The ‘right to the truth’ involves disclosing all the pertinent facts to a patient so that an informed decision can be made. However, this concept of a ‘right to the truth’ entails certain ambiguities, especially since it is difficult to apply the concept in medical practice based mainly on current evidence-based data that are probabilistic in nature. Furthermore, in some situations, the doctor is confronted with a moral dilemma, caught between the necessity to inform the patient (principle of autonomy) and (...) the desire to ensure the patient's well-being by minimising suffering (principle of beneficence). To comply with the principle of beneficence as well as the principle of non-maleficence ‘to do no harm’, the doctor may then feel obliged to turn to ‘therapeutic privilege’, using lies or deception to preserve the patient's hope, and psychological and moral integrity, as well as his self-image and dignity. There is no easy answer to such a moral dilemma. This article will propose a process that can fit into reflective practice, allowing the doctor to decide if the use of therapeutic privilege is justified when he is faced with these kinds of conflicting circumstances. We will present the conflict arising in practice in the context of the various theoretical orientations in ethics, and then we will suggest an approach for a ‘practice of truth’. Last, we will situate this reflective method in the broader clinical context of medical practice viewed as a dialogic process. (shrink)

Once common, therapeutic privilege—the practice whereby a physician withholds diagnostic or prognostic information from a patient intending to protect the patient—is now generally seen as unethical. However, instances of therapeutic privilege are common in some areas of clinical psychiatry. We describe therapeutic privilege in the context of borderline personality disorder, discuss the implications of diagnostic non-disclosure on integrated care and offer recommendations to promote diagnostic disclosure for this patient population. There are no data in (...) this work. (shrink)

Given Kant's exceptionless moral prohibition on lying, one might suspect that he is committed to a similar prohibition on withholding diagnostic and prognostic information from patients. I confirm this suspicion by adapting arguments against therapeutic privilege from his arguments against lying. However, I show that all these arguments are importantly flawed and submit that they should be rejected. A more compelling Kantian take on informed consent and therapeutic privilege is achievable, I argue, by focusing on Kant's (...) duty of beneficence, which requires us to aim at furthering others’ ends. But I show that there are some cases in which furthering a patient's ends requires withholding material medical information from her. Although I concede that these cases are probably quite rare, I conclude that the best Kantian thinking agrees with that of therapeutic privilege's advocates. (shrink)

Communicating an unfavourable prognosis while maintaining patient hope represents a critical challenge for healthcare professionals. Duty requires respect for the right to patient autonomy while at the same time not doing harm by causing hopelessness and demoralisation. In some cases, the need for therapeutic privilege is discussed. The primary objectives of this study were to explore HPs’ perceptions of hope in the prognosis communication and investigate how they interpret and operationalise key ethical principles. Sixteen qualitative semistructured interviews with (...) HPs from different positions and experience, including doctors and nurses in four different departments, were conducted in the Ticino Cantonal Hospital, Switzerland. The interviews were recorded, transcribed verbatim and analysed using thematic analysis. HPs defined prognosis and patient hope as interdependent concepts related to future perspectives for subjective quality of life. Two main factors allow HPs to maximise the benefits and minimise the harm of their communication: respecting the patient’s timing and sharing the patient’s wishes. Time is required to reframe needs and expectations. Furthermore, communication needs to be shared by HPs, patients and their relatives to build common awareness and promote a person-centred approach to prognosis. In this process, interprofessional collaboration is key: doctors and nurses are complementary and can together guarantee that patients and relatives receive information in the most appropriate form when they need it. Organisational aspects and the HPs’ emotional difficulties, particularly in coping with their own despair, are barriers to effective communication that need further investigation. (shrink)

Providing patients with information is fundamental to respecting autonomy. However, there may be circumstances when information may be withheld to prevent serious harm to the patient, a concept referred to as therapeutic privilege. This paper provides an analysis of the ethical, legal and professional considerations which impact on a decision to withhold information that, in normal circumstances, would be given to the patient. It considers the status of the therapeutic privilege in English case law and concludes (...) that, while reference is made to circumstances when information (primarily in relation to risk disclosure) may be withheld, further clarification is required on the status of therapeutic privilege. I suggest there has been shift in English law relating to the standard of information disclosure towards one set by the test of the reasonable, prudent patient. It is this shift that necessitates the existence of a therapeutic privilege which enables doctors to withhold information that would usually be given to the patient in order to prevent serious harm. I then explore the professional guidance in relation to information disclosure and how this relates to the legal position. There are strong ethical arguments in favour of disclosure of information to patients. In light of these, further clarification is required to identify and define the grounds on which this exception exists, the information that could lawfully be withheld and how this exception extends to rest of the health care team, particularly nurses. As such, explicit ethical and legal scrutiny of therapeutic privilege is needed in order to consider how this concept might be articulated, constrained and regulated. (shrink)

Therapeutic privilege is a defence that may be available to doctors who fail to disclose to the patient relevant information when seeking informed consent for treatment if they have a reasonable belief that providing that information would likely cause the patient concerned serious physical or mental harm. In a landmark judgement, the Singapore Court of Appeal introduced a novel interpretation of TP, identifying circumstances in which it might be used with patients who did not strictly lack capacity but (...) might be inclined to refuse recommended treatments. In this paper, we explore the conceptual and practical challenges of this novel interpretation of TP. We propose that more emphasis should be placed on forms of shared and supported decision-making that foster the autonomy of patients with compromised mental capacity while being mindful of the need to safeguard their well-being. The kind of privilege that doctors might need to invoke is one of time and supportive expertise to ensure a flexible, responsive approach calibrated to the individual patients’ needs. The provision of such service would extinguish the need for the novel TP proposed by the Singapore Court of Appeal. (shrink)

This article examines the standard of disclosure, set by law, of risks of treatment and alternative procedures that should normally be disclosed to patients. Therapeutic privilege has been recognized by the courts as an exception to this standard of disclosure. It provides a justification for withholding such information from competent patients in the interests of patient welfare. The article explores whether this justification is either legally or ethically defensible. In assessing patient welfare, the health care professional is required (...) to consider the patient's overall best interests - but this is not limited to an assessment of medical best interests. It is contended that the health care professional is neither qualified nor justified in making such a judgement, as the law recognizes that a competent adult patient determines her own best interests. This is not possible without sufficient information of risks to inform the decision. (shrink)

In the past few decades, a multi-billion-dollar “therapeutic boarding school” industry has emerged for America’s troubled upper-class youth. This article examines the therapeutic models prominent in these programs and the ways they conflict with dominant notions of masculinity. Using in-depth interviews and ethnographic fieldwork inside a Western therapeutic boarding school, I show how privileged young men navigate this masculinity dilemma by constructing hybrid masculinities that incorporate qualities associated with femininities and subordinate masculinities. However, these qualities are incorporated (...) strategically and in ways that reproduce and obscure privileges associated with students’ positions as young, upper-class, white men. Using hybrid masculine styles that include humility, commitment to service, and open emotional expression, students re-assert dominant positions as leaders and as “better” men in contrast to various others. (shrink)

The mental health professions operate largely so as to objectify a language of mental deficit. In spite of their humane intentions, by constructing a reality of mental deficit the professions contribute to hierarchies of privilege, reduce natural interdependencies within the culture, and lend themselves to self-enfeeblement. This infirming of the culture is progressive, such that when common actions are translated into a professionalized language of mental deficit, and this language is disseminated, the culture comes to construct itself in these (...) terms. This leads to an enhanced dependency on the professions and these are forced, in turn, to invent additional terms of mental deficit. Thus, concepts of infirmity have spiraled across the century, and virtually all remaining patterns of action stand vulnerable to deficit translation. Required within the professions are new linguistic formulations that create a reality of relationships without evaluative fulcrum. (shrink)

This article presents a critical discursive analysis around the concept of menstrual health in a series of texts published in book format and in social networks in the last five years (2019-2023) by different activists and menstrual educators in Argentina. In a reading itinerary that goes from the singular to the collective, I identify the configuration of an experiential episteme that redefines the menstruating body as informational and multidimensional, which enables that, in addition to a physiological dimension, its role in (...) different social, political, cultural, environmental and economic contexts is vindicated. I place these examples in the context of the neoliberal precariousness that installs the therapeutic-managerial culture as a moral imperative, while at the same time it challenges certain subjectivities with relative privilege —white, urban, trained and educated women— to dispute and strain meanings. (shrink)

Mental health courts, premised on the notion of therapeutic justice, have become an increasingly appealing way of dealing with what is widely, although not uniformly, seen as the inappropriate incarceration of people who engage in criminal behavior caused by mental illness. Nevertheless, mental health courts are not without their critics and a number of objections have been raised against the implementation of these courts. Among these criticisms is that mental health courts may inappropriately privilege criminal behavior by the (...) provision of expedited comprehensive services to persons with mental illness who commit criminal of enses and, in doing so, reduce or delay the provision of services to persons with mental illness who do not engage in criminal behavior. This article explores the mechanisms that may result in “queue-jumping” and analyzes whether a priority to of enders, when it does occur, is justii able. (shrink)

This essay focuses on cases in which a physician elects to withhold, either temporarily or permanently, certain information from a patient for arguably beneficent reasons. That is, the physician is not being self-serving, to herself or her institution, by not revealing this information. Rather, the goal is purely to promote what the physician believes to be in the patient’s best interest by withholding information that may be harmful to him. This practice of informational guardianship is known as the “therapeutic (...) privilege.” This discussion is thus also limited to clinical interactions and not explicitly discuss withholding information from research subjects, which raises distinct ethical issues and elicits different reasons used to justify or nullify the moral permissibility of nondisclosure. (shrink)

In the United States the delivery of health care traditionally has been hierarchical and strictly controlled by physicians. Physicians typically provided patients with little information about their diagnosis, prognosis, and treatment plan; patients were expected to follow their physicians’ orders and ask no questions. Beginning in the 1970s, with the widespread adoption of the doctrine of informed consent to treatment, the physician-patient relationship began to be more collaborative, although the extent of the change has been subject to debate. At a (...) minimum, physicians began to give patients more information and asked them to consent to recommended treatment, the therapeutic privilege to withhold information from patients lost support and eventually was repudiated, and physicians embraced — at least in theory — a more patient-centered conception of health care.More recently, health care and health promotion activities have moved beyond clinical encounters and the strict confines of physician-patient interactions. (shrink)

In the United States the delivery of health care traditionally has been hierarchical and strictly controlled by physicians. Physicians typically provided patients with little information about their diagnosis, prognosis, and treatment plan; patients were expected to follow their physicians’ orders and ask no questions. Beginning in the 1970s, with the widespread adoption of the doctrine of informed consent to treatment, the physician-patient relationship began to be more collaborative, although the extent of the change has been subject to debate. At a (...) minimum, physicians began to give patients more information and asked them to consent to recommended treatment, the therapeutic privilege to withhold information from patients lost support and eventually was repudiated, and physicians embraced — at least in theory — a more patient-centered conception of health care.More recently, health care and health promotion activities have moved beyond clinical encounters and the strict confines of physician-patient interactions. (shrink)

Regarding the appropriateness of deception in clinical practice, two (apparently conflicting) claims are often emphasised. First, that ‘clinicians should not deceive their patients.’ Second, that deception is sometimes ‘in a patient’s best interest.’ Recently, Hardman has worked towards resolving this conflict by exploring ways in which deceptive and non-deceptive practices extend beyond consideration of patients’ beliefs. In short, some practices only seem deceptive because of the (common) assumption that non-deceptive care is solely aimed at fostering true beliefs. Non-deceptive care, however, (...) relates to patients’ non-doxastic attitudes in important ways as well. As such, Hardman suggests that by focusing on belief alone, we sometimes misidentify non-deceptive care as ‘deceptive’. Further, once we consider patients’ beliefs and non-doxastic attitudes, identifying cases of deception becomes more difficult than it may seem. In this essay, I argue that Hardman’s reasoning contains at least three serious flaws. First, his account of deception is underdeveloped, as it does not state whether deception must be intentional. The problem is that if intention is not required, absurd results follow. Alternatively, if intention is required, then identifying cases of deception will be much easier (in principle) than Hardman suggests. Second, Hardman mischaracterises the ‘inverse’ of deceptive care. Doing so leads to the mistaken conclusion that common conceptions of non-deceptive care are unjustifiably narrow. Third, Hardman fails to adequately separate questions about deception from questions about normativity. By addressing these issues, however, we can preserve some of Hardman’s most important insights, although in a much simpler, more principled way. (shrink)

Is it ever permissible to publish a patient’s confidences without permission? I investigate this question for the field of psychoanalysis. Whereas most medical fields adopted a 1995 recommendation for consent requirements, psychoanalysis continues to defend the traditional practice of nonconsensual publication. Both the hermeneutic and the scientific branches of the field justify the practice, arguing that it provides data needed to help future patients, and both branches advance generalizations and causal claims. However the hermeneutic branch embraces methods tending to undermine (...) the reliability of such claims, while the scientific branch aims to improve the field’s empirical base – in their words, to advance psychoanalysis as a science. The scientific branch therefore has the stronger claim to the traditional practice, and it their claim that I consider. An immediate concern arises. We seem unable to answer the applied ethical question without first determining which ethical theory is correct; for defenders of the practice appeal variously to therapeutic privilege, principlism, and utilitarianism, while opponents wage autonomy-based arguments. The concern turns out to be unfounded, however, because all of these ethical approaches fail to justify the traditional practice. The more promising defenses fail partly because even the scientific branch of the field lacks empirically sound methods for establishing its causal claims and generalizations, often appealing to authority instead. I conclude that it is currently unethical for analysts to continue publishing their patients’ confidences without permission, and I suggest that the field help future patients by attending to its methodological problems. (shrink)

Is it ever permissible to publish a patient’s confidences without permission? I investigate this question for the field of psychoanalysis. Whereas most medical fields adopted a 1995 recommendation for consent requirements, psychoanalysis continues to defend the traditional practice of nonconsensual publication. Both the hermeneutic and the scientific branches of the field justify the practice, arguing that it provides data needed to help future patients, and both branches advance generalizations and causal claims. However the hermeneutic branch embraces methods tending to undermine (...) the reliability of such claims, while the scientific branch aims to improve the field’s empirical base – in their words, to advance psychoanalysis as a science. The scientific branch therefore has the stronger claim to the traditional practice, and it their claim that I consider. An immediate concern arises. We seem unable to answer the applied ethical question without first determining which ethical theory is correct; for defenders of the practice appeal variously to therapeutic privilege, principlism, and utilitarianism, while opponents wage autonomy-based arguments. The concern turns out to be unfounded, however, because all of these ethical approaches fail to justify the traditional practice. The more promising defenses fail partly because even the scientific branch of the field lacks empirically sound methods for establishing its causal claims and generalizations, often appealing to authority instead. I conclude that it is currently unethical for analysts to continue publishing their patients’ confidences without permission, and I suggest that the field help future patients by attending to its methodological problems. (shrink)

Legal precedent, professional‐society statements, and even many medical ethicists agree that some situations may call for a clinician to engage in an act of lying or nonlying deception of a patient or patient's family member. Still, the moral terrain of clinical deception is largely uncharted, and when it comes to practical guidance for clinicians, many might think that ethicists offer nothing more than the rule never to deceive. This guidance is insufficient to meet the real‐world demands of clinical practice, and (...) this article endeavors to articulate a framework to help clinicians better navigate the ethics of clinical deceit. The framework articulates four morally relevant dimensions of a potential deceptive act that should be examined to better determine the moral justification that might be required: the target of the act, the nature of the information, the nature of the act, and the context of the act. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 11.2 (2001) 165-168 [Access article in PDF] UPMC Presbyterian Policy and Procedure Manual Guidelines for Disclosure and Discussion of Conditions and Events with Patients, Families and Guardians* I. Introduction and Background In the course of hospital care, an extensive amount of clinical information is generated. It includes diagnostic findings, treatment options, responses to interventions, and professional opinions. The information can be positive or negative. (...) Clinical events may or may not be caused by clinicians and consequently may be iatrogenic (caused by medical treatment), nosocomial (occurring in the hospital) or natural events.In accordance with the informed consent policy (#4011), Patients' Bill of Rights (# 0154, Section II H), and the Guidelines on Forgoing Life Sustaining Treatment (#4007), patients have the right to information regarding their condition and care. Physicians and other caregivers are obligated to provide accurate information as expeditiously as possible. While it is usually easy to provide positive information, negative information is more difficult to disclose, especially when the cause is iatrogenic."Therapeutic privilege" has been invoked to explain why certain negative information might be withheld. By invoking therapeutic privilege, the physician refrains from full disclosure to protect the patient from the effects of receiving the information itself. The use of therapeutic privilege is increasingly being called into question because it decreases patient autonomy and reduces trust.The following recommendations are provided to clinicians to help guide delivery of sensitive information, positive and negative. Specific recommendations [End Page 165] are provided for situations where the information is about an unfavorable or adverse event, or where the information might best be characterized as "bad news." II. Definitions Unfavorable event or unfavorable condition. For the purposes of these guidelines, an unfavorable condition is an occurrence or diagnosis that results in or is likely to result in a significant negative outcome, and/or a significant alteration in the care plan.An unfavorable event in this context is not the same as a sentinel event, which in policy #4025 is defined as, "a serious, unexpected, adverse patient event which has resulted in, or if repeated would have a significant probability of resulting in, loss of life or serious physical or psychological injury, that is judged to be a warning of an underlying problem involving hospital facilities, policies, procedures, systems or personnel."Adverse Event. An unfavorable event for the purposes of these guidelines is also distinguished from the FDA definition of the term "adverse event", which is a reportable negative effect of a drug or device potentially resulting in death, hospitalization, or medical or surgical intervention. (See policy #4022 Safe Medical Device Act.)Examples of unfavorable events or conditions for the purpose of these guidelines include a new diagnosis of cancer, a perioperative myocardial infarction, or unintended delivery of an incorrect medication that results in clinical change.Examples of events not covered by these guidelines are intravenous saline infiltration and medication dosing errors that have no clinical impact on care.Iatrogenic. Event caused by the treatment of a healthcare provider. III. Guidelines and Principles It is appropriate that UPMC Presbyterian support basic principles for patient and family notification regarding all clinical events and conditions, including unfavorable ones. Physicians must be honest because that is a cornerstone of the patient-physician relationship, and because it fosters patient autonomy.UPMC Presbyterian supports the following AMA position regarding patient information: [End Page 166] It is a fundamental ethical requirement that a physician should at all times deal honestly and openly with patients. Patients have a right to know their past and present medical status and to be free of any mistaken beliefs concerning their conditions. Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician's mistake or judgement. In these situations, the physician is ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred. Only through full disclosure is a patient able to make informed decisions regarding future medical care. Ethical responsibility includes informing patients of changes in their diagnoses... (shrink)

Is it ever permissible to publish a patient’s confidences without permission? I investigate this question for the field of psychoanalysis. Whereas most medical fields adopted a 1995 recommendation for consent requirements, psychoanalysis continues to defend the traditional practice of nonconsensual publication. Both the hermeneutic and the scientific branches of the field justify the practice, arguing that it provides data needed to help future patients, and both branches advance generalizations and causal claims. However the hermeneutic branch embraces methods tending to undermine (...) the reliability of such claims, while the scientific branch aims to improve the field’s empirical base – in their words, to advance psychoanalysis as a science. The scientific branch therefore has the stronger claim to the traditional practice, and it their claim that I consider. An immediate concern arises. We seem unable to answer the applied ethical question without first determining which ethical theory is correct; for defenders of the practice appeal variously to therapeutic privilege, principlism, and utilitarianism, while opponents wage autonomy-based arguments. The concern turns out to be unfounded, however, because all of these ethical approaches fail to justify the traditional practice. The more promising defenses fail partly because even the scientific branch of the field lacks empirically sound methods for establishing its causal claims and generalizations, often appealing to authority instead. I conclude that it is currently unethical for analysts to continue publishing their patients’ confidences without permission, and I suggest that the field help future patients by attending to its methodological problems. (shrink)

Nature sports include pursuits such as paragliding, white-water kayaking, free diving, mountaineering, and surfing. Participants in nature sports interact with geographical features (e.g. mountains, rivers, oceans, snow fields, ice sheets, caves, rock faces) as well as the dynamic forces that produce them (e.g. gravity, waves, thermal currents, flowing water, wind, rain, sun). In this article, I engage a representational approach to analyze how participants in nature sports interact with nature. Anthropocentric representations privilege participants’ interests, wants, desires, and ends; they (...) typically refer to claims of conquest/achievement in nature, or praise nature for its therapeutic qualities. In contradistinction, ecocentric representations recognize humankind as one entity in an interdependent world that comprises all living organisms and the geological processes and geomorphological features that sustain them. Ecocentric representations of nature sports highlight networks of participants and landforms that help preserve a balance between people and the environment. Yet, notwithstanding the allure of ecocentric representations, especially in the wake of evidence that human-induced greenhouse gases are predisposing environmental calamities, there is a substantial gap between the ontological concepts and categories of ecocentrism and lived sporting experiences and practices in nature. (shrink)

Trust is central to the therapeutic relationship, but the epistemic asymmetries between the expert healthcare provider and the patient make the patient, the trustor, vulnerable to the provider, the trustee. The narratives of pain sufferers provide helpful insights into the experience of pain at the juncture of trust, expert knowledge, and the therapeutic relationship. While stories of pain sufferers having their testimonies dismissed are well documented, pain sufferers continue to experience their testimonies as being epistemically downgraded. This kind (...) of epistemic injustice has received limited treatment in bioethics. In this paper, we examine how a climate of distrust in pain management may facilitate what Fricker calls epistemic injustice. We critically interrogate the processes through which pain sufferers are vulnerable to specific kinds of epistemic injustice, such as testimonial injustice. We also examine how healthcare institutions and practices privilege some kinds of evidence and ways of knowing while excluding certain patient testimonies from epistemic consideration. We argue that providers ought to avoid epistemic injustice in pain management by striving toward epistemic humility. Epistemic humility, as a form of epistemic justice, may be the kind disposition required to correct the harmful prejudices that may arise through testimonial exchange in chronic pain management. (shrink)

Trust is central to the therapeutic relationship, but the epistemic asymmetries between the expert healthcare provider and the patient make the patient, the trustor, vulnerable to the provider, the trustee. The narratives of pain sufferers provide helpful insights into the experience of pain at the juncture of trust, expert knowledge, and the therapeutic relationship. While stories of pain sufferers having their testimonies dismissed are well documented, pain sufferers continue to experience their testimonies as being epistemically downgraded. This kind (...) of epistemic injustice has received limited treatment in bioethics. In this paper, we examine how a climate of distrust in pain management may facilitate what Fricker calls epistemic injustice. We critically interrogate the processes through which pain sufferers are vulnerable to specific kinds of epistemic injustice, such as testimonial injustice. We also examine how healthcare institutions and practices privilege some kinds of evidence and ways of knowing while excluding certain patient testimonies from epistemic consideration. We argue that providers ought to avoid epistemic injustice in pain management by striving toward epistemic humility. Epistemic humility, as a form of epistemic justice, may be the kind disposition required to correct the harmful prejudices that may arise through testimonial exchange in chronic pain management. (shrink)

In Wittgenstein and the Study of Politics, Michael Temelini outlines an innovative new approach to understanding the political implications of Wittgenstein’s philosophy. Most political philosophers who have approached Wittgenstein have done so through the idea of therapeutic skepticism, implying politics that privilege conservatism or non-interference. Temelini interprets Wittgenstein differently, emphasizing his view that we come to understand the meanings of words and actions through a dialogue of comparison with other cases. Examining the work of Charles Taylor, Quentin Skinner, (...) and James Tully, Temelini highlights the ways in which all three, despite their differences, share a common debt to that dialogical approach.A cogent explanation of how Wittgenstein’s epistemology and ontology can shed light on political issues and offer a solution to political challenges, Wittgenstein and the Study of Politics highlights the importance of Wittgensteinian thinking in contemporary political science, political theory, and political philosophy. (shrink)

This paper describes the semiotic process by which parents, as attachment figures, enable infants to learn to make meaning. It also applies these ideas to psychotherapy, with the therapist functioning as transitional attachment figures to patients where therapy attempts to change semiotic processes that have led to maladaptive behavior. Three types of semiotic processes are described in attachment terminology and these are offered as possible precursors of a neuro-behavioral nosology tying mental illness to adaptation. Non-conscious biosemiotic processes in infant-parent attachment (...) are the basis for early adaptation as well as adaptation or maladaptation in adulthood. Mother-infant interaction can be described as a series of signs, each interpreted so as to dispose the behavior of the other interactant towards the goal of protecting the infant from danger and distress. Regulating arousal, scaffolding infants’ behavior in the infants’ zone of proximal development, and repairing ruptures in the interaction are crucial to infants’ development and adaptation. In semiotic terms, each person activates multiple interpretants to make meaning of sensory stimulation. Non-verbal semiotic synchrony establishes the relationship whereas shared repair of ruptures promotes change. Attachment strategies, as learned adaptations to threat, are neuro-psychological strategies for making meaning of sensory information so as to dispose protective behavior. Type A privileges cognitive-temporal information, Type C affective information, Type B has no bias. Type A and C limit semiotic freedom by using ‘short-cuts’ in processing that produce quick protective behavior in the short-term. Type B includes more representations, and thus more semiotic freedom, resulting in slower responses and long-term flexibility. Attachment strategies function as meta-interpretants for applying one semiotic process to most incoming information about danger. A, B, and C case examples are analyzed in semiotic terms. Psychotherapy can be considered a helping process embedded in a transitional attachment relationship. For psychotherapy to be successful, both somatic stabilization and a therapeutic relationship are needed. Treatment that uses scaffolded semiotic processes in each patient’s ZPD to repair moment-to-moment ruptures holds the potential to reorganize attachment strategies and transfer that potential to reflective language and relationships outside the therapy. The outcome should be greater semiotic freedom such that the individual can trust their own mental processes and use them to establish safe relationships. Language can speed the process, but premature reliance on verbal transformations of non-conscious information can carry misattributions into a second layer of misconstrued meaning and maladaptive behavior. Even when dangerous family relationships and external danger cannot be changed, patients can come to know their own minds and use information to regulate their behavior. The goal of psychotherapy is to free patients from their past by enabling them to be secure about the functioning of their own minds, so that they can both avoid eliciting harm and also establish supportive relationships. (shrink)

This article examines the relationship between bioethics and the therapeutic standards in HIV prevention research in the developing world, focusing on the closure of the pre-exposure prophylaxis (PrEP) trials in the early 2000s. I situate the PrEP trials in the historical context of the vertical transmission debates of the 1990s, where there was protracted debate over the use of placebos despite the existence of a proven intervention. I then discuss the dramatic improvement in the clinical management of HIV and (...) the treatment access movement, and consider how these contexts have influenced research practice. I argue that as HIV prevention trials oblige researchers to observe the rate at which vulnerable people under their care acquire HIV, there is an obligation to provide antiretroviral treatment to seroconverters and other health care benefits that fall within the scope of researchers' entrustment, both to avoid exploitation and to enact reciprocal justice. I argue against propositions that the obligations to provide specific benefits are vague, fall only upon researchers and sponsors, and create injustices by privileging the few over the many. Finally, I contend that the realisation of a broader standard of care in HIV prevention research broadens the role of research from being a simple tool to produce knowledge to a complex intervention that can play a part in the reduction of health disparities. (shrink)

This paper argues that practitioners of psychedelic-assisted therapy could learn a great deal from Deleuze and Guattari’s critique of psychoanalysis in Anti-Oedipus, as well as the practice of materialist psychiatry – schizoanalysis – that they offer in its stead. Much of the clinical research on psychedelics (particularly psilocybin) over the past fifteen years has privileged mystical experience, assessed according to a quantifiable scale, as the goal of psychedelic-assisted psychotherapy and source of cure ( Griffiths et al. 2006, 2016 ; Barrett (...) and Griffiths 2018 ; Pollan 2018 ). Has ‘mystical experience’ become the ‘imperialism of Oedipus’ within the psychedelic revival, towards which all psychedelic experience and activity of the unconscious is expected to tend? Distressed patients would be better held, I contend, through a therapeutic practice that adopts Deleuze and Guattari’s concept of the unconscious as a desiring-machine and the cure as a completion of the process of desiring-production that is not arrested and reduced to pre-assigned ends. In this mode of working with psychedelics, the embodied memories, visions and sensations of the patient do not in a predetermined way ‘express’ or ‘represent’ a perennial, quantifiable experience (or myth). Rather, they enable the positive task of schizoanalysis of learning what a subject’s desiring-machines are and how they work, and the negative task of identifying and destroying all that stands in the way of their functioning. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Post-Traumatic Hermeneutics: Melancholia in the Wake of TraumaAngelika Rauch (bio)1Classical Analysis: Problems for Trauma TherapyAccording to the Journal of the American Psychoanalytical Association, American ego psychology has taken a leading role in debunking what it considers antiquated Freudian approaches to the study of trauma. As neutral observers and students of the facts, ego psychologists have purportedly reclaimed the study of trauma as the search for an objectifiable traumatic event (...) in the past, one that can be accessed as recovered memory, as a specimen of pathogenic development, or as cognitive and behavioral effects that point to an inaccessible implied memory buried in the psyche. Central to this revision of psychoanalytical trauma therapy is the dismissal of Nachträglichkeit as an antiquated and irrelevant concept. Harold P. Blum, for instance, writes in a recent article of JAPA that “‘deferred action’ is an ambiguous concept, a dubious, antiquated, theoretical legacy.” According to Blum, “deferred action overlooks the immediate and potentially powerful effects of preoedipal trauma and is dissociated from considerations of cumulative trauma and developmental disturbance.” [1155]. With respect to Freud’s case of the Wolf-Man, Blum states that “[d]eferred action emphasized traumatic events and memory rather than cumulative developmental effects of shock and strain trauma, and pathogenic object relationships.” Key to Blum’s view, then, is the assertion that “the concept of deferred action deterred consideration of real infantile experience and the complex overdetermination of pathogenesis through development” [1156]. Blum apparently takes the side of those who like to argue that trauma is more real than imagined. Whereas oedipal trauma is an imaginary or illusory trauma, preoedipal trauma is comprehensible as real shock and, as such, is empirically true. This is an idea that is very compatible with “recovered memory” therapy, a subject that has become controversial in recent debates about child abuse and recovered memory syndrome.In contrast, Arnold H. Modell in Other Times, Other Realities points out that “[t]he concept of Nachträglichkeit is virtually unknown among American psychoanalysts. This may be due in part to Strachey’s faulty translation; but this idea is also inconsistent with the belief in an orderly hierarchical psychic development such as that envisioned by ego psychologists.” [3]. In other words, Freudian Nachträglichkeit violates the principles of space and time assumed by empirical scientists whose conceptions are founded on the causality of such principles as stimulus/response. It is here, of course, that ego psychology’s treatment of trauma would come into conflict not only with Freudian analysis, including its French Freudian variants, but with the kind of trauma studies being conducted by the contributors to Cathy Caruth’s Trauma: Explorations in Memory. They include Bessel [End Page 111] van der Kolk, Onno van der Hart, Shoshana Felman, Dori Laub, Robert Lifton, and, of course, Cathy Caruth herself.Emphasis on the reality of traumatic shock (as abuse, stress, accident, and so on), however important it may be, loses sight of a hermeneutical dimension of psychoanalytic therapy that Caruth and her contributors emphasize: the question of how meanings are associated or bound to the understanding of life’s events. My own clinical approach to psychoanalysis favors the introduction of an even stronger hermeneutical perspective that is sensitive to the kinds of issues raised by philosophers like Dilthey, Heidegger, Benjamin, and Gadamer, for whom the question of experience is not reducible to restricted understandings of stimulus/response, nor—as in the case of Caruth (for example, in Unclaimed Experience)—to the privileging of language as a formal (that is, literary) construct. Rather, I am interested in emphasizing a hermeneutics of the therapeutic encounter within which questions of language, culture, history, and behavior are situated. With respect to trauma therapy, I will introduce a number of well-known analytical contributions even as I take the following statement of Arnold Modell’s as my point of departure:The analyst or therapist becomes an unwitting collaborator in the recreation of the past, while still retaining a proximity to present time. The therapist becomes the person with whom one can reexperience trauma within a new context or experience for the first time what has been absent in the past. Affects belonging to... (shrink)

Black people experience lower quality and lesser quantity of sleep than white people. Researchers, however, do not believe that racial disparities in sleep sufficiency are caused by biological differences, but rather by various social differences, such as differences in sleeping environments and socioeconomic status. Racial disparities in sleep sufficiency are a matter of social justice because sleep is important to mental and physical health, meaning racial disparities in sleep sufficiency can contribute to unequal and unjust disparities in overall health. Racial (...) disparities in sleep may also be linked to other racial disparities in health that black people disproportionately experience such as hypertension and obesity. Sleep hygiene, common therapeutic advice given to help induce sleep, is often the first step to helping people sleep. Sleep hygiene, however, does not address the social, legal, cultural, and economic causes of racial disparities in sleep sufficiency. Sleep hygiene, as an ideal theory, addresses sleeplessness under ideal circumstances, only which a small group of privileged people live. Sleep hygiene ignores the unequal circumstances that contribute to some black people’s sleeplessness. Nonideal theory, however, acknowledges the less than ideal circumstances of certain groups, including people of color, and gives us a framework to develop solutions to racial disparities in sleep sufficiency. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Beyond EngelClinical Pragmatism as the Foundation of Psychiatric PracticeDavid H. Brendel (bio)Keywordsbiopsychosocial model, pluralism, pragmatism, psychiatryFor many years now, there has been growing recognition of the powerful role of pragmatic reasoning in numerous disciplines, including bioethics, medicine, law, political science, and philosophy (Dickstein 1998; Rosenthal, Hausman, and Anderson 1999). But until recently, philosophical pragmatism was neglected by scholars exploring the clinical challenges and theoretical underpinnings of psychiatry. In his (...) noteworthy article The Biopsychosocial Model and Philosophic Pragmatism: Is George Engel a Pragmatist?, Bradley Lewis offers a significant contribution to the small but gradually increasing literature in this area. Lewis appropriately presents Engel as a major figure in twentieth-century American medicine and psychiatry, a critic and a visionary who dared to question the dominant paradigm of biomedical reductionism (Engel 1977)—a paradigm that led to important scientific advances, but also restricted the physician’s understanding of the patient as a complex individual with an inner world and interpersonal relationships. Lewis argues that medicine and psychiatry a generation after Engel’s seminal 1977 paper can be revitalized by reinterpreting Engel in the intellectual tradition of classical American pragmatism and neo-pragmatism. Placing Engel in the pragmatic tradition, Lewis suggests, could enhance the biopsychosocial model and have substantial benefits for both individual patients and society as a whole.There is no disputing Lewis’s argument that a pragmatic philosophy of medicine and psychiatry is a noble goal. In fact, in my book Healing Psychiatry: Bridging the Science/Humanism Divide (Brendel 2006), I present philosophical pragmatism as the most compelling theoretical approach to clinical psychiatry in the twenty-first century—the approach that is most likely to empower the clinician and the patient to collaboratively develop a treatment plan that heeds the multidimensional complexity of the patient’s life, recognizes the confusion and uncertainty that grows out of this complexity, and aims for a favorable therapeutic outcome. Drawing on work of the classical American pragmatists and contemporary pragmatic bioethicists, I identify four dimensions of philosophical pragmatism that provide a sound foundation for clinical work, which I call the “four ps”: (1) diagnostic formulations and treatment plans in psychiatry are practical insofar as they focus on results rather than a commitment to any particular theory; (2) they are pluralistic [End Page 311] insofar as they incorporate explanatory concepts that span the biopsychosocial spectrum; (3) they are participatory and collaborative, not imposed authoritatively by the clinician; and (4) they are provisional, open-ended, and malleable to newly acquired information and evolution of the patient’s condition.Lewis casts Engel as a philosophical pragmatist who battled the Goliath of biomedical reductionism that had come to dominate American medicine and psychiatry in the latter half of the twentieth century. Unfortunately, however, regardless of how elegantly Lewis reinterprets Engel, he cannot render him a full-blown pragmatist for the medicine and psychiatry of the twenty-first century. Lewis provides quotations to suggest that Engel valued a results-oriented clinical sensibility, for example “the value of a scientific model is measured not by whether it is right or wrong but by how useful it is” (Engel 1980). But Engel was not fully committed to clinical outcome as the supreme judge of theory in medicine and psychiatry. Lewis notes that Engel understood the biopsychosocial model as less “a matter of compassion and humanity” and more a matter of “rigorous application of the principles and practices of science”; he was a man of his time who could not fully escape the scientism of the day. Working within this scientistic world, he distinguished himself by reintroducing psychological, sociological, and humanistic concepts into clinical medicine, which had become obsessed with the power and robustness of the natural sciences but had neglected the suffering human subject and the social context of illness. Engel undoubtedly hoped the biopsychosocial model would lead to better clinical results but, unlike the classical American pragmatists and contemporary pragmatic bioethicists, he did not make a systematic case for privileging clinical outcome above strict adherence to scientific theory.In fact, Engel’s biopsychosocial model runs the risk of becoming a reified end in itself; those who unquestioningly espouse its basic tenets are in danger of... (shrink)

The problem of identity is one of the milestones of philosophical thinking. It is a complex question, a prism with multiple vertices. In this paper I will focus on two key-concepts related to identity, namely, death and community. Death stands as end of life, but as a possibility of it. The ghost "appears", then, in a privileged position for the dialogue and the understanding of this phenomenon. Moreover, as social beings, neither individuals can be separated from the community in which (...) they are registered; nor it is possible to distance the ghosts and functions historically fulfilled in this respect. Throughout the text I will discuss the functions that have been and those that would be of ghosts; understanding ghosts as a referring dialogic and therapeutic constitution of identity. El problema de la identidad constituye uno de los hitos fundamentales de pensamiento filosófico. Es una cuestión compleja, un prisma con múltiples vértices. El presente artículo se centrará en dos hitos fundamentales relacionados con la identidad, a saber: muerte y comunidad. La muerte se sitúa como fin de la vida, pero como posibilidad de la misma. "Aparece", entonces, el fantasma en una posición privilegiada para el diálogo y la comprensión de este fenómeno. Además, en tanto seres sociales los individuos no pueden ser separados de la comunidad en la que se inscriben. Tampoco es posible distanciar a los fantasmas y las funciones cumplidas históricamente en este aspecto. A lo largo del texto se examinarán cuáles han sido y pueden ser estas funciones a cumplir por los fantasmas entendidos como referente dialógico y terapéutico de la constitución de la identidad. (shrink)

Classical medicine operates in a climate of rational discourse, scientific knowledge accretion and the acceptance of ethical standards that regulate its activities. Criticism has centred on the excessive technological emphasis of modern medicine and on its social strategy aimed at defending exclusiveness and the privileges of professional status. Alternative therapeutic approaches have taken advantage of the eroded public image of medicine, offering treatments based on holistic philosophies that stress the non-rational, non-technical and non-scientific approach to the unwell, disregarding traditional (...) diagnostic categories and concentrating on enhancing subjective comfort and well-being, but remaining oblivious to the organic substrate of disease. This leads to questionable ethics in terms of false hopes and lost opportunities for effective therapy. (shrink)

A new study entitled “Normal gut microbiota modulates brain development and behavior”, published in the Proceedings of the National Academy of Sciences, requires that we reconsider the notion that the brain is an immune‐privileged site. The authors demonstrate that intestinal microbiota must be present within a set time‐frame for normal synaptogenesis to occur in the brain. In the absence of intestinal microbiota, histopathological and behavioral abnormalities arise. These observations necessitate a new look at the many interconnections of the immune system (...) and the brain, suggesting new frontiers for research and new therapeutic strategies for neurodevelopmental diseases. (shrink)

Package leaflets belong to the complex communication system related to the minimization and prevention of pharmaceutical risk. Their legal nature is not exhausted by safety regulation though: as a privileged form of product instruction, they are also subject to liability regulation with a consequent reallocation of damage responsibility through risk disclosure. This article presents the results of a doctoral dissertation devoted to the legal and communicative analysis of PL information. After illustrating the articulation of pharmaceutical risk through risk prevention norms, (...) the paper goes on with a discussion of the PL role within the therapeutic decision as a complementary vehicle to doctor’s information. It results that the liability framework in which both information channels are embedded determines a communication model, which far from promoting a shared decision process, radicalizes the two-step communication structure typical of the informed consent model inherited by surgery judicature. The second part investigates PL information as a source of knowledge updating through the methodological tools provided by Bayesian decision theory. Finally, an empirical study conducted over a sample of 55 drug consumers investigates the impact of PL information on drug risk perception and its perceived value to therapeutic decision. (shrink)

In this article, based on my doctoral research, I discuss the appropriation of religious elements from South America by Finnish ‘mystical tourists’. The plant medicine ceremonies are approached as spiritual commodities. Imagining local beliefs and practices as ancient cultural heritage, essentially and authentically spiritual, Finnish mystical tourists adapt these practices for their own therapeutic uses. They are accompanied by singing prayers to various plant spirits. Among the appropriated elements are the ceremonial ingestion of imported organic cacao, sacred tobacco and (...) ayahuasca, as well as praying by singing to plant spirits understood in terms of animism. My findings indicate how the appropriated cultural elements are given therapeutic functions in collectively created musical and ritual spaces for individual well-being. I analyse appropriation in categories introduced by Richard A. Rogers (2006) and understand the ceremonies to provide ‘mystical tourists’ with a role as a racially privileged group over the subaltern indigenous peoples through processes of commercialization, where reimagined cultural elements become spiritual commodities to be bought and sold in commercial networks on the basis of access. I argue that the associated forms of cultural appropriation align with the individualistic spiritual well-being needs of the Finnish participants and are related to the theme of ‘sacralization of the self’. (shrink)

For decades, Anderson has been pressing critical theorists and literary scholars to acknowledge the inescapably normative dimensions of their work. Through careful attention to rhetorical styles, she has persuasively argued that epistemological positions and social theories are tethered to “characterological” judgments—to implicit endorsements of ethos. Meanwhile, critical discourse has warmed to the claims of lived experience (the “turn to ethics,” the interest in “affect”), but the “ethical” has remained a negative movement, either as the critique of social and discursive structures (...) or as clearing space for the “other”—and “affect” has been construed as the pleasure and self-care that enable resistance to the pressure of these structures. The questions that galvanize ethical criticism (What is wrong with the way things are?) and theories of affect (How can I survive?) continue to evade the deeper one that Anderson sees as basic to any theorizing: How should I live?The lesson of Anderson's The Way We Argue Now is that ethics without ethos is shallow. In Psyche and Ethos, the lesson is that psychology without morality is benumbed. Though Anderson is characteristically judicious in her reconstruction of the arguments she opposes, there are several rhetorical targets in these lectures. The first is contemporary cognitive science, which pictures moral thinking as either the “belated” rationalization of decisions really made by “automatic” psychological processes or as a mechanism for eliminating “cognitive dissonance.” Anderson shows how these pictures assume an abstracted, “punctual” model of moral experience; their “deflationary” zeal ironically depends on an untenable ideal of moral voluntarism that is then speciously “debunked.” By contrast, novels are able to explore the temporal dimension of moral consciousness, especially through their representation of what she calls “moral rumination,” a concept further developed in her recent contribution to Character: Three Inquiries in Literary Studies. Anderson shows, moreover, that narrative fictions like The Winter's Tale, Middlemarch, and The Beast in the Jungle understand “belatedness” not as evidence for the superficiality of morality but as a distinct mode of moral recognition that can unfold only across time.Anderson worries that the new “eudaimonic” literary criticism, which explores “enabling moods,” unwittingly perpetuates the moral confusion of empirical psychology and “privileg[es] psychological over moral desiderata,” even as certain “psychological states” are “presented as morally desirable.” This contradiction is another iteration of one she has been confronting throughout her career: the strange incapacity of critical discourse either to recognize or to avow the normative claims—the elaboration of an ethos as good or valuable—with which it is nonetheless saturated. Still, the contradiction has been a defining feature of modern “therapeutic culture” (a formulation she employs): the neutral, functionalist descriptions of empirical psychology ostensibly bracket morality, yet some descriptions are inevitably coded as “better” or “worse,” and they are consistently harnessed to fully moral evaluations. It is rare to hear a literary theorist of Anderson's provenance reanimate, if indirectly, the criticism that Philip Rieff, Christopher Lasch, and Jackson Lears directed toward “therapeutic culture,” which has largely been forgotten or vulgarized by right-wing pundits. In essence, however, her plea is similar to theirs: she wants us to acknowledge that the moral life is integral to the “healthy” life; and she wants critics to stop dismissing it as epiphenomenal to either psychology or politics. She sees the novel, and the humanities more broadly, as the preeminent cultural vehicles for “clarifying” the moral life. (shrink)

This chapter examines Thoreau’s experiences on Mt. Katahdin, vis-à-vis exposure science and wilderness therapy. A close reading of Thoreau’s account suggests the experience had a profound effect on him, emotionally and philosophically, an effect that is relevant to environmental exposure and eco-vulnerability in the contexts of the COVID-19 pandemic and climate change. Thoreau’s experience on that mountain presented to him an aspect of wilderness antithetical to the romantic, transcendentalist notions he previously held and ultimately led to more nuanced, therapeutic (...) depictions found in works like “Walking” and Walden. That such a reconciliation was possible for Thoreau suggests a privileged insulation from trauma not afforded to many. It also indicates the value of both philosophical contemplation and wilderness therapy to promote psychological resilience and adaptability. The author argues philosophers should begin to engage conceptually and normatively with exposure, vulnerability, and resilience. (shrink)

The term “patent” is an abbreviation of “letters patent”, the open form of document historically issued by the Crown for the purpose of conferring a right or privilege or otherwise communicating the royal will. In contemporary law it denotes the species of intellectual property that is granted as an inducement for the creation and disclosure of novel, inventive and industrially applicable inventions. In the UK that property is conferred under the Patents Act 1977, or with similar effect the European (...) Patent Convention (EPC), and comprises the exclusive right to use and sell a protected invention for up to 20 years. A protected invention may be any subject matter having technical character; a definition derived from the Act’s express exclusion from patentability of (among other things) discoveries, scientific theories, business methods and computer programs “as such”. Also excluded are surgical, therapeutic and diagnostic methods (for lack of industrial applicability), and inventions the commercial exploitation of which would be contrary to public policy or morality. In these and other respects the Patents Act follows the EPC, which it was the explicit purpose of that Act to implement. Patents are territorial, and are thus only valid and infringed in their country of issue. For a UK inventor to obtain protection outside the UK s/he must therefore obtain a patent from that country, either directly by applying under its laws, or if it is a party to the EPC or other intergovernmental agreement, indirectly by applying under that agreement. Inventors seeking protection for an invention in more than one country will often do so by means of the Patent Cooperation Treaty. (shrink)

A definition of virtual or virtuality is not an easy task. Both words are of recent application in Philosophy, even if the concept of virtual comes from a respectable Latin tradition. Today’s meaning brings together the notions of potentiality, latency, imaginary representations, VR, and the forms of communication in digital media. This contagious, and spontaneous synonymy fails to identify a common vein and erases memory as a central notion. In the present essay, I’ll try to explain essential features of the (...) concept of virtual, taking the investigation of memory troubles in Pierre Janet’s work as an exemplification. Pierre Janet’s work represents a rare combination of medical observation and description of symptoms of mental illnesses, therapeutic guidance in hypnosis and philosophical writing about the main psychological themes of an epoch in transition from a Metaphysics of the Soul to the modern Experimental Psychology. Pierre Janet’s intellectual evolution since the 1880s until the end of his life is dominated by the philosophical project of a theory of the psychic system supported by three basic pillars: a concept of personality, a theory of memory and a sketch of a general theory of conduct. Such complex endeavour cannot be abstracted from the initial connections with Jean-Martin Charcot’s school at La Salpêtrière which meant a turning point in the tradition of the “animal magnetism” concerning the treatment of epileptic-hysterical symptoms along with the contributions of Hyppolite Bernheim’s “Nancy School” of hypnotism. J.-M. Charcot’s or H. Bernheim’s theorising about the organic and psychological aspects of the hypnotic treatment of the hysterical symptoms was already aware of the difficulty in dealing with the extent of the dissimulation of the patients regarding the symptoms of the illness, under hypnotic suggestion, even if Charcot insisted in the identification and cataloguing of the organic expressions, such as contractures or the posture of the body in arc during the attacks. The precise location of the “great hysteria” in the organic-psychic corridor was itself a riddle. If a symptom is a special type of sign, in the case of the “great hysteria” nobody knew for sure what it stood for. The clinical symptom of the attack stood for an organic trouble with cerebral causes, a psychological interruption of the normal sensorial and muscular movements or a disguise of the female desire? Pierre Janet described many hysterical patients, somnambulism and multiple personality since his articles in La Revue Philosophique de la France et l’ Étranger, a Journal founded by the philosopher, experimental psychologist and his intellectual predecessor Théodule-Armand Ribot. The description of the case of the “great hysterical” Lucie, treated by him, is an example of a theoretical hypothesising on multiple personality and discontinuity of memories fragments. There are more cases revealing the same relation between hysteria, somnambulism, personality dissociation and “alternating memory”. Decisively inspired by and corroborating P. Janet’s ideas, S. Freud conceived also the essential of the hysterical sicknesses as disorders of memory. The theme of memory came even more to the foreground in the dissertation L’Automatisme Psychologique. Here, the strange world of somnambulism was scrutinised along with hysterical contractures and convulsions, anaesthesia, the compulsion to repetition, obsessions, “automatic writing” in hysterical patients, multiple personality and “alternating memories”. In the depicted cases memory could not be taken as a homogenous series of remembrances or as a stock of disposable information but as a variable of the depth of the personalities’ inner formation. The so-called “seconde existence” of some somnambulists referred not only unconscious representations and unconscious thoughts but complete or inceptive latent personalities provided with multiple virtual existences and multiple memories. Hypnosis was the privileged technique to access to such multiple memories ignored by the official personality. Later and after the writing of his M.D. Dissertation, Contribution à l’ Étude des Accidents Mentaux chez les Hystériques, P. Janet addressed again the themes of memory and alternating memories in a series of lectures at the Collège de France but now according to the larger framework of a general theory of conduct which included a description of the social actions participating in the narrative construction of personal memories, and the role of social memory. (shrink)