This paper focuses on one of the original moments of the development of the “phenomenological” current of psychiatry, namely, the psychopathological research of Ludwig Binswanger. By means of the clinical and conceptual problem of schizophrenia as it was conceived and developed at the beginning of the twentieth century, I will try to outline and analyze Binswanger’s perspective from a both historical and epistemological point of view. Binswanger’s own way means of approaching and conceiving schizophrenia within the scientific, medical, and (...) class='Hi'>psychiatric context of that time will lead us to grasp the epistemological stakes at the origins of his project of reforming psychiatry by means of phenomenology. I will finally attempt to upgrade and update Binswanger’s project in light of the current reappraisal of phenomenology within the ongoing debate on psychopathology engaged by studies in the field of science and philosophy of mind. (shrink)

This paper examines the planning process and architecture of two public psychiatric institutions built around 1900 in Trieste and Lower Austria. From 1864, the building of new asylums was the responsibility of Crown land governments, which by the end of the nineteenth century had emerged as sites of power and self-presentation by minority groups and new political parties. At the same time, the area of asylum planning was establishing itself as a branch of asylum psychiatry and promoting the idea (...) of the asylum as model settlement, contributing to social reform. I analyse the interaction of psychiatrists, architects and government officials involved in planning the two institutions in the context of Crown land governments’ self-positioning within the empire and internationally . The Trieste asylum planners were working for a government controlled by Italian nationalists, but their desire for a ‘modern’ asylum turned them towards German models. The Christian Social government in Lower Austria sought to supplant Germany as the leader in this branch of science. The spatial arrangement and visual articulation of the two asylums is interpreted in the context of the interaction of psychiatry and the politics of regional autonomy. (shrink)

This paper provides an interpretation, based on the social systems theory of German sociologist Niklas Luhmann, of the recent paradigmatic shift of mental health care from an asylum-based model to a community-oriented network of services. The observed shift is described as the development of psychiatry as a function system of modern society and whose operative goal has moved from the medical and social management of a lower and marginalized group to the specialized medical and psychological care of the whole population. (...) From this theoretical viewpoint, the wider deployment of the modern social order as a functionally differentiated system may be considered to be a consistent driving force for this process; it has made asylum psychiatry overly incompatible with prevailing social values (particularly with the normative and regulative principle of inclusion of all individuals in the different functional spheres of society and with the common patterns of participation in modern function systems) and has, in turn, required the availability of psychiatric care for a growing number of individuals. After presenting this account, some major challenges for the future of mental health care provision, such as the overburdening of services or the overt exclusion of a significant group of potential users, are identified and briefly discussed. (shrink)

Last year marks the first year of implementation for both the Patient Protection and Affordable Care Act and the Mental Health Parity and Addiction Equity Act in the United States. As a result, healthcare reform is moving in the direction of integrating care for physical and mental illness, nudging clinicians to consider medical and psychiatric comorbidity as the expectation rather than the exception. Understanding the intersections of physical and mental illness with autonomy and self-determination in a system realigning (...) its values so fundamentally therefore becomes a top priority for clinicians. Yet Bioethics has missed opportunities to help guide clinicians through one of medicine's most ethically rich and challenging fields. Bioethics' distancing from mental illness is perhaps best explained by two overarching themes: 1) An intrinsic opposition between approaches to personhood rooted in Bioethics' early efforts to protect the competent individual from abuses in the research setting; and 2) Structural forces, such as deinstitutionalization, the Patient Rights Movement, and managed care. These two themes help explain Bioethics' relationship to mental health ethics and may also guide opportunities for rapprochement. The potential role for Bioethics may have the greatest implications for international human rights if bioethicists can re-energize an understanding of autonomy as not only free from abusive intrusions but also with rights to treatment and other fundamental necessities for restoring freedom of choice and self-determination. Bioethics thus has a great opportunity amid healthcare reform to strengthen the important role of the virtuous and humanistic care provider. (shrink)

Despite three major reform movements over the last 300 years, the mental health system has been remarkably resistant to change. Today, another period of reform is underway, only this time, new players - dissatisfied ex-psychiatric patients - are organizing to affect the process of change. This paper discusses characteristics of previous movements and examines their similarity to and difference from the present consumer and psychiatric survivor movement. It appears that the new participants have shaped the rhetoric (...) of reform but it remains to be seen if they can affect the reality. (shrink)

The rules governing recovery for negligently inflicted psychiatric injury are among the most criticized of all of tort law. However, one area which, to date, has escaped with a minimum of judicial or academic scrutiny concerns the very threshold requirement for these actions: proof of a ‘recognized psychiatric illness’. This article critiques that longstanding requirement of English law from two perspectives. First, it is argued that the international classifications of psychiatric disorders (ICD-10 and DSM-IV) are being misapplied (...) and misconstrued in the English medico-legal context and that the role (and limitations) of these classifications are worthy of far greater judicial examination and critical scrutiny than has typically been the case to date. Secondly, it is contended that the insistence upon a recognized psychiatric illness, as a threshold requirement, is giving rise to inconsistencies and distortions in the law and that the requirement is neither legally nor medically supportable in the modern era. Instead, it is argued that the stage has been reached whereby something lesser than a recognized psychiatric illness should be sufficient to trigger a compensable injury in law. The article concludes by suggesting various legal avenues by which to feasibly and robustly ‘ring-fence’ the number of potential claims in negligence, should the reform-oriented approach of this article be adopted. (shrink)

This article offers a comprehensive critical review of the most popular theoretical accounts on the recent processes of deinstitutionalization and reform of mental health services and their possible underlying factors, focusing in the sharp contrast between the straightforward ideas and models maintained by mainstream psychiatry and the different interpretations delivered by authors coming from the social sciences or applying conceptual tools stemming from diverse social theories. Since all these appraisals tend to illuminate only some aspects of the process while (...) obscuring others, or do not fit at all with some important points of the actual changes, it is concluded that the quest for an adequate explanation is far from having been completed. Finally, some methodological and conceptual strategies for a renewed theoretical understanding of these significant transformations are also briefly discussed, including a comprehensive empirical evaluation of the facts, the consideration of the shifting social values and needs involved in mental health care provision and the historical analysis of deinstitutionalization policies within the framework of the broader social and cultural trends of the decades following World War II. (shrink)

The paper examines the roles of manager and therapist as formed by an emotivist culture, by a recognition of tragedy, and by a Christian narrative. The Christian story provides resources to resist an emotivist culture, to cope with tragedy, and to reform the roles of manager and therapist. The context for the examination is provided by reflection about the development of a mission statement for Pine Rest Christian Hospital.

The approach to managing the involuntary detention of people suffering from psychiatric conditions can be divided into those with clinicians at the forefront of decision-making and those who rely heavily on the judiciary. The system in England and Wales takes a clinical approach where doctors have widespread powers to detain and treat patients involuntarily. A protection in this system is the right of the individual to challenge a decision to deprive them of their liberty or treat them against their (...) will. This protection is provided by the First-tier Tribunal; however, the number of successful appeals is low. In this paper, the system of appeal in England and Wales is outlined. This is followed by a discussion of why so few patients successfully appeal their detention with the conclusion that the current system is flawed. A number of recommendations about how the system might be reformed are offered. (shrink)

This article argues in favor of modifying the medical model of severe psychiatric disturbances that underlies calling them "mental illness." The key reason for this proposal is that numerous specialists other than physicians as well as non-specialists contribute to the process of assisting a person recover from what the author suggests might better be called "extraordinary functional disability." There is little uniformity in existing definitions under state laws, but all involve three types of intervention: civil commitment; civil determination of (...) legal competency; and standing to be subject to criminal law. Physicians typically make relevant determinations in each of these areas; but non-physicians are the principal care-givers once a determination has been made. (shrink)

Megan1 is a young teenage patient who suffered a stillbirth at 28 weeks, leading to a year long police investigation dropped only after postmortem tests found that her pregnancy was lost due to natural causes. The stress of the investigation and her isolation from friends and support network following the seizure of her mobile and laptop compounded the trauma of the stillbirth, leaving her requiring emergency psychiatric care. Aisha1 is a vulnerable patient who suffered a premature delivery, having experienced (...) similar problems in earlier pregnancies. Things happened so quickly that Aisha delivered on her own at home, only then seeking medical care. She told hospital staff that earlier in her pregnancy she had considered an abortion. As a result, she found herself interviewed under police caution and was required to surrender her phone and tablet, limiting access to friend and family support just when most needed. Aisha was denied unsupervised access to her baby in the intensive care unit, needing to hand over expressed breast milk to a receptionist. These stories, which were reported in a recent meeting in Parliament,1 are sadly far from unusual. They reflect the collateral damage of a growing trend towards more enthusiastic enforcement of the archaic abortion laws of England and Wales.2–5 In such cases, women who present with miscarriage, stillbirth or a premature delivery have aroused the suspicion of health professionals, sometimes because—like Aisha—they speak honestly about having considered abortion earlier in their pregnancies. They then find themselves reported to the police, required to surrender electronic devices and sometimes advised by duty solicitors to speak to no one about events leading to their investigation, thus being denied emotional and full clinical support at a time of significant trauma. These women are not the only victims of British abortion laws: so …. (shrink)

The main objective of this work is to understand the daily practices of user management in post-reformist devices in the Brazilian mental health field. Through Foucault's genealogical work on government practices, understood as forms of conducting the behavior of others, it is possible to open a possible field for the study of the practices of psi knowledge, considering them as forms of management that act by through the free and natural acts of individuals. More specifically, our goal is to examine (...) day-to-day practices on some reformist devices such as CAPS through user files. Basically, two driving models have been found in the new devices: 1) Cases with frank intervention of production of commitments and agreements with users, seeking the entry of this to varied activities and political leadership ; 2) Cases with little response from the user, in which the forms of conduction are implemented by policies of inclusion of family members and close reference characters in the management of the patient's life. (shrink)

This paper offers a panoramic assessment of the significant changes experienced by psychiatric care in Western Europe and North America in the course of the last decades of deinstitutionalization and reform. Drawing on different comparative studies and an own review of relevant data and reports, the main transformations in the mental health field are analyzed around seven major topics: the expanding scope of psychiatry; the decline and metamorphosis of the asylum; the introduction of alternative and diversified forms of (...) care; the new challenges posed by chronic mental illness; the emergence of modern psychopharmacology; the deployment of subspecialization; and the new forms of coercion implemented with community mental health practices. Following a renewed diagnosis on the essential features of the reformed mental health systems based on the pattern of social inclusion inherent to the new devices and philosophies of care, some major challenges for the future such as the overburdening of services or the overt exclusion of a significant part of potential users are also identified and briefly discussed. (shrink)

Individual and institutional memories tend to form hegemonic narratives that serve to create identity and meaning. If history is written by experts and not by professional historians, historical retrospectives and narratives are usually written by leading figures in a particular field. They try to use their idea of exclusive knowledge about certain events, backgrounds and motivations to shape these narratives. In order to question such narratives, a critical analysis of scientific memory and its cultural significance is required. This article reflects (...) on the methodological challenges of oral history projects in medicine, using a project on psychiatric reform in the Federal Republic of Germany as an example. In particular, the interviewees’ claim to interpretatively dominate the marginalised co-actors is examined. (shrink)

Drawing on a historical ethnography of how Brazil’s post-dictatorial psychiatric reforms have shaped young people’s lives, this paper builds on Eve Sedgwick’s analysis of the hermeneutics of suspicion to show that narrow applications of Foucault’s biopower concept nurture forms of resistance to bio-reductionism centred primarily on epistemic deconstruction. To unsettle this hermeneutic, I put young people’s theories of power into conversation with Georges Canguilhem’s concept of the milieu and with feminist scholars’ work on prefigurative politics. I introduce the concepts (...) of threading and unthreading to consider how one subject of biopower, the child-like biobehavioural figure, was continuously being threaded within a specific milieu and in relation to another key figure: the elite angst-ridden ‘storm-and-stress’ adolescent. Young people’s subsequent unthreading and reweaving politics, flourishing in co-construction with what I call the politicizing clinic, illustrate how decolonial pedagogies can incrementally change the patterning of social life. (shrink)

Analisa-se a articulação entre a proposição de políticas públicas de saúde mental e as estratégias para a reorientação do modelo assistencial em saúde mental a partir dos movimentos pela Reforma Psiquiátrica brasileira. Parte-se da perspectiva genealógica de Michel Foucault, o que implica descrever ..

Apresenta-se, de forma sintética, o pensamento de Basaglia e sua influência na conceituação da Reforma Psiquiátrica Brasileira, como objetivo de adentrar o campo das políticas públicas de saúde mental. Com base na Teoria dos Quatro Discursos de Lacan, apontam-se as limitações da Reforma Psiquiátrica..

An in-depth reform of the asylum system took place in Great Britain from the 1830s onwards, under the influence of Dr John Conolly, who succeeded in imposing a new model at Hanwell pauper lunatic asylum, near London, a model that was more respectful of the patients and based on the abandonment of mechanical restraint (non-restraint) combined with occupational therapy. The success of this system at Hanwell, the largest asylum in the country with over a thousand inmates, contributed to the (...) spread of what became a form of psychiatric orthodoxy for the next thirty years. Far from being a strictly medical measure, this reform was anchored in a general reform of poor relief. In this respect, it was in line with the Poor Law of 1834 (inspired by Jeremy Bentham, notably under the aegis of Edwin Chadwick, secretary of the Poor Law Commission). This reform was also part of a more political reflection on the extension of civil and social rights for the working classes, in particular under the... (shrink)

ABSTRACTThis article engages Bhaskar's category of absence and Foucault's notion of problematization in the context of explaining an example of the historical emergence of political activism. Specifically, it considers the emergence of the ‘psychiatric survivors’ social movement in the UK, with a focus on the ‘politics of self-harm’. The politics of self-harm refers to acts of self-injurious behaviour, such as drug over-dosage or self-laceration, which do not result in death and which bring individuals to the attention of psychiatric (...) services. For many years survivors have protested about the harmful treatment they receive from such services and have campaigned for their reform and for new, non-psychiatric understandings of the meaning of self-harm. The article explains how such activism emerged in the late 1980s. Its contribution is at the interface of critical realism and social movement studies. (shrink)

With the waves of reform occurring in mental health legislation in England and other jurisdictions, mental capacity is set to become a key medico-legal concept. The concept is central to the law of informed consent and is closely aligned to the philosophical concept of autonomy. It is also closely related to mental disorder. This paper explores the interdisciplinary terrain where mental capacity is located. Our aim is to identify core dilemmas and to suggest pathways for future interdisciplinary research. The (...) terrain can be separated into three types of discussion: philosophical, legal and psychiatric. Each discussion approaches mental capacity and judgmental autonomy from a different perspective yet each discussion struggles over two key dilemmas: whether mental capacity and autonomy is/should be a moral or a psychological notion and whether rationality is the key constitutive factor. We suggest that further theoretical work will have to be interdisciplinary and that this work offers an opportunity for the law to enrich its interpretation of mental capacity, for psychiatry to clarify the normative elements latent in its concepts and for philosophy to advance understanding of autonomy through the study of decisional dysfunction. The new pressures on medical and legal practice to be more explicit about mental capacity make this work a priority. (shrink)

The profession of medicine is predicated upon an ethical mandate: first do no harm. However, critics charge that the medical profession’s culture and its public health mission are being undermined by the pharmaceutical industry’s wide-ranging influence. In this article, we analyze how drug firms influence psychiatric taxonomy and treatment guidelines such that these resources may serve commercial rather than public health interests. Moving beyond a conflict-ofinterest model, we use the conceptual and normative framework of institutional corruption to examine how (...) organized psychiatry’s dependence on drug firms has distorted science. We suggest that academic-industry relationships have led to the corruption of the evidence base upon which accurate diagnosis and sound treatment depend. We describe the current dependency corruption and argue that transparency alone is not a solution — and sometimes even produces iatrogenic effects. Furthermore, we argue that the corruption of the evidence base for diagnostic and practice guidelines renders obsolete the traditional informed consent process, and we offer suggestions for reforming this process. (shrink)

In 1995, a Swedish pilot study of Dialectical Behaviour Therapy (DBT) was launched to investigate its therapeutic efficacy and cost-effectiveness as treatment for Borderline Personality Disorder (BPD) in suicidal women. In the same year, a sweeping reform of psychiatric care commenced, dramatically reducing the number of beds by the end of the decade. The psychiatry reform was presented as an important factor prompting the need for a community-based treatment for Borderline patients. This article suggests that the introduction (...) of DBT in Sweden, and its relationship to the reform, can only be adequately explained with reference to the wider political shift occurring at the time, whereby the Swedish welfare state and its guiding ethos of egalitarianism were abandoned in favour of a neoliberal ‘choice revolution’. With the new liberalism, hard work and individual responsibility replaced the idea of a Swedish ‘people’s home’, a nationwide community and social support network. This language was reflected in DBT, which sought to teach patients the ‘skills’ necessary ‘to create a life worth living’. In this context, therapy was constituted as a form of ‘work’ that the patient had to undertake to improve. Moreover, DBT rejected the prevailing view of Borderline patients as ‘manipulative’ and ‘aggressive’, suggesting instead that they were ‘helpless’, ‘weak’ and unable to regulate their emotions. This new Borderline persona fit neatly into the new liberal discourse: she could be taught to become a rational and independent person able to cope in a society that valued individual responsibility over social support. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:IRBs Under the MicroscopeJonathan D. Moreno (bio)The spring and summer of 1998 were seasons in the sun for institutional review board (IRB) aficionados. Rarely have the arcana of the local human subjects review panels been treated to so much attention in both the executive and the legislative branches of government, not only at the federal but also at the state level. And it looks as if the attention will (...) continue for some time. The spate of interest is due to a series of coincidences: a powerful House of Representatives subcommittee held hearings after its chairman learned about the IRB system during a previous session on research in underdeveloped communities; the Department of Health and Human Services’s Inspector General (DHHS-IG) released a report on IRBs; the National Institutes of Health (NIH) Office of Extramural Research completed a report on clinical trial monitoring; the National Bioethics Advisory Commission (NBAC) readied a report on research involving persons with mental disorders; the states of Maryland and New York completed studies of research with subjects who lack decision-making capacity; and advocacy groups protested a psychiatric research project involving inner city children.Underlying these proximate causes for the IRB blitz is a growing realization that the already considerable clinical trial enterprise will expand significantly over the next few years. Congress is talking about giving the politically popular NIH half again the budget it currently receives, which in turn will stimulate more commercially supported research. The director of the National Cancer Institute is considering a five-fold increase in the number of subjects enrolled in oncology studies over the next several years. Phase I cancer studies are among the most ethically sensitive, so IRBs will have more work cut out for them if this goal is reached. Adding to the rush of interest in IRBs are the government’s recent apology to the survivors of the syphilis study in Tuskegee, continuing congressional dissatisfaction with the way the Pentagon handled its vaccine distribution during the Gulf War, and the controversy about AZT trials in developing countries.On the HillCongressman Christopher Shays, the moderate Connecticut Republican who has developed an interest in human research issues, convened hearings on human [End Page 329] subjects research and the IRB system on 11 June 1998. Shays chairs the House Government Reform/Human Resources Subcommittee. The committee’s ranking minority member is Edolphus Towns of Brooklyn, NY, who shares Shays’s interest in this area.The immediate rationale for the hearings was the release that day of the DHHS-IG report, Institutional Review Boards: A Time for Reform. The subtitle was changed from A System in Jeopardy apparently after some people in DHHS expressed reservations about its seemingly alarmist tone, but the IG staffers who testified before Shays’s subcommittee insisted that they stood behind the message that the IRB system is in trouble if considerable reforms are not undertaken. Among the factors in the research environment cited as support for the bleak forecast: managed care, commercialization, multi-site trials, high IRB workloads, minimal IRB oversight of approved studies, conflicts of interest, insufficient training of IRB members and investigators, and lack of IRB self-studies (DHHS-IG 1998).As is normally the case for congressional oversight hearings, the first panel of witnesses consisted of executive branch officials, including Eric Meslin, Executive Director of the National Bioethics Advisory Commission, and Gary Ellis, Director of the Office for Protection from Research Risks (OPRR). Shays pressed Ellis on the extent to which OPRR conducts on-site investigations of complaints about abuse of human subjects. Admitting that on-site investigations are rare, Ellis suggested that the agency is inadequately staffed to follow up on complaints as quickly as it might wish. The members of Congress who were present at the hearings generally expressed concern about the DHHS-IG’s findings.The second panel that day, which Shays was unable to attend, set a different tone. Four of the panelists—Paul Appelbaum of the University of Massachusetts at Worcester, Robert Levine of Yale University, Angela Bowen of the Western IRB (a private clinical trials review firm), and I—were invited as authorities on the current condition of the IRB system. Bert Spilker... (shrink)

Invited commentary on Nicole A. Vincent and Emma A. Jane, “Interrogating Incongruence: Conceptual and Normative Problems with ICD-11’s and DSM-5’s Diagnostic Categories for Transgender People” Australasian Philosophical Review, in press. -/- The core of Vincent and Jane’s Interrogating Incongruence is critical of the appeal to the concept of incongruence in DSM-5 and ICD-11 characterisations of trans people, a critique taken to be ground-clearing for more trans-positive, psychiatrically-infused medical interventions. I concur with Vincent and Jane’s ultimate goals but depart from the (...) view developed in the paper on two fronts. The first is that I remain sceptical about the overall prospects for truly trans-positive psychiatry. Trans should follow homosexuality and other categories of sexual orientation that have been abandoned rather than reformed as constituents of psychiatric diagnosis and categorisation. The second is that I think that the authors’ central criticisms of the appeal to incongruence are misplaced. (shrink)

Current health care standards, in many countries, Australia included, are regrettably poor. Surprisingly, practitioners and treating teams alike in mental health and disability sectors, in particular, make far too many basic care-related mistakes, in addition to the already abundant diagnostic mistakes that cause and amplify great harm. In part, too many practitioners also fail to distinguish adverse effects for what they are and all too often treat adverse effects, instead, as comorbidities. Diagnostic failures are dangerous, the result of which generates (...) and perpetuates harms that are extremely costly in terms of patient welfare, in addition to the financial burden placed on everyone. In this essay, I contend that the authority bestowed upon psychiatry is misplaced. Subsequently, this misplaced authority affects the governing and investigatory institutions reliant and informed by psychiatry. The examination process undertaken in this investigation traces the metaphysics of psychiatric disorders relative to the Diagnostic-Statistical-Manual (DSM) in all its iterations and to the epistemological construction process that serves to underpin the fundamentals of psychiatric practice. There exists a crisis of confidence in psychiatric practice and I urge drastic reform be undertaken to arrest the damage. (shrink)

Sri Lanka completed eloquent pull Dage described the love of wisdom is a holistic, practical way of life, which of course requires an abstract, theoretical science of meditation, more importantly, it also contains many religious practices is legal, such as flexible do not rot the soul, bitter conduct regular ring legal, social and political reform program, sustained ethics reflection, body control, dietary rules and taboos. However, this Pythagorean philosophy as a better life to all the light and fade away (...) In order to view at any time. The original philosophy of travel to another utterly abnormal interest in the pilgrimage of the way, that is abstract, a clear knowledge and commitment of this knowledge by the certainty of pursuit. "Knowledge" and "real management" into the vocabulary of philosophy In order systems, "smart" In order to become a college corridor in the West has been seriously neglected under the words. With the flow of time driving on the theory and psychiatric abstract admiration, which means practical wisdom, rhetoric and aesthetics into a whole都In order to two yuan regardless. Philosophy - the "love of wisdom" - in all intent and purposes都becomes In order to philo-episteme-"love of knowledge certainty." Started with the ancient Chinese culture, hope臘different. It is rooted in Confucianism, "the next school on up," the admonition of Chinese philosophy from the initial thinking on the road from the daily behavior persist in the pursuit of wisdom, relationships conducted by the "self" as the meaning of things by the event source. Everyone from family, community, political relations, to obtain a unique perspective, they participate in the growth of sperm heart and minds of thinking, their family and community relationships to adjust to a clearer, more meaningful position. Personal self-cultivation increased by the universe meaning, and meaning of the universe has increased over the coming anti-In order for individuals to provide a self fertile soil. For the eloquent Pythagoras, the holistic way of life he described as philosophia-"the love of wisdom"-while entailing the contemplation of abstract, theoretical science, involved much more importantly religious practices based upon the immortality of the soul, ascetic observances, a program of social and political reform, ethical reflection, a physical regimen, and even dietary prescriptions and prohibitions. But this conception of philosophy as a holistic vision of the good life faded in time, and gave way to the search for apodictic knowledge and its promise of certainty. "Knowledge" and "truth" became the vocabulary of systematic philosophy, and "wisdom" was banished from conversation in the corridors of the Western academy. The worship of the theoretically and spiritually abstract meant that in the fullness of time practical wisdom , rhetoric, and the aesthetic were relegated to the down side of a prevailing dualism. The Chinese cultural narrative unfolded differently. Grounded in the Confucian exhortation-"Study what is near at hand and aspire to what is lofty the next school on the up"-the Chinese philosophical narrative has from earliest times sustained a commitment to the pursuit of wisdom by understanding personal cultivation as the ultimate source of an emergent cosmic meaning. It is the revolution currently taking place within the Western philosophical community as an attempt to reinstate wisdom that provides an opening and an invitation to take Chinese philosophy and culture more seriously. An internal critique continues to be waged within professional Western philosophy under the many banners of process philosophy, hermeneutics, post-modernism, neo-pragmatism, neo-Marxism, deconstructionism, feminist philosophy , and so on, that takes as a shared target what Robert Solomon has called "the transcendental pretense"-idealism, objectivism, logocentrism, essentialism, the master narrative, "the myth of the given"-the familiar reductionistic "isms" that have emerged as putatively novel choices as philosophers switch horses on the merry-go-round of systematic philosophy. In place of a Cartesian philosophical language that privileges the function of clear and distinct ideas in our quest for an objective certainty, vocabularies of process, change, and indeed productive vagueness have increasingly come into vogue. These recent developments in Anglo-European philosophy itself have begun to foreground interpretative vocabularies more relevant to the articulation of Chinese culture. In this essay, I will argue that the pragmatic theory of truth as expounded by William James and particularly John Dewey is an attempt to reauthorize "wisdom" as a philosophical goal in the Western philosophical narrative. This development opens a space for a conversation between Deweyan pragmatism and Confucianism on how best to achieve it. (shrink)

The World Health Organization (WHO) has identified mental health as a priority for global health promotion and international development to be targeted through promulgation of evidence-based medical practices, health systems reform, and respect for human rights. Yet these overlapping strategies are marked by tensions as the historical primacy of expert-led initiatives is increasingly subject to challenge by new social movements — in particular, disabled persons' organizations (DPOs). These tensions come into focus upon situating the WHO's mental health policy initiatives (...) in light of certain controversies arising under the Convention on the Rights of Persons with Disabilities (CRPD), particularly as it applies to persons with mental (psychosocial) disabilities. I examine two such controversies — concerning, respectively, the legitimacy of involuntary psychiatric interventions and the legitimacy of regimes of substitute decision-making. These controversies illustrate the radical challenges to global and domestic mental health policy that have gained new momentum through the participation of DPOs in the CRPD process. At the same time, they illustrate the need for ongoing, inclusive forums for deliberation at the nexus of mental health policy and human rights, aimed at enabling human flourishing within a framework of respect for diversity. (shrink)

This paper conducts a critical examination of the "usual psychopharmacology standards" for clinical research. Four main areas are inspected: What is "it" that is being treated in a clinical drug study? How much is really known concerning the psychological alterations brought about by psychiatric drug treatment? To what extent are sources of bias actually controlled for in "controlled" drug treatment studies? How does the usual "dropout pattern" influence the alleged "clinical findings" of controlled drug treatment studies? The overall conclusion (...) reached is that the "usual standards" cannot produce a realistic picture of either safety or efficacy. Conceptual and methodological reforms are suggested. (shrink)

Translation as philosophical program: An explorative reviewWhat does the concept of translation mean in the expression ‘translational neuroscience’? What are the different steps, or components, in the translation of neuroscientific findings to psychiatry? There are serious concerns about the validity and productivity of the traditional idea of a translational pipeline, starting in the fundamental sciences (chemistry, molecular and cellular biology) and ending in the practice of clinical medicine, including psychiatry. The article defends the thesis that the difficulties in the traditional (...) approach result, at least partially, from insufficient reflection on the philosophical premises upon which the concept of translation is based. The linear pipeline model is strongly determined by the traditional biomedical approach to disease. The translation crisis signifies some of the limitations of this approach, especially in the realm of clinical practice and patient experience. The biomedical model suggests that illness manifestations should be conceived as causally determined expressions of an underlying biological derailment or dysfunction. This model lacks the language and conceptual tools to address the role of contextual and person-bound factors in the manifestation of illness. It is only recently that personalized and context-sensitive approaches to psychopathology have gained scientific attention. In the wake of this conceptual and practical reform, network-like approaches to translation have emerged. These network approaches are based on a different conception of transdisciplinarity. They address all stakeholders, by asking them what kind of translation they need. Stakeholders are not only scientists and clinicians, but also patient- and family support groups; and parties that are responsible for the institutional embedding, the financial and logistic infrastructure, and the legal frameworks that support psychiatric care. It is the interaction between science (as producer of knowledge) and the contexts that are supposed to benefit from this knowledge, that should be put at the centre of conceptual reflection. The degree and fruitfulness of this interaction will be decisive for the future of both psychiatry and clinical neuroscience. Philosophy can play an important role in this interaction, by making explicit underlying logical and practical tensions and ambiguities in this interaction. (shrink)

Philippe Pinel is widely regarded as one of the founders of modern evidence-based psychiatry. Yet, until recently, his most important contributions to psychiatric theory and practice were effectively lost in myth, or lost in translation. It is instructive to review the history of these developments in order to correct any errors or omissions that may stand in the way of an accurate recognition of Pinel’s contributions to psychiatry, while at the same time highlighting some of his achievements that have (...) been hidden by his celebrated mythical status as a pioneering humanitarian reformer. The aim of this article is to motivate further historical study of Pinel’s work, especially his 1809 Medico-Philosophical Treatise on Mental Alienation, which has only recently become available in English translation. (shrink)

Philippe Pinel is widely regarded as one of the founders of modern evidence-based psychiatry. Yet, until recently, his most important contributions to psychiatric theory and practice were effectively lost in myth, or lost in translation. It is instructive to review the history of these developments in order to correct any errors or omissions that may stand in the way of an accurate recognition of Pinel’s contributions to psychiatry, while at the same time highlighting some of his achievements that have (...) been hidden by his celebrated mythical status as a pioneering humanitarian reformer. The aim of this article is to motivate further historical study of Pinel’s work, especially his 1809 Medico-Philosophical Treatise on Mental Alienation, which has only recently become available in English translation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Introducing a “Deleuze Effect” into PsychiatryLarry Davidson (bio) and Golan Shahar (bio)Keywordsdesire, intentionality, psychopathology, agency, action theory, desiring-production, active and reactive forcesYou have to keep small rations of subjectivity in sufficient quantity to enable you to respond to the dominant reality.(Deleuze and Guattari 1987160)We are very pleased with the variety of responses our article has generated thus far and hope that it continues to provoke dialogue. That was, we (...) think, our in tent—should we be allowed to hold on to any such “thing” as an intention. We also take the diversity of these responses to reflect one of our key challenges in using Deleuze’s thought to reform (as op posed merely to inform) psychiatric practice: How to make a radical philosophy accessible enough to a broad enough audience for it to bring about substantive, real change in an existing culture in the hic et nunc, the here and now. That is why we chose the quotation above from Mille Plateaux. Even Deleuze (with Guattari) encourages us to keep “small rations” of subjectivity at hand if we are interested in responding to the “dominant reality.” And that has been our main agenda; to engage with the dominant reality of deficit-based psychiatric theory and practice to overturn it, or, in Clegg’s terms, “explode” it from within.In this regard, we certainly agree with Evangelista and Clegg that much more remains to be done, both in developing our position and in exploring its implications for practice. We view our “Deficit to Desire” paper as simply a first step in this direction (e.g., Shahar and Davidson, in press). We thought it necessary first, as we wrote in the original paper, to articulate the theoretical underpinnings of an action model for clinical understanding and practice “at a philosophical level of discourse on the one hand, but also in such a way that they provide a concrete, substantially different point of departure for empirical studies of psychopathology, on the other.” But why is this important, and what implications does it have for our response to these three thoughtful commentaries?A first implication is that our primary aim is not to provide a comprehensive exposition of Deleuze’s thought. In our opinion, even attempting to give a comprehensive exposition of Deleuze’s thought would actually go directly against its main thrust, which we view as to ignite and propagate ever new and creative lines of flight which carry desiring-production into “a small plot of new land at all times” (Deleuze and Guattari 1987, 161). “Experiment,” entreats Deleuze, “don’t interpret” (Deleuze and Guattari 1987, 139). We would guess, in fact, that Deleuze no more wanted to [End Page 243] produce Deleuzeans than Kierkegaard wanted disciples going around the Danish countryside after his death spreading the word that Kierkegaard did not want disciples going around the Danish countryside after his death (one of our favorites among his many ironies). So although we agree that there is much more in Deleuze’s thought than what is contained in our paper, we think that to some degree it misses its point. In Deleuzean fashion, we want to use the “Deleuze effect” to bring radical change to psychiatry (and we appreciate the irony of that too). Although both Evangelista and Clegg seem to welcome this effort, despite their misgivings, Weiner clearly is worried. Weiner also seems to have had the most intimate experience of the psychiatric system—that is, is most familiar with the world we are trying to change—so we focus in particular on his very understandable concerns.It also happens to be the case that focusing on Weiner’s concerns brings us immediately back to the nature of the effect we were hoping to have. Weiner explains that people with serious mental illnesses are “oppressed from within” and that their affliction seems to be coming “from a seemingly autonomous place” that is “within us, but not ultimately of us.” We could not agree more, and appreciate the lucidity and eloquence with which he makes this astute and important point. Several years ago, one of us even attempted a Husserlian-inspired analysis of how a person... (shrink)

Career transitions in psychiatry have rarely been discussed openly. Yet, in the light of health care reform and other forces affecting clinical practice, it is more important than ever that psychiatrists have information about the career options within their specialty. _Career Pathways in Psychiatry: Transition in Changing Times_ serves that purpose. It explores the professional development and career choices of prominent American psychiatrists, each of whom is identified with a particular career track and many of whom have themselves experienced (...) one or more career transitions. The autobiographical accounts of the contributors survey a wide range of career pathways in psychiatry, including clinical practice, HMO practice, research, administration, entrepreneurism, psychoanalysis, organized medicine, the pharmaceutical industry, public psychiatry, occupational psychiatry, forensic psychiatry, and military psychiatry. These accounts are as engaging as they are informative; their anecdotal nature and conversational tone make for pleasurable reading. References at the end of each chapter serve as recommended reading for those who wish to learn more about specific career options. Intended for psychiatric residents and psychiatrists early in their careers, _Career Pathways in Psychiatry_ will also appeal to their more experienced colleagues, including seasoned clinicians who have contemplated career changes. With a preface summarizing research on career transitions in medicine and numerous chapters shedding light on factors contributing to resistance to change, this book will also be of interest to social scientists, mental health administrators, and professional recruiters. (shrink)

Career transitions in psychiatry have rarely been discussed openly. Yet, in the light of health care reform and other forces affecting clinical practice, it is more important than ever that psychiatrists have information about the career options within their specialty. _Career Pathways in Psychiatry: Transition in Changing Times_ serves that purpose. It explores the professional development and career choices of prominent American psychiatrists, each of whom is identified with a particular career track and many of whom have themselves experienced (...) one or more career transitions. The autobiographical accounts of the contributors survey a wide range of career pathways in psychiatry, including clinical practice, HMO practice, research, administration, entrepreneurism, psychoanalysis, organized medicine, the pharmaceutical industry, public psychiatry, occupational psychiatry, forensic psychiatry, and military psychiatry. These accounts are as engaging as they are informative; their anecdotal nature and conversational tone make for pleasurable reading. References at the end of each chapter serve as recommended reading for those who wish to learn more about specific career options. Intended for psychiatric residents and psychiatrists early in their careers, _Career Pathways in Psychiatry_ will also appeal to their more experienced colleagues, including seasoned clinicians who have contemplated career changes. With a preface summarizing research on career transitions in medicine and numerous chapters shedding light on factors contributing to resistance to change, this book will also be of interest to social scientists, mental health administrators, and professional recruiters. (shrink)

An in-depth analysis of the recent reform in Italian psychiatry reveals that the relevance of these changes transcends national borders. However, these changes are, from the scientific point of view, worth much more than mere biased pragmatic interest. The reshaping of theory made possible by the transformation of Italian psychiatry in fact opens up new prospects for a scientifically founded form of psychiatric care. Thanks to the new Mental Health Act (No. 180 of 1978),2 it has been possible (...) to set up a type of administrative and institutional organization in which the psychiatric hospital no longer constitutes a functional part of the structures of psychiatric care. This reform thus provides the launching path for a real alternative where current psychiatric ideas and working methods can no longer be accepted as the gospel truth. This paper discusses how a correct problem-definition of psychiatric admission can provide a basis for a correct approach to psychopathological behaviour in a setting where the psychiatric hospital has no role to play and for the consolidation of this new practice. (shrink)

This essay considers the creation of a gender identity clinic at Rikshospitalet, the National Hospital of Norway, in the early 2000s and its implications for the production of medical knowledge during that era. In the preceding decades, medical transition was overseen by an informal, self-organized, multidisciplinary team of medical experts, but this situation changed when a centralized gender identity clinic was established under psychiatric control. The essay argues that shifting institutional, societal, economic, legal, and bureaucratic circumstances redistributed expertise and (...) authority on trans medicine. Economic framing, institutional frictions, patient activism, and media attention restricted the doctors’ room for maneuver and created a scientific crisis of legitimacy in trans medicine. These processes changed medical knowledge regarding medical transition; eventually, “sex change” and, therefore, all that is denoted by “sex” became intertwined with and inseparable from the politico-bureaucratic processes of reforming a modern public health-care system and welfare state. By anchoring the analysis in the history of science and expertise, this inquiry offers a new focus on the role of bureaucratic practices in the production, structuring, and circulation of medical knowledge in the welfare state. (shrink)

Discourse and rhetoric of service-user involvement are pervasive in all mental health services that see themselves as promoting a Recovery ethos. Yet, for the service-user movement internationally, ‘Recovery’ was articulated as an alternative discourse of overcoming and resisting an institutionalized and oppressive psychiatric model of care. Power is all pervasive within mental health services yet often overlooked in official discourse on user-involvement. Critical research is required to expose the unacknowledged structural and power constraints on participants. My research problematizes practices (...) of user involvement in one mental health service area in Ireland. Part I of this article examines the background context of policies and practices of user-involvement from the service-user perspective and explains developments in relation to service-user involvement in the case of Ireland. Participants in my study articulate their motivation for engagement with mental health service reform in terms of the right to participate in social justice terms, of wanting to improve services and humanise care. Power dynamics emerge as one of the primary obstacles to equitable involvement. Part II of this article presents an explanatory framework of power, using a model developed in the field of development studies; Gaventa’s (2006) ‘power cube.’ The three dimensions of the cube represent the forms, spaces and levels of power. The explanatory potential of this model to highlight how hidden and invisible power operates in mental health services is illustrated by selected comments from the same participants. The power cube is a useful tool to illuminate the dynamics occurring in service-user involvement spaces. Showing how different forms of power operate in the spaces and levels of mental health involvement can develop service-users’ awareness of the hidden and invisible aspects of power. Through this awareness, they can strategize around their potential to influence decision-making in mental health services. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Wilhelm Griesinger: Psychiatry between Philosophy and PraxisKatherine Arens (bio)AbstractThis essay discusses Wilhelm Griesinger’s seminal work on mental illness, Mental Pathology and Therapeutics (1867, trans. 1882), in the context of transcendental idealism, as an outgrowth of the work of Kant, Herbart, and Hegel. Griesinger drew on an adaptation of Hegel’s dialectical model of history and science to offer both a new way to interpret mental illness as a product of (...) an individual’s long-term interactions with both nature and culture and a new norm for therapeutic practice based on the patient’s role in his community and history.Mental Pathology and Therapeutics rests on Griesinger’s adaptation of the Hegelian dialectic to the context of pragmatic science, first by adopting its model of the mind, then by describing the etiology of mental disease and a taxonomy of its forms. Griesinger’s work thus stands in a largely unacknowledged tradition alive as late as Sigmund Freud and Jacques Lacan.KeywordsGriesinger, history of psychiatry/psychology, idealism, Hegel, dialecticIn the nineteenth century, Wilhelm Griesinger (1817–68) emerged as a leader in a range of fields: modern-day psychiatric clinical practice, neuropathology, and diagnostics of mental diseases. 1 Griesinger was a theoretician, a clinician, a textbook author, and the founding editor of major professional organs in his field during the political and social ferment in the German-speaking world that allowed new, more socially responsible institutional practices to be considered by intellectual communities. As a consequence of 1849 German civil reforms, theory and practice became mutually enlightening, actually allowing Griesinger to implement his theories into concrete institutional reforms in the German mental health system.Wilhelm Griesinger’s education and career were in many ways typical for his generation. He enrolled at the University of Tübingen in 1834 as a medical student; there, he became politically active (as a member of a forbidden fraternity), and, like many of his contemporaries, became familiar with Hegelian philosophy. After holding several private positions, he was appointed an associate professor (ausserordentlicher Professor) for pathology, “materia medica” and history of medicine at Tübingen in 1847. In 1848, he was called to Kiel; in 1850, to Egypt. Tübingen reappointed him as a full professor for clinical medicine and head of the university clinic in 1854. By 1860, he had moved to Zurich in a professorship for the medical clinic, where, starting in 1863, he was a key person in the planning of a new clinic for mental diseases—the Burghölzli, where Jung later worked. By 1865, he went to Berlin, as director of the Charité (mental institution), among other positions, and he wrote extensively about reform in asylum practice until his premature death in 1868.To a degree, the eminence of this career is contradicted today by his reputation. Contemporary wisdom describes Griesinger as a synthesizer [End Page 147] rather than an innovator, a man who mixed medical psychology with psychology and psychiatric practice, allowing neurology to take a major role in the treatment of mental disease. 2 In one version, Griesinger simply pulled the clinic and the laboratory together, and so bridged Romanticism (i.e., speculative natural philosophy) and materialism (i.e., empirical science) while failing to effect crucial modern reforms. 3 In other descriptions, Griesinger is identified as an activist (Doerner 1981), a key player in the debates between the Hegelian left and right about the reformulation of public institutions (cf. Verwey 1985), 4 or a typical (but effective) member of the intellectual elite of his age. 5 None of these options explains the attractive or threatening aspects of his clinical practice, or suggests why a psychiatrist of his rank could have been so thoroughly refuted after his death. 6The discussion which follows will try to remedy this lack by setting Griesinger’s approach to mental illness in the context of a transformation of a model from philosophy into medical practice. Griesinger’s scientific context strongly combined philosophical theorizing and empirical practice, a synthesis that later generations tended to denigrate as a “speculative” approach to a branch of medicine that required a more empirical foundation. Drawing on an adaptation of Hegel’s dialectical model of history and... (shrink)

This paper examines how photography shaped the American public’s perception of psychiatric hospitals during the immediate post-WWII period. I will analyze photographs that appeared in popular exposé articles of that period and that used photography as a visual aid for disclosing the poor conditions of state hospitals, intending to promote reform efforts focused on turning antiquated asylums into modern hospitals. Existing scholarship has mentioned how these photographs had a significant influence on shaping the public’s view of asylum conditions. (...) Through a close examination of these photographs, I will argue that they often contained unintentional messages which stigmatized disabled people. (shrink)

The discriminatory effects of categorizing psychiatric patients into competent and incompetent, have urged lawyers, philosophers and health care professionals to seek a functional approach to capacity assessment. Dutch and English law have produced some guidelines concerning this issue. So far, most legal systems under investigation have concentrated on alternatives for informed consent by the patient in case of mental incapacity, notably substitute decision-making, intervention of a judge and advance directives. It is hard to judge the way in which the (...) law may further adapt to a more functional assessment of capacity, because the nature of law shows that legal reforms usually take place only when new methods have been accepted by the field. This is not yet the case today. (shrink)

This new edition of Psychiatric Ethics continues to serve as the most authoritative and comprehensive text on the many complex ethical dilemmas which face the clinician in everyday practice. In addition to addressing questions about drug therapy, sex therapy, suicide, and child psychiatry, among others, this up-to-date revision adds six new chapters discussing abuses in psychiatry in Japan and Nazi Germany; a conceptual analysis of what mental illness is; psychiatry as a profession; the ethical aspects of psychogeriatrics; and deinstitutionalization. (...) This book is essential reading for all mental health professionals. (shrink)

The paper considers whether psychiatric kinds can be natural kinds and concludes that they can. This depends, however, on a particular conception of ‘natural kind’. We briefly describe and reject two standard accounts – what we call the ‘stipulative account’ (according to which apparently a priori criteria, such as the possession of intrinsic essences, are laid down for natural kindhood) and the ‘Kripkean account’ (according to which the natural kinds are just those kinds that obey Kripkean semantics). We then (...) rehearse a more permissive account: Richard Boyd’s ‘homeostatic property cluster’ (HPC) account. We argue that psychiatric kinds can in principle count as natural kinds on the HPC account. Moreover, specific psychiatric kinds (Tourette’s, schizophrenia, etc.) can be natural kinds even if the category psychiatric disorder is not itself a natural kind. (shrink)