. We will also briefly glance, in this presentation, at the window that the comprehension of lithium cellular efficacy offers for future developments of more specific and safer treatment options “after lithium.”
In conclusion, this presentation aims to clarify: 1) Core phenomenological temporal experiences in mania. 2) Correlations between the manic experience and neurobiology. 3) Consequences for current and potential interventions at personal, therapeutic, social and biological (including pharmacological) levels.
This presentation will focus upon the above paradox: In stark contrast to our almost boundless delight in the physical, ethnic and cultural expressions of human diversity, there is, at the same time, a narrow, and perhaps even increasingly narrow tolerance for a variety of behavioral and experiential human differences. In such human realms, present-day cosmopolitan societies increasingly call for behavioral and experiential conformity rather than diversity. For example, at meetings such as this one, we can freely and delightfully express and celebrate our racial, ethnic, and culturally differences. We can look different, dress differently, even think differently, but we must communicate – within remarkably narrow ranges – diplomacy, cordiality, spontaneity, agreeableness, respectful disagreement and tact. Diversity yes, but at the same time it is imperative that we conform our conduct to broadly consensually validated norms. And if we cannot?? We will propose in our presentation that the phenomenon of mental illness arises as a consequence of the phenomenon of human diversity coming up against constraints and limitations in expressed and experienced mental and behavioral realms.
This presentation will focus upon evolutionary, genetic, biological, anthropological, historical and cultural aspects of the primary role that human diversity plays in mental illness. We will discuss the adaptive origins and strengths associated with the extraordinary diversity of humans (and our pets and domestic animals) as well as some vulnerabilities that accompany this diversity. For example, diversity associated with skin pigmentation has enabled humans to extend successfully across the globe. A consequence however, is an enhanced human vulnerability to skin cancer for some with fair skin and to Vitamin D deficiency for others with dark skin. Psychological diversities can be viewed in an analogous and pervasively more problematic manner. And furthermore, unlike physical diversities, often increasingly celebrated in present-day cosmopolitan societies, mental and psychological diversity are – with notable exceptions, increasingly problematic. While diversities of physique, race, region and society are affirmed and applauded, decorum, temperaments and conduct arguably must conform to ever narrower norms.
Our presentation will illustrate our thesis – that mental illness is an inevitable consequence of the singular diversity of the human species – through the examples of mental disorders such as attention deficit disorder, melancholia, schizophrenia and antisocial personality disorder.
The models here - biomedical and/or biopsychosocial - are suitable for the territory. But what about schizophrenia and many other mental disorders? What about personality disorders? Can most people, or even a large percentage of people, achieve an analogous sign-and-symptom-free recovery? Or does the above medical models even fit? We think not, and in this presentation we will describe another, profoundly social and we think valid model of recovery from mental illness.
We will start by examining the increasing demographics of mental illness in our modern and post-modern era; in nations that have undergone globalization and modernization more or less than others, and in present day immigrant populations in nations such as the USA. Our conclusion is that the many benefits of Westernization and modernization certainly do not include protection against mental disorders. To the contrary. We will go on to clarify this phenomenon - focusing on differences between "community" and "society" and the substantial advantages derived from communities as well as the substantial disadvantages in societies for a broad spectrum of people who are vulnerable to mental disorders (One salient exception will be described). Our analysis will let us see how important communities are for recovery; but at the same time we will see that, in present-day cosmopolitan societies, communities are increasingly rare and vanishing. Social pressures arguably accelerate this trend. We may long for community; we may comprehend their profound value especially for those who are recovering from mental illnesses, but we must appreciate how anomalous and out-of-synch they are nowadays. And, to facilitate recovery from profound mental disorders, we should - indeed we must - create genuine recovery-focused communities.
However, far from clinical practice – in courtrooms – a growing US problem called for radical revision. Primitively conceived psychiatric classification invited trouble. Given “Not guilty by reason of insanity,” the “right diagnosis” could mean the difference between conviction or acquittal. And given Freudian, Jungian, eclectic and biological psychiatrists, the diagnosis often said more about the psychiatrist than the patient. Ennis and Litwack’s 1974 manuscript expresses the dilemma: “Psychiatry and the Presumption of Expertise: Flipping Coins in the Courtroom.”
To resolve this crisis, Hempel’s then preeminent logical empiricist philosophy of science provided an answer, and APA’s DSM-III a methodology for psychiatric classification that persists to today. With valid psychiatric entities “not here yet,” uniform lists of reliable operationalized diagnostic criteria could still delineate reliable disorders. These entities could be studied and in time achieve validity. Ongoing revolutions in neuroscience and genetics would assure this.
In short – the problem is simple -- reliable entities need never achieve validity. But is there an alternative?
This presentation will argue “yes.” Psychiatric disorders – forms of abnormal psychology -- are real. But the only conceptual coherence is at the methodological level. As complex emergent phenomena, mental disorders can sometimes be typified. And they can be approached variously and in combination as diseases, dimensions, behaviors, life stories, and diversity. The remainder of this presentation will spell out this framework.
We shall focus on the acquisition of "expertise" in seeing and interpreting the patient's difficulties. Such expertise is shaped by three sorts of major factors. Over time each clinician develops his or her personal style of thinking. Expert sills are developed by working with many different patients and by encountering many different successes and failures in the process. These successes and failures confirm some ways of thinking and disconfirm others. Secondly, much of the expertise is developed through the socialization process the clinician undergoes that gradually educates the less experienced psychiatrist into the ways of reasoning of highly skilled ones. Thirdly, evidence-based studies of various kinds can also contribute to understand the patient as long as their use is guided by the psychiatrist's overall expertise and clearly fit into this larger context. The acquisition of such expertise from these sources enables the clinician to more easily interpret the evidence of the patient's problem that is expressed through the patient's words and behaviors. The novice in clinical practice has not yet acquired such expertise and remains therefore relatively blind to what is evidenced in these words and behaviors. Hence every practitioner has his or her own personal thought-style that shapes the interaction between him or her and the patient. But such personal elements have been partially formed by the socialization process that had rendered the individual's reasoning similar to that of other clinicians. Evidence-based studies provide the background knowledge that informs the clinical skills. However, it is the evidence that is disclosed in direct clinical interaction with the patient that tests and grounds the psychiatrist's beliefs about and plans for him or her. Such beliefs and plans should be tentatively adopted so that they can be corrected and changed by further evidence that may emerge as the relationship with the patient unfolds.
This characterization of clinical reasoning closely resembles Aristotle's account of ethical perception, deliberation, and judgment in his Nichomachean Ethics. Accordingly, the expertise that the psychiatric practitioner needs to acquire in order to be a "good" clinician could qualify, we think, as one of the "intellectual virtues" in Aristotle's sense.
US medicine was essentially a trade until the landmark 1910 Flexner Report. There were numerous schools, some outstanding – for example Johns Hopkins – most charitably not so. Many of the brightest and best were educated abroad in Edinburgh, Paris, or Germany. Charged by Carnegie/Rockefeller, Flexner’s visit to and report on every US medical school and the major centers in Europe changed everything. Within decades most schools closed. Those that remained embraced Flexner’s vision: A foundation in science-based medicine (the sciences of “knowing how” and “knowing what) and standardization by an empowered AMA. “Scientific conviction” coupled with “laboratories and libraries, apprenticeship,” and “standardized licensing exams.”
Who would study in these centers? “Educated men.” No longer trade schools – college education was for the first time a requirement for medical school admission – the “substantial admission base” among core Flexnarian reforms.
Is person-centeredness in Flexner? “Practitioners deal with facts of two categories. Chemistry, physics, biology enable him to apprehend one set, he needs a different apperceptive and appreciative apparatus to deal with other, more subtle elements. In this direction… one must rely for the requisite insight and sympathy on a varied and enlarging cultural experience. Furthermore, “The physician’s function is fast becoming social and preventive, rather than individual and curative.” Hence, “Upon (the physician) society relies to ascertain, and through measures essentially educational to enforce, the conditions that prevent disease and make positively for physical and moral well-being.”
But how to advance such humanistic intentions? From Flexner’s time forward, this dilemma – still without resolution – has plagued modern medicine. The problem remains the vagueness of humanistic goals in contrast to the exactitude/precision of scientific goals in a naturalized, evidence-based world.
The first half century after Flexner was triumphant for scientific medicine – by mid-century, medicine was a solidly scientific craft, its humanism “more subtle.” I recall the beginning of my own 1969 internship, walking late at night into a patient’s room – one of my teachers, approximately my present age, struggling with a painful carcinoma. Unanticipated, my goal was to assure that his IV line was open and avoid being paged in early morning hours to restart it….. In the moonlight, I could see that he, intending suicide, had slashed vessels in his neck and extremities. “Please leave!” – he pleaded. Absolutely nothing in my education prepared me for that.
Advocates for person-centered medicine include Hippocrates, Maimonides, Osler and Hamburger. In the past century, we will focus on George Engel’s “biopsychosocial” in contrast to “biomedical” practice – an inclusive, general systems based medicine at the heart of which is the person. Yet even for Engel, the person was the pinnacle from only one viewpoint. Not fundamentally – at the apex of the general systems pyramid is physics, with other systems nesting around, in domains vaguer and vaguer. And if all systems are relevant, how to prioritize assertions and how to develop an evidence base?
Osborne Wiggins and I asked in the early 1980’s: If all of these systems are relevant, how to weigh evidence and bring all together? We started with phenomenology and person-centeredness: The experiences and behaviors of people in everyday life – their “lived experience” in the “lifeworld” - is fundamental – not atoms/molecules. To assert otherwise is to embrace a “spirit of abstraction” (Marcel) and “fallacy of misplaced concreteness” (Whitehead). Atoms and molecules, are not “the most basic reality,” in fact we “abstract from,” or ignore, much that is real to investigate them.
More recently, “evidence-based medicine,” aptly described as a “second-Flexnerian medical revolution” is resurgent/ triumphant for exactitude and statistics over that which is more concrete. Yet, looking closer at the hierarchy of sciences remains instructive. Physics is our most mathematizable science, but the precision and exactitude of physics arises because much of reality is set aside. Physicists abstract from meanings, values, intentions, and feelings and disregard the social, most of the human, and part of the living world to isolate physical reality. The gain is exact description and precise prediction. But the concepts of physics are so defined that they refer to only few selected elements of reality.
Alternatively, sciences closer to everyday life have their evidence too, although, less abstract, they must take into account facets of reality that fail to deliver exact evidence. Yet they do provide evidence. Durkheim, founder of sociology, cites language as an example – learn one, and if you don’t believe in rules and laws you will certainly stub your tongue. Nonetheless, social sciences remain faithful to the ambiguity/indefiniteness of their domains. The crucial issues: 1. Evidence re what/how? 2. A critical attitude towards that evidence.
In summary, while searching for evidence in every domain applicable to medicine, we must also maintain a critical attitude about that evidence. Furthermore, natural sciences serve their purposes only when they find their rightful place within larger knowledge of the patient as an individual human being. Outside context, abstract conceptions and techniques dehumanize. The understanding we have of other people in their ordinary/extraordinary sufferings and joys provides the foundation on which we draw when we seek to understand them scientifically. Medicine of course goes beyond everyday understanding and seeks to extend it through additional evidence. But without the humanism of medicine we remain blind to the complexities/details of human evidence.
Because it is a practical discipline, medicine is defined not as much by a body of knowledge as by its goal: health promotion and the amelioration of illness. Such goals make medicine scientific and humanistic. Medical humanism is possible because to dome extent we already understand human beings through everyday life with/among them. Everyday understanding, founded in everydayness, can be enlarged/developed through scientific understanding that follows the leads of evidence. Within this enlarged, person-centered context, exact explanatory concepts of the natural sciences can effectively serve humanistic ends.
Purpose: The notion of PF, although quite popular in the classical nosography and psychopathology, gradually lost its clinical significance with the introduction of the operational criteria for diagnosis in the 1980's with the DSM-III. Our study aims to examine the relevance of this phenomenon for contemporary clinical practice.
Methodology: We have set an international and multicentric survey (France, USA, the UK) based on a questionnaire addressed to junior and senior psychiatrists and examining the role of pre-reflective judgement, feelings and intentions in decision making in diagnosing schizophrenia (in 2017). In addition, we have examined the 50+ years of literature concerning the subject (in French, German and English).
Results: Preliminary results indicate that about half of the psychiatrists experience some sort of PF (the majority of senior and the minority of junior psychiatrists). We address the problem of validity in the absence of reliability and the notion of expertise in clinical diagnosis.
Conclusions: The PF is still used in clinical practice and phenomenology is important in understanding psychiatric judgement.
Purpose: The notion of PF, although quite popular in the classical nosography and psychopathology, gradually lost its clinical significance with the introduction of the operational criteria for diagnosis in the 1980's with the DSM-III. Our study aims to examine the relevance of this phenomenon for contemporary clinical practice.
Methodology: We have set an international and multicentric survey (France, USA, the UK) based on a questionnaire addressed to junior and senior psychiatrists and examining the role of pre-reflective judgement, feelings and intentions in decision making in diagnosing schizophrenia (in 2017). In addition, we have examined the 50+ years of literature concerning the subject (in French, German and English).
Results: Preliminary results indicate that about half of the psychiatrists experience some sort of PF (the majority of senior and the minority of junior psychiatrists). We address the problem of validity in the absence of reliability and the notion of expertise in clinical diagnosis.
Conclusions: The PF is still used in clinical practice and phenomenology is important in understanding psychiatric judgement.