The dominance of the medical-model in American psychiatry over the last 30 years has resulted in the subsequent decline of the “talking cure”. In this paper, we identify a number of problems associated with medicalized psychiatry, focusing primarily on how it conceptualizes the self as a de-contextualized set of symptoms. Drawing on the tradition of hermeneutic phenomenology, we argue that medicalized psychiatry invariably overlooks the fact that our identities, and the meanings and values that matter (...) to us, are created and constituted by our dialogical relations with others. While acknowledging the importance of medical and pharmaceutical interventions, we suggest that it is only by means of the dialogical interplay of the talking cure that the client can both recognize unhealthy and self-defeating ways of being and be opened up to the possibility of new meanings and self-interpretations. (shrink)

In this paper, my goal is to use an epistemic injustice framework to extend an existing normative analysis of over-medicalization to psychiatry and thus draw attention to overlooked injustices. Kaczmarek has developed a promising bioethical and pragmatic approach to over-medicalization, which consists of four guiding questions covering issues related to the harms and benefits of medicalization. In a nutshell, if we answer “yes” to all proposed questions, then it is a case of over-medicalization. Building on an epistemic injustice framework, (...) I will argue that Kaczmarek’s proposal lacks guidance concerning the procedures through which we are to answer the four questions, and I will import the conceptual resources of epistemic injustice to guide our thinking on these issues. This will lead me to defend more inclusive decision-making procedures regarding medicalization in the DSM. Kaczmarek’s account complemented with an epistemic injustice framework can help us achieve better forms of medicalization. I will then use a contested case of medicalization, the creation of Premenstrual Dysphoric Disorder in the DSM-5 to illustrate how the epistemic injustice framework can help to shed light on these issues and to show its relevance to distinguish good and bad forms of medicalization. (shrink)

Medicalization was the theme of the 29th European Conference on Philosophy of Medicine and Health Care that included a panel session on the DSM and mental health. Philosophical critiques of the medical model in psychiatry suffer from endemic assumptions that fail to acknowledge the real world challenges of psychiatric nosology. The descriptive model of classification of the DSM 3-5 serves a valid purpose in the absence of known etiologies for the majority of psychiatric conditions. However, a consequence of the (...) “atheoretical” approach of the DSM is rampant epistemological confusion, a shortcoming that can be ameliorated by importing perspectives from the work of Jaspers and McHugh. Finally, contemporary psychiatry’s over-reliance on neuroscience and pharmacotherapy has led to a reductionist agenda that is antagonistic to the inherently pluralistic nature of psychiatry. As a result, the field has suffered a loss of knowledge that may be difficult to recover. (shrink)

Machine generated contents note: -- Notes on Contributors -- Preface; R.Dallos -- Carving Nature at its Joints? DSM and the Medicalization of Everyday Life; M.Rapley, J.Moncrieff&J.Dillon -- Dualisms and the Myth of Mental Illness; P.Thomas&P.Bracken -- Making the World Go Away, and How Psychology and Psychiatry Benefit; M.Boyle -- Cultural Diversity and Racism: An Historical Perspective; S.Fernando -- The Social Context of Paranoia; D.J.Harper -- From 'Bad Character' to BPD: The Medicalization of 'Personality Disorder'; J.Bourne -- Medicalizing Masculinity; S.Timimi (...) -- Can Traumatic Events Traumatise People? Trauma, Madness and 'Psychosis'; L.Johnstone -- Children Who Witness Violence at Home; A.Vetere -- Discourses of Acceptance and Resistance: Speaking Out About Psychiatry; E.Speed -- The Personal Is the Political; J.Dillon -- 'I'm Just, You Know, Joe Bloggs': The Management of Parental Responsibility for First-Episode Psychosis; C.Coulter&M.Rapley -- The Myth of the Antidepressant: An Historical Analysis; J.Moncrieff -- Antidepressants and the Placebo Response; I.Kirsch -- Why Were Doctors so Slow to Recognise Antidepressant Discontinuation Problems?; D.Double -- Toxic Psychology; C.Newnes -- Psychotherapy: Illusion With No Future?; D.Smail -- The Psychologization of Torture; N.Patel -- What Is To Be Done?; J.Moncrieff, J.Dillon&M.Rapley -- Figure: Papers Using Term 'Antidepressant' On Medline 1957-1965 -- Index. (shrink)

In mental health policy, a central ethical dilemma concerns involuntary outpatient commitment (OPC), which aims to treat vulnerable individuals with serious mental illness who decline services. The first concern regards whether coercive services undermine the quality of clinical interactions within treatment, particularly as it relates to psychiatric medication use. The second concern is the unexamined role that OPC, and coercive psychiatric programs more broadly, play in the broader landscape of social welfare policy. To examine these concerns, the purpose of this (...) dissertation is to analyze how the management of psychiatric medications in involuntary outpatient services is undergirded by (a) provider and client interpretations of psychiatric medication effects and (b) moral discourses related to coercion and client autonomy. To achieve this aim, I examined data from a team-based ethnography that consisted of 1000 hours of participant observations and 56 semi-structured interviews with 20 clients, 21 providers, and 12 client family members with diverse backgrounds. I analyzed how medication compliance was discussed, monitored, and enforced in an involuntary outpatient program. My analysis demonstrates that medications were interpreted as a technology to control clinical symptoms (clinical control) though, particularly among clients, were also viewed as a method to control client mental experiences, behavioral expression, and autonomy (social control). Providers believed that medications were a necessary component of services (compulsory compliance) and could reduce client vulnerability to violence victimization and perpetration related to clinical symptoms (medicating vulnerability). To address client noncompliance, providers employed several strategies that I categorized as client manipulation. These strategies included providers, family members, and court officials strategizing ways to undermine client autonomy without clients’ knowledge (concealed collusion), deceiving clients into believing that medications were mandated when they were not (performing coercion), and minimizing the role of client consent and preferences in decision-making processes (circumventing consent). These findings demonstrate the pervasive role of manipulation to gain client medication compliance in OPC, which I named institutional coercion. They also highlight that the broader moral justifications for manipulating clients relate to their status as structurally vulnerable in their community settings and a growing relationship between the erosion of the welfare state and psychiatric coercion. (shrink)

The interface between religion, psychiatry, and ethics is often a locus for considerable controversy. This article focuses on the response of American psychiatry to religious nonconformism, and to religious conversion generally. At issue is the societal pressure against unpopular religious movements. The author argues for an ethic that conserves the freedom of religious conscience, and that guards against inquisitions in the guise of medical expertise and nosology.

Nonadherence to treatment continues to be one of psychiatry's greatest challenges. To improve adherence and thus improve the care of patients, clinicians and patients' family members sometimes resort to hiding medication in food or drink, a practice referred to as covert/ surreptitious medication. The practice of covert drug administration in food and beverages is well known in the treatment of psychiatrically ill world-wide but no prevalence rates exist. Covert medication may seem like a minor matter, but it touches on (...) legal and ethical issues of a patient's competence, autonomy, and insight. Medicating patients without their knowledge is not justifiable solely as a shortcut for institutions or families wishing to calm a troublesome patient and thus alleviate some of the burdens of care giving. The paramount principle is ensuring the well-being of a patient who lacks the competence to give informed consent. Ethically, covert/surreptitious administration can be seen as a breach of trust by the doctor or by family members who administer the drugs. Covert medication contravenes contemporary ethical practice. Legally, treatment without consent is permissible only where common law or statute provides such authority. The practice of covert administration of medication is not specifically covered in the mental health legislation in developing countries. Many of the current dilemmas in this area have come to public attention because of two important developments in medical ethics and the law - the increasing importance accorded to respect for autonomy and loss of the parens patriae jurisdiction of the courts [parens patriae means 'parent of the country'; it permitted a court to consent or refuse treatment on behalf of an 'incapacity', or alternatively to appoint a guardian with such powers]. (shrink)

Maxime F. Giguère Cet article propose une nouvelle stratégie pour écarter la conclusion sceptique, mise de l’avant par Thomas Szasz, selon laquelle la psychiatrie est illégitime. La conclusion sceptique repose sur une démarcation radicale entre troubles mentaux et somatiques. Afin de minimiser cette démarcation, Jerome Wakefield emploie une analyse conceptuelle stipulant que les troubles mentaux et somatiques sont tous les deux des dysfonctions préjudiciables. De récentes critiques ont toutefois montré que son analyse bute sur la difficulté pratique de distinguer les (...) fonctions normales des dysfonctions. En raison de ce problème, l’analyse de Wakefield ne permet pas d’écarter la conclusion sceptique. Une nouvelle stratégie ne nécessitant pas de résoudre le problème reconnu par ces critiques s’annonce alors préférable pour écarter la conclusion sceptique. (shrink)

Pozzi provides a thought-provoking account of how machine-learning clinical prediction models (such as Prediction Drug Monitoring Programmes (PDMPs)) may exacerbate testimonial injustice.1 In this response, I generalise Pozzi’s concerns about PDMPs to traditional models of clinical practice and question the claim that inaccurate clinicians are necessarily preferential to inaccurate machine-learning models. I then explore Pozzi’s concern that such models may deprive patients of a right to ‘convey information’. I suggest that machine-learning tools may be used to enhance, rather than frustrate, (...) this right, through the perspective of hermeneutical justice. Pozzi objects to the introduction of machine-learning risk prediction tools in clinical care, due to their being ‘epistemically opaque’, often inaccurate, and a threat to patients’ testimonial justice. Through the example of psychiatry, I suggest this stance idealises traditional models of clinical practice. I propose that clinicians’ judgements are often equally vulnerable to opaque subjectivity, bias and epistemic injustice. For instance, the use of clinical observation or collateral interviewing might be conceptualised as a threat to testimonial justice, by neglecting patients’ own perspectives or voices. In practice, clinical risk prediction often follows inconsistent and somewhat subjective clinical heuristics, which are difficult to summarise or evaluate. Further, although Pozzi diminishes machine-learning …. (shrink)

In psychiatry there is no sharp boundary between the normal and the pathological. Although clear cases abound, it is often indeterminate whether a particular condition does or does not qualify as a mental disorder. For example, definitions of ‘subthreshold disorders’ and of the ‘prodromal stages’ of diseases are notoriously contentious. -/- Philosophers and linguists call concepts that lack sharp boundaries, and thus admit of borderline cases, ‘vague’. Although blurred boundaries between the normal and the pathological are a recurrent theme (...) in many publications concerned with the classification of mental disorders, systematic approaches that take into account philosophical reflections on vagueness are rare. This book provides interdisciplinary discussions about vagueness in psychiatry by bringing together scholars from psychiatry, psychology, philosophy, history, and law. It draws together various lines of inquiry into the nature of gradations between mental health and disease and discusses the individual and societal consequences of dealing with blurred boundaries in medical practice, forensic psychiatry, and beyond. -/- Part I starts with an overview chapter that helps readers to navigate through the philosophy of vagueness and through the various debates surrounding demarcation problems in the classification and diagnosis of mental illness. Part II encompasses historical and recent philosophical positions on gradualist approaches to health and disease. Part III approaches the vagueness of present psychiatric classification systems, and the debates concerning their revisions by scrutinizing controversial categories, such as posttraumatic stress disorder, and the difficulties of day-to-day diagnostic and therapeutic practice. Part IV finally focuses on social, moral, and legal implications that arise when being mentally ill is a matter of degree. (shrink)

_Disaster Psychiatry: Intervening When Nightmares Come True_ captures the state of disaster psychiatry in the aftermath of the terrorist attacks of September 11, 2001. This emergent psychiatric specialty, which is increasingly separated from trauma and grief psychiatry on one hand and military psychiatry on the other, provides psychotherapeutic assistance to victims during, and in the weeks and months following, major disasters. As such, disaster psychiatrists must operate in the widely varying locales in which natural and man-made (...) disasters occur, and they must establish their role among the chaotic array of organizations involved in direct disaster response. Editors Anand Pandya and Craig Katz have captured the challenge and promise of disaster psychiatry through first-person narratives. We hear from psychiatrists who have encountered disasters at various stages of their career and in widely varying social, political, and personal contexts. Accounts of psychiatric involvement with adults and children during and after 9/11 have understandable pride of place in this collection. But they are balanced by richly informative narratives about other domestic and international disasters. Fraught with the drama attendant to the events they describe, these essays delineate the dizzying array of challenges that confront the disaster psychiatrist. They range from the intense emotional responses that are part of the aftermath of any disaster, to the need to legitimize a psychiatric presence within diverse cultural and medical contexts, to the subtle task of providing therapeutic boundaries at a time when all rules seem to be suspended. Special attention is given to the daunting task of working with children whose parents' are disaster victims. What emerges from these testimonies is compelling documentation of skilled and compassionate psychiatrists at the outer limits of their specialty, pursuing their calling into uncharted realms of therapeutic engagement. (shrink)

Psychiatry is becoming a cognitive neuroscience. This new paradigm not only aims to give new ways for explaining mental diseases by naturalizing them, but also to have an influence on different levels of psychiatric norms. We tried here to verify whether a biological paradigm is able to fulfill this normative goal. We analyzed three main normative assumptions that is to say the will of giving psychiatry a valid nosology, a rigorous definition of what is a mental disease, and (...) new tools for destigmatizing mentally ill patients. Although these different kinds of normativity are very heterogeneous, we must conclude that, in all these cases, biological psychiatry is a failure, in part because of a lack of epistemological conceptualization. (shrink)

Machine generated contents note: -- Clinical Theory -- 1. Psychiatry on schizophrenia: clinical pictures of a sublime object -- 2. Schizophrenia: the sublime text of psychoanalysis -- Cultural Theory -- 3. Antipsychiatry: schizophrenic experience and the sublime -- 4. Anti-Oedipus and the politics of the schizophrenic sublime -- 5. Schizophrenia, modernity, postmodernity -- 6. Postmodern schizophrenia -- 7. Glamorama, postmodernity and the schizophrenic sublime -- Conclusion.

The target article shows that the application of the evolutionary theory to psychopathology should not necessarily consist in finding hidden adaptive benefits for each psychiatric syndrome. However, in rejecting lax adaptationism, Darwinian psychiatrists should not forget that the search for adaptive behavioral polymorphisms can be a powerful antidote against the normative attitude of mainstream psychiatry and its growing tendency to medicalize human diversity. (Published Online November 9 2006).

The authors describe the arrival and treatment of 164 severe chronic psychiatric patients who were displaced from the Serbian army-controlled Jakes psychiatric hospital and off-loaded on the afternoon of 28th of May, 1992 at the gates of the Psychiatry Clinic in Tuzla. Through analysis of their incomplete medical records, which arrived with the patients in Tuzla, and analysis of their activities during and after the war, they found that 83 of the patients (50%) were males and 147 (89.6%) were (...) admitted to the Psychiatry Clinic in Tuzla. Of the patients, 86 (58.5%) were found to be Serbs. The majority of them were incapable of independent living and required ongoing medical and social care. They were from all regions of Bosnia-Herzegovina, 81.6% had schizophrenia and 70 (47.6%) were over 50 years of age. For its humanitarian work, its contribution to peace and for the maintenance of the multi-ethnic Bosnia-Herzegovina, the Psychiatry Clinic in Tuzla received the Golden Award for Peace from the International Legion of Humanists in May 1998. (shrink)

Evidence-based medicine (EBM) made its first appearance in the medical lexicon in 1990 and since then has enjoyed widespread support from within the medical profession, including among psychiatrists. Proponents of evidence-based psychiatry (EBP) point to its ability to demonstrate the efficacy of various psychiatric treatments, promising improved mental health outcomes and more efficient use of healthcare resources as a result. Policymakers and insurers have embraced EBP in hopes that these goals will be realized. However, the question of whether EBM (...) is even applicable to psychiatry remains largely unaddressed, even though it is an urgent one, given the various corporate, professional, and governmental pressures .. (shrink)

Substantially revised to include a wealth of new material, the second edition of this highly acclaimed work provides a concise, coherent introduction that brings structure to an increasingly fragmented and amorphous discipline. Paul R. McHugh and Phillip R. Slavney offer an approach that emphasizes psychiatry's unifying concepts while accommodating its diversity. Recognizing that there may never be a single, all-encompassing theory, the book distills psychiatric practice into four explanatory methods: diseases, dimensions of personality, goal-directed behaviors, and life stories. These (...) perspectives, argue the authors, underlie the principles and practice of all psychiatry. With an understanding of these fundamental methods, readers will be equipped to organize and evaluate psychiatric information and to develop a confident approach to practice and research. Praise for the original edition: "This brilliant book illuminates psychiatry more clearly than any other work I know.... This is the best (and the shortest) single volume on psychiatry that anyone could read."-- New England Journal of Medicine "Every psychiatry department, regardless of ideology, should build a course around this... work. Open-mindedness might become fashionable."-- Journal of Clinical Psychiatry "An elegantly reasoned and eloquently written book that enriches our understanding of clinical events.... [It provides] an opportunity to open our eyes to new possibilities."-- Hospital and Community Psychiatry. (shrink)

Coercion in the treatment of persons suffering from mental disorders is one of the major ethical controversies in psychiatry. Despite great efforts to reduce the use of coercive interventions, they are still widespread and differ between European countries regarding the specific type of intervention and the number of patients affected. It is common to justify measures against the present will of patients under the assumption that they promote their well-being, that is, by reference to the ethical principal of beneficence. (...) However, it is indisputable that such measures can also cause severe harm to the patients concerned and that these measures are often experienced as degrading. In which situations can coercive interventions be labeled justifiably as “beneficial”? How can they be reduced to a minimum? This volume addresses these issues from an interdisciplinary and international perspective, combining contributions from, among others, medical ethicists, philosophers, legal scholars, psychologists and psychiatrists from different European countries. Theoretical and conceptual essays are complemented by contributions with a strong relationship to clinical practice. (shrink)

Contemporary psychiatry maintains the myth that it is value neutral by appeal to modern medical science for both its diagnostic categories and its therapeutic interventions, leaving the impression that it relies on reason—that is to say, reason divorced from tradition—to master human nature. Such a practice has a certain way of characterizing and defining humanity's lapses from acceptable human behavior—a lapse from human being. The modern practice of psychiatry applies a particular notion (largely influenced by Enlightenment ideals) of (...) scientific instrumentation to the human person in order to diagnose the ailment and manufacture a corresponding treatment in keeping with a hidden conception of human biological flourishing. This covert vision is an impoverished (and possibly dangerous) one. As much as the practice of psychiatry is constrained by the goals of the dominant moral tradition of our day, it becomes a tool (or technique) for achieving the transient and partial ends of modern individualism. Given this truncated view of human nature and human end, modern psychiatry fails to attend comprehensively to the unity of a life, missing altogether the essential relevance of character formation, and thereby forfeiting excellence in human flourishing. (shrink)

Background Medical boards and fitness-to-practice committees aim to ensure that medical students and physicians have “good moral character” and are not impaired in their practice of medicine. Method Presented here is an ethical analysis of stalking behavior by physicians and medical students, with focus on the case of Teleka Patrick, MD (a psychiatry resident practicing medicine while under a restraining order due to her alleged stalking behavior). Conclusions While a restraining order is not generally considered a criminal conviction, stalking (...) behavior is clearly unprofessional and a marker of inappropriate character and fitness, yet the reporting obligations for such matters are complex. Medical schools and training programs that fail to assess, record, and report matters of moral conduct such as this potentially allow impaired students to graduate and enter the work force (unless a robust licensing process identifies them). Patrick’s case should be a wake-up call for medical schools and medical boards to better integrate the professionalism domain into their operations. Further, the professionalism of students and doctors need to be integrated into the legal domain, so that those who are unfit to practice are, in fact, prevented from doing so. Guidance for integration is provided. (shrink)

This issue of the Hastings Center Report includes a special report that comes out of a three-year Hastings Center research project on controversies surrounding the diagnosis and treatment of mental disorders in children. Over the last couple of decades, the number of children diagnosed with mental disorders has risen significantly, and so, too, has the number of children prescribed medications. Some critics have accused psychiatry of overdiagnosis—of sometimes diagnosing children with psychiatric disorders when their behavior is actually within the (...) range of normal. This controversy led Erik Parens and Josie Johnston, authors of the report and the Hastings Center investigators in this project, to ask what a .. (shrink)

Background This study used a scenario- and discussion-based approach to teach preclinical medical students the socio-philosophical aspects of psychiatry and qualitatively evaluated the learning outcomes in a medical humanities course in Taiwan. Methods The seminar session focused on three hypothetical psychiatry cases. Students discussed the cases in groups and were guided by facilitators from multiple disciplines and professions. At the end of the semester, students submitted a narrative report comprising their reflections on the cases and discussions. The authors (...) utilized content analysis to categorize students’ narratives into three facets, namely, the philosophical, social and individual. Results In total 163 preclinical medical students participated in the class; 150 of them mentioned the scenario-based lesson in their reports; 33.3% of these reports discussed the case at the philosophical dimension (n = 50), 45.3% at the social dimension (n = 68), and 26.6% at the individual dimension (n = 40). Four major themes emerged: (1) a psychiatric diagnosis has far-reaching consequences for an individual’s life, (2) the social structure affects how patients experience psychiatric disorders, (3) students related personal experience or those of friends and family to understand psychiatric disorders, and (4) medical humanities are of particular importance in psychiatric education. Conclusions This study demonstrated that the scenario-based discussions led by a multidisciplinary team of facilitators can benefit medical students with limited clinical experience to contemplate the socio-philosophical aspects of psychiatry. The authors suggest that this pedagogical model during preclinical education should be encouraged. (shrink)

Pt. 1. The context -- pt. 2. Principles of ethics in psychiatry -- pt. 3. The applications of the ethical principles in psychiatric practice and research -- pt. 4. Non-medical uses of psychiatry -- pt. 5. Teaching ethics in psychiatry -- pt. 6. Conclusions and summary.

This multidisciplinary collection explores three key concepts underpinning psychiatry -- explanation, phenomenology, and nosology -- and their continuing relevance in an age of neuroimaging and genetic analysis. An introduction by Kenneth S. Kendler lays out the philosophical grounding of psychiatric practice. The first section addresses the concept of explanation, from the difficulties in describing complex behavior to the categorization of psychological and biological causality. In the second section, contributors discuss experience, including the complex and vexing issue of how self-agency (...) and free will affect mental health. The third and final section examines the organizational difficulties in psychiatric nosology and the instability of the existing diagnostic system. Each chapter has both an introduction by the editors and a concluding comment by another of the book's contributors. Contributors: John Campbell, Ph.D.; Thomas Fuchs, M.D., Ph.D.; Shaun Gallagher, Ph.D.; Kenneth S. Kendler, M.D.; Sandra D. Mitchell, Ph.D.; Dominic P. Murphy, Ph.D.; Josef Parnas, M.D., Dr.Med.Sci.; Louis A. Sass, Ph.D.; Kenneth F. Schaffner, M.D., Ph.D.; James F. Woodward, Ph.D.; Peter Zachar, Ph.D. (shrink)

Background: In psychiatry, the issue of providing palliative and end-of-life care for what would be a “terminal psychiatric condition” or considering a palliative approach to severe and persistent mental health problems is still a taboo. Methodology: This question is addressed through an analysis of a case arising during a clinical ethics consultation, using Hubert Doucet’s scenario method. It is about Mrs. Sanchez, a patient over 90 years of age with a psychiatric profile, expressing the desire to die by suicidal (...) gestures, refusing the proposed treatments, and refusing as well to drink and eat. Her clinical history is told through the filter of reflexive support offered in clinical ethics to the various stakeholders. Results: The case analysis, far from responding to the challenges posed by the concept of palliative and end-of-life care in a psychiatric context, nevertheless presents an opportunity to name its main ethical issues: psychic suffering, refusal to eat and drinking as well as refusal of treatment, palliative sedation and medical assistance in dying, wishes and advanced medical directives and clinical-organizational challenges for geriatric psychiatry clients. Conclusion: There are still many challenges for professionals and decision-makers to meet the needs of older mental health clients. We call for further development of knowledge on this specific topic. (shrink)

Medicalization in contemporary psychopharmacology is increasingly dominated by commercial interests that threaten the scientific and ethical integrity of psychiatry. At the same time, the proliferation of new social media has altered the manner in which the social groups and institutions that have stakes in medicalization interact. Consumers are at once more powerful than ever before, but also more vulnerable. The upshot of all these developments is that medicalization is no longer simply the professed enemy of anti-psychiatry and its (...) supporters. It is now also an enemy of psychiatry. Once a welcome ally of psychiatry, medicalization appears to have turned into a fearsome enemy. (shrink)

For political reasons, the social control functions of psychiatry are not openly recognized as such but are disguised as benevolent medical treatment. The roots of this disguise may be traced to the political revolutions in which the rule of man was replaced by the rule of law. This transformation generated a conflict between the desire for freedom under law and the desire for a greater degree of social control than is provided by law. Involuntary mental hospitalization is the neurotic (...) resolution of this conflict by society. The social control functions of psychiatry are disguised and justified by the medical model which describes the moral action of both psychiatrist and patient in the ostensibly value neutral language of science and medicine. The cost of this disguise is great. It negates individuals as moral agents and obscures the moral nature of the problems that psychiatrists seek to understand which, in turn, handicaps them in helping the persons they seek to assist. The task of the philosopher in this situation is honestly and critically to analyze and evaluate psychiatric language, psychiatric practices and the moral issues involved. (shrink)

ABSTRACTThe authors describe the arrival and treatment of 164 severe chronic psychiatric patients who were displaced from the Serbian army‐controlled Jakes psychiatric hospital and off‐loaded on the afternoon of 28th of May, 1992 at the gates of the Psychiatry Clinic in Tuzla.Through analysis of their incomplete medical records, which arrived with the patients in Tuzla, and analysis of their activities during and after the war, they found that 83 of the patients were males and 147 were admitted to the (...) Psychiatry Clinic in Tuzla. Of the patients, 86 were found to be Serbs. The majority of them were incapable of independent living and required ongoing medical and social care. They were from all regions of Bosnia‐Herzegovina, 81.6% had schizophrenia and 70 were over 50 years of age.For its humanitarian work, its contribution to peace and for the maintenance of the multi‐ethnic Bosnia‐Herzegovina, the Psychiatry Clinic in Tuzla received the Golden Award for Peace from the International Legion of Humanists in May 1998. (shrink)

Psychiatry, as a subspecialty of medicine, is a quintessentially modernist project. Yet across the main campus, throughout the humanities and social sciences, there is increasing postmodern consensus that modernism is a deeply flawed project. Psychiatry, the closest of the medical specialties to the humanities and social sciences, will be the first to encounter postmodern theory. From my reading, psychiatry, though likely defensive at first, will eventually emerge from a postmodern critique, not only intact, but rejuvenated. Postmodern theory, (...) at its best, provides a liberating effect on modernist practices, freeing them from an enslavement to Method and Objectivity in order to allow the more human (all charges of antihumanism not withstanding) to emerge as valued and respected. The net result could be the evolution of a new postmodern psychiatry and a new model of medicine which would be much more enjoyable to practice and much more connected to the concerns of patients. (shrink)

Essential Philosophy of Psychiatry is a concise introduction to the growing field of philosophy of psychiatry. Divided into three main aspects of psychiatric clinical judgement, values, meanings and facts, it examines the key debates about mental health care, and the philosophical ideas and tools needed to assess those debates, in six chapters. In addition to outlining the state of play, Essential Philosophy of Psychiatry presents a coherent and unified approach across the different debates, characterized by a rejection (...) of reductionism and an emphasis on the ineliminability of uncodified skilled judgement. The first part, Values, outlines the debate about whether diagnosis of mental illness is essentially value-laden and argues that the prospects for reducing illness or disease to plainly factual matters are poor. It also explains the important role of skilled contextual judgement, rather than a principles-based deduction, in ethical judgement. The second part, Meanings, examines the central role of understanding and a shared first person perspective, both against attempts to reduce meaning to basic information-processing mechanisms and to explain away the difficulties of understanding psychopathology in recent models of delusion. The third part, Facts, shows the importance of uncodified clinical judgements, both in assessing the validity of psychiatric taxonomy and in the application of Evidence Based Medicine. Despite advances in the codifaction of practice and operationalism of diagnosis, an element of judgement remains in the assessment both of what, at one level, is good evidence for diagnosis and treatment and what, at a higher level, is good evidence for the validity of classification overall. (shrink)

The specificities of mental health care combined with the contemporary context of health care make ethical issues particularly salient in psychiatry. Thus, residents in training in this medical discipline may be particularly exposed to difficult situations involving an ethical dilemma, which can be a cause of distress and moral suffering. Future physicians are equipped with knowledge and skills that should enable them to address the ethical issues inherent to clinical practice, as teaching of this discipline is now a requirement (...) for accreditation of residency training programs in Canada. However, many questions remain about the design of a valid and effective clinical ethics education for these young practitioners. In this essay, we attempt to sketch out possible answers to this wide range of questions, based on our experience as residents. After having examined some of the specificities of the ethics curriculum which we benefited from the psychiatry residency program at the University of Sherbrooke, we analyze how its structure can be a good example for ethics training of other young professionals, that is, residents. More specifically, we highlight how creating a space to acknowledge the suffering of the care giver in-training can have an impact on their own sensitivity to the suffering of the patient who they are treating. (shrink)

Medicalisation is a social phenomenon in which conditions that were once under legal, religious, personal or other jurisdictions are brought into the domain of medical authority. Low sexual desire in females has been medicalised, pathologised as a disease, and intervened upon with a range of pharmaceuticals. There are two polarised positions on the medicalisation of low female sexual desire: I call these the mainstream view and the critical view. I assess the central arguments for both positions. Dividing the two positions (...) are opposing models of the aetiology of low female sexual desire. I conclude by suggesting that the balance of arguments supports a modest defence of the critical view regarding the medicalisation of low female sexual desire. (shrink)

From the perspective of values-based practice, there is much of interest in Lorenzo Gilardi and Giovanni Stanghellini's "I am a Schizophrenic." Their dialogue exhibits many of the key elements of VBP, it exemplifies the particular challenges presented by VBP in mental health, it illustrates the power of phenomenology in meeting these challenges, and it points by extension to an insight into contemporary psychiatry's professional identity as a medical profession.VBP is a resource for working with values—with what matters or is (...) important to those concerned—in healthcare. Avoiding preset answers, it offers instead a process that supports those concerned in a given situation... (shrink)

Psychiatric involvement in patient morality is controversial. If psychiatrists are tasked with shaping patient morality, the coercive potential of psychiatry is increased, treatment may be unfairly administered on the basis of patients’ moral beliefs rather than medical need, moral disputes could damage the therapeutic relationship and, in any case, we are often uncertain or conflicted about what is morally right. Yet, there is also a strong case for the view that psychiatry often works through improving patient morality and, (...) therefore, should aim to do so. Our goal is to offer a practical and ethical path through this conflict. We argue that the default psychiatric approach to patient morality should be procedural, whereby patients are helped to express their own moral beliefs. Such a procedural approach avoids the brunt of objections to psychiatric involvement in patient morality. However, in a small subset of cases where patients’ moral beliefs are sufficiently distorted or underdeveloped, we claim that psychiatrists should move to a substantive approach and shape thecontentof those beliefs when they are relevant to psychiatric outcomes. The substantive approach is prone to the above objections but we argue it is nevertheless justified in this subset of cases. (shrink)

A common theme in the contemporary medical model of psychiatry is that pathophysiological processes are centrally involved in the explanation, evaluation, and treatment of mental illnesses. Implied in this perspective is that clinical descriptors of these pathophysiological processes are sufficient to distinguish underlying etiologies. Psychiatric classification requires differentiation between what counts as normality (i.e.- order), and what counts as abnormality (i.e.- disorder). The distinction(s) between normality and pathology entail assumptions that are often deeply presupposed, manifesting themselves in statements about (...) what mental disorders are. (shrink)

As a discipline, psychiatry is in the process of finding the right set of concepts to organize research and guide treatment. Dissatisfaction with the status quo as expressed in standard manuals has animated a number of computational paradigms, each proposing to rectify the received concept of mental disorder. We explore how different computational paradigms: normative modeling, network theory and learning-theoretic approaches like reinforcement learning and active inference, reconceptualize mental disorders. Although each paradigm borrows heavily from machine learning, they differ (...) significantly in their methodology, their preferred level of description, the role they assign to the environment and, especially, the degree to which they aim to assimilate psychiatric disorders to a standard medical disease model. By imagining how these paradigms might evolve, we bring into focus three rather different visions for the future of psychiatric research. Although machine learning plays a crucial role in the articulation of these paradigms, it is clear that we are far from automating the process of conceptual revision. The leading role continues to be played by the theoretical, metaphysical and methodological commitments of the competing paradigms. (shrink)