Tuesday, May 15, 2012

Philosophy and Mental Health - Tim Thornton

Philosophy and Mental Health - Tim Thornton

Philosophy and Mental Health
Because of its very nature, mental health care raises as many conceptual questions as empirical ones. The philosophy of mental health - also called the 'new philosophy of psychiatry' although it is not narrowly psychiatric - is a rapidly developing field developed by philosophers, clinicians (e.g. psychiatrists and mental health nurses) and mental health service users.
As well as its youth, the new philosophy of psychiatry has two further features that make it stand out. Firstly, it is not a 'natural kind'. There is not an established set of inter-related problems with familiar, if rival, solutions. It is an area where philosophical methods, accounts and theories can be applied to psychiatric phenomena and thus it also serves to test those accounts. To take one type of example, psychopathology is a test track for theories in the philosophy of mind. Symptoms such as thought insertion, where subjects experience their thoughts as somehow not their own, challenge accounts of the everyday 'ownership' of thoughts. But there is also traffic the other way. Three centuries of discussing the relationship of mind and body have furnished philosophers with a variety of subtle models (from forms of dualism, through gradations of physicalism, to eliminativism with modern alternatives such as enactivism) which can help in the interpretation of psychiatric data.
Secondly, unlike some areas of philosophy, philosophy of psychiatry can have a genuine impact on practice. It is a philosophy of, and for, mental health care. It provides tools for critical understanding of contemporary practices, and of the assumptions on which mental health care more broadly, and psychiatry more narrowly, are based. Thus it is not merely an abstract area of thought and research, of interest only to academics. In providing a deeper, clearer understanding of the concepts, principles and values inherent in everyday thinking about mental health, psychiatric diagnoses and the theoretical drivers of mental health policy, it can impact directly on the lives of people involved in all aspects of mental health care.
Values, meanings, facts
A brief examination of the history of the subject reveals why the discipline of psychiatry is particularly suited to contributions from philosophy. Whilst the father of psychopathology, the German philosopher and psychiatrist Karl Jaspers, combined psychiatric and philosophical expertise, within the English speaking tradition philosophy and psychiatry went their separate ways throughout most of the twentieth century. (By contrast, in mainland Europe the connection between psychiatry and phenomenological philosophy has continued since Jaspers' day.)
But towards the end of the twentieth century, the rise of the anti-psychiatry movement prompted a resurgence of philosophical interest in psychiatry. This was because a key element of the anti-psychiatric criticism of mental health care turned on a contentious claim about the nature of mental illness: mental illness does not exist; it is a myth. Such a sceptical claim is paradigmatically philosophical and one of the main proponents of anti-psychiatry, the psychiatrist Thomas Szasz, put forward a number of philosophical arguments in support of it. These turned on the fact that psychiatric diagnosis is essentially evaluative. From this he concluded that, unlike physical illness, it could not be medically treated because as illness it was not real. (The apparent reality of mental illness is best explained, according to Szasz, as the reality of non-medically treatable life problems.)
Szasz's sceptical arguments spurred responses by both psychiatrists and philosophers questioning whether diagnosis is, after all, essentially evaluative and, if it is, whether Szasz's conclusions followed. Thus the analysis of mental illness, and the role of values in that analysis, lies at the heart of recent philosophy of psychiatry.
In addition to the importance of values, two further key areas of mental health care prompt immediate philosophical questioning. Firstly, psychiatry since Jaspers has sought to balance two key elements: investigation of the bio-medical facts and empathic investigation of subjects' experiences. Both bio-medical facts and meanings (broadly construed to include experiences, beliefs and utterances) need somehow to be integrated into mental health care. This marks a sharp delineation from other areas of medicine where subjects' experiences are subordinate to the physically described symptoms and organic pathology with which they present. By contrast, psychiatric disorders seem to involve problems of the 'self' (however this is construed) in which experiences, behaviour and beliefs play a fundamentally important role in the onset, course and recovery of symptoms.
This raises questions of both the nature of the distinction between explanation according to the canons of the natural sciences (the 'realm of law') and understanding meaningful connections (in the 'space of reasons') and the relationship between natural scientific facts and meanings. If there is a clear distinction and meanings are conceptually irreducible to biomedical facts, efforts to understand the nature of this relationship become all the more philosophically interesting.
Secondly, there has been much work by psychiatrists since the Second World War to develop psychiatric classification or taxonomy. This has, historically, been in response to a concern about a lack of agreement or reliability about psychiatric diagnosis. More recently, there has been growing concern that reliability has been improved but only at the cost of validity, or underlying truth, of classificatory schemas. The worry is that psychiatric diagnostic systems may not 'carve nature at the joints'. This concern has also been reflected in philosophy of psychiatry as an instance of a broader question of the role of science in mental health care. Thus the nature of the facts in question is still very much up for grabs.

Philosophical Perspectives on Psychiatric Diagnostic Classification (The Johns Hopkins Series in Psychiatry and Neuroscience): Dr. John Z. Sadler MD, Dr. Osborne P. Wiggins Jr. PhD, Dr. Michael A. Schwartz MD: 9780801847707: Amazon.com: Books

Philosophical Perspectives on Psychiatric Diagnostic Classification (The Johns Hopkins Series in Psychiatry and Neuroscience): Dr. John Z. Sadler MD, Dr. Osborne P. Wiggins Jr. PhD, Dr. Michael A. Schwartz MD: 9780801847707: Amazon.com: Books

Philosophical Perspectives on Psychiatric Diagnostic Classification (The Johns Hopkins Series in Psychiatry and Neuroscience) [Paperback]

Dr. John Z. Sadler MD (Editor), Dr. Osborne P. Wiggins Jr. PhD (Editor), Dr. Michael A. Schwartz MD (Editor)


Book Description

April 1, 1994 The Johns Hopkins Series in Psychiatry and Neuroscience
As the biological and psychosocial technologies in psychiatry continue to expand, the need for careful critical reflection on the scientific, ethical and practical aspects of psychiatry becomes ever greater. In "Philosophical Perspectives on Psychiatric Diagnostic Classification", John Osborne Wiggins, Michael Scwartz and others present a philosophical exploration of conceptual difficulties in psychiatric taxonomies or nosologies, using the current official American Psychiatric Association diagnostic handbook, the "Diagnosis and Statistical Manual of Mental Disorders (DSM)" as an example.

Editorial Reviews


"The book begins with a 'must read' introductory and historical chapter by Edwin R. Wallace IV that provides a good foundations for readers embarking on a philosophical journey through psychiatric taxonomy." -- Journal of the American Medical Association

Values and Psychiatric Diagnosis - John Z. Sadler - Google Books

Values and Psychiatric Diagnosis - John Z. Sadler - Google Books

Front Cover
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Values and Psychiatric Diagnosis

By John Z. Sadler

Break Up the Psychiatric Monopoly - Friday, May 11, 2012 - By ALLEN FRANCES | D.S.M. Panel Backs Down on Diagnoses - Tuesday, May 08, 2012 - By BENEDICT CAREY - NYT > Psychiatry and Psychiatrists - Behavior and Law

Behavior and Law

NYT > Psychiatry and Psychiatrists

Behavior and Law: Mike Nova: American Psychiatry At The Crossroads - short version

Behavior and Law: Mike Nova: American Psychiatry At The Crossroads

Thursday, 8:23 AM 5/13/2012

Mike Nova: American Psychiatry At The Crossroads

Mike Nova: American Psychiatry At The Crossroads

Last Update: 8:55 AM 5/11/2012

"It should broaden its theoretical and conceptual outlook... it should assume its rightful leadership role in World Psychiatry... by discarding the outdated stereotypes, not reinforcing them" |

Thank you, Dr. Frances; for your previous work and for your courageous and independent stand now. |

James Phillips: "Indeed, psychiatric nosology and the DSMs provide a vast arena for what are, explicitly or not, hermeneutic deliberations." |

Did American Psychiatry sell its soul to profit-hungry (Psycho)Pharmaceutical Industry for a couple of their logo pens? Is it not the time to stop all this "DSM-s In Perpetuity" madness? And not to spend another $25 or more ml. for the next round of controversies and wide-spread public scepticism and criticism?" |

"Empirical explanation and treatment repeatedly fail for psychiatric diagnoses. Diagnosis is mired in conceptual confusion that is illuminated by Ludwig Wittgenstein's later critique of philosophy (Philosophical Investigations).

A diagnosis is a sort of concept that cannot be located in or explained by a mental process. Conclusion: A diagnosis is an exercise in language and its usage changes according to the context and the needs it addresses."

Psychiatric diagnoses are not mental p... [Aust N Z J Psychiatry. 2012] - PubMed - NCBI


"Much less clear, even in the US, is whether
the approach is commonly used by clinicians in ordinary
practice, thus really resulting in an increase of the reliability
of psychiatric diagnosis in clinical settings. It has been, for
instance, reported that several US clinicians have difficulties
to recall the DSM-IV criteria for major depressive disorder
and rarely use them in their practice (e.g., 2). Furthermore,
some of the DSM-IV cut-offs and time frames have been
found not to have a solid empirical basis (e.g., 3) and to
generate a high proportion of sub-threshold and “not otherwise
specified” cases (e.g., 4).

The spontaneous clinical process does not
involve checking in a given patient whether each of a series
of symptoms is present or not, and basing the diagnosis on
the number of symptoms which are present. It rather involves
checking whether the characteristics of the patient
match one of the templates of mental disorders that the clinician
has built up in his/her mind through his/her training
and clinical experience."

Mario Maj
President, World Psychiatric Association
Psychiatric diagnosis: pros and cons of prototypes...

Drug companies like Pfizer are accused of pressuring doctors into over-prescribing medications to patients in order to increase profits - GALLO/GETTY


American Psychiatry should broaden its theoretical and conceptual outlook beyond the narrow professional concerns about diagnostic systems and classifications (at this time, with all the enormous importance of these issues, we are not ready for the true scientific approach towards resolving them; and the practical problems with "reimbursements" and "parities" should be left for actuaries and medical records departments to resolve). Recent controversies about DSM-5 indicate that the whole conceptual direction of improving and perfecting diagnostic pseudonosological labeling system (and the professional and social power of labeling that comes with it) hit a roadblock and is in "no exit" blind alley. How can we introduce a true, medically scientific and evidence based classification system for mental disorders if we still know so little about their nature and origins? The attempts to codify the current clinical labels are methodologically and epistemologically dangerous because they reinforce the current clinical belief system with its multitude of misconceptions. The history of science and medicine in particular is replete with these kind of errors. Preoccupation with improving the reliability by forced agreement (which by itself proved to be impractical and next to impossible) does not affect the much more important issues of validity of psychiatric diagnosis, and, if anything, leads to their neglect and displacement (not only in psychodynamic, but real sense) from our area of interests and scientific horizons, almost relegating these issues to the province of "conspiracy of silence". How can we agree on something, if we don't really know what this "something" is or if it even really and "truly scientifically" exists? And why should we agree on this "unknown something?"
Medicine and psychiatry are empirical and "practical sciences"; we are not just "talkers" and "labellers"; we are "doers": our task is to ease mental pain and suffering (of which this world is aplenty) for individuals, groups and societies. We do it in the dark, our knowledge is still limited and trues are hidden. We should not reinforce these limitations, presenting "blind spots" as medical facts, but should accept them, be aware of them and work further, relentlessly, and completely with an open mind to resolve them. Narrow professional concerns with "parities and reimbursements" or any business interests of any kind (including the profits from publishing  a manual - APA is not just a publishing house) should not be a consideration and should not stand in the way of scientific research and progress in modern psychiatry. This probably was the "primal and original sin" which lead the whole DSM improvement effort astray.
American Psychiatry should assume its rightful leadership role in World Psychiatry with its bold and broad, open and independent minded, scientifically eclectic stance, discarding the outdated stereotypes, not reinforcing them; the stance worthy of this great nation and its spirit.

References and Links:

Mike Nova: Breivik Trial and The Crisis Of Psychia...

Thursday, April 19, 2012

Mike Nova: Breivik Trial and The Crisis Of Psychiatry As A Science

Mike Nova

Breivik Trial and The Crisis Of Psychiatry As A Science

Breivik is not the only one who is on this trial. Psychiatry as a science is on this trial also, just like on many other trials where forensic psychiatric involvement is sought. This is highlighted by the two contradictory psychiatric assessments of the accused, with their directly opposing diagnostic impressions and directly conflicting main general conclusions. The first forensic psychiatric evaluation, completed on November 29, 2011 by the psychiatrists Torgeir Husby and Synne Sørheim found Breivik to be "paranoid schizophrenic" and "psychotic" at the time of the alleged crime and presently and therefore legally "insane". A leaked copy of the initial psychiatric examination described his crusader fantasy as a product of the "bizarre, grandiose delusions" of a sick mind.
The second evaluation, about 300 pages long, made by the psychiatrists Terje Toerrissen and Agnar Aspaas on a request from the court after widespread criticism of the first one, was completed on April 10, 2012, just six days before the trial, but was not released, and according to the leaked information, found him afflicted with "narcissistic personality disorder" with "grandiose self" and not psychotic at the time of the alleged crime and presently and therefore legally "sane".
The latest psychiatric report was confidential, but national broadcaster NRK and other Norwegian media who claimed to have seen its conclusions said it described Breivik as narcissistic but not psychotic.
Torgensen gets the impression that Breivik found an ideal place to nourish his delusions of grandeur in the anti-Islamic scene full of crusader fantasies. “This was coupled with an extremely sadistic disorder,” Torgensen says. “This disastrous combination could explain the scale of his violence.”
The new report from forensic psychiatrists Terje Tørrissen and Agnar Aspaas concludes that he did not have “significantly weakened capacity for realistic evaluation of his relations with the outside world, and did not act under severely impaired consciousness”.
"Our conclusion is that he (was) not psychotic at the time of the actions of terrorism and he is not psychotic now," Terje Toerrissen, one of the psychiatrists who examined Breivik in prison, told The Associated Press.
Thus, as it almost always happens in complex forensic psychiatric cases, it was left for the infinite wisdom and common sense of the court, unburdened by the "sophisticated" and empty psychiatric jargon, to decide by itself, and rightly so, the "main questions" of the accused's mental illness or mental health and his "sanity" or "insanity" and to make its own, judicial decision regarding the issue of legal responsibility. Both mutually conflicting (but not mutually exclusive) forensic psychiatric evaluations, which, no doubt, were performed in good faith and with utmost professional diligence, will be taken into account by the court, but were rendered almost irrelevant by their contradictions. Once again, psychiatry, pretending to be a medical discipline and a science, was humiliated and reduced to the position of a laughing stock for the public and the media.
Mr. Breivik's skillful and astute lead defense lawyer, Mr. Geri Lippestad, treating his client with respect and at the same time with appropriate professional distance and apparently convinced of his client's mental illness and "insanity", chose a strategy of presenting Mr. Breivik to the court and to the public "as is", letting him to reveal himself and his presumed mental illness fully as the engine of alleged criminal behavior, apparently counting that it will be convincing enough for both the judges and for the court of public opinion.
“This whole case indicated that he is insane,” Geir Lippestad told reporters. “He looks upon himself as a warrior. He starts this war and takes some kind of pride in that,” Lippestad said. Lippestad said Breivik had used “some kind of drugs” before the crime to keep strong and awake, and was surprised he had not been killed during the attacks or en route to Monday’s court hearing.
Lippestad, a member of the Labour party whose youth wing had been the target of Friday’s shooting rampage, said he would quit if Breivik did not agree to psychological tests.
Geir Lippestad said the new report means Breivik's testimony will be crucial "when the judges decide whether he is insane or not." The trial started on April 16 and is scheduled to last 10 weeks.
Mr. Breivik declared himself undoubtedly and completely "sane" and consistently, if somewhat eerily out of place and time, painted a self-portrait as a model and self-sacrificing ideological warrior, taking as an insult any, albeit "professional" opinions otherwise and dismissed them with anger and indignation.
“On this day,” he said, “I was waging a one-man war against all the regimes of Western Europe. I felt traumatized every second that blood and brains were spurting out. War is hell.”
"Breivik told the court that "ridiculous" lies had been told about him, rattling off a list which accused him of being a narcissist who was obsessed with the red jumper he wore to his first court hearing, of having a "bacterial phobia", "an incestuous relationship with my mother", "of being a child killer despite no one who died on Utoya being under 14".
He was not insane, he repeated many times. He claimed it was Norway's politicians who should be locked up in the sort of mental institution he can expect to spend the rest of his days if the court declares him criminally insane at the end of the ten-week trial. He said: "They expect us to applaud our ethnic and cultural doom... They should be characterised as insane, not me. Why is this the real insanity? This is the real insanity because it is not rational to work to deconstruct ones own ethnic group, culture and religion."
All this is fine and dandy, and, no doubt, the aforementioned infinite wisdom of Scandinavian level headed justice (embodied in a stern but motherly demeanor of the presiding Judge Wenche Elisabeth Arntzen) will eventually emanate from its somewhat obscure, slowly but surely turning and unstoppable wheels, hopefully to almost every one's satisfaction. And eventually, this horrendous crime, the purp and the trial will be almost forgotten and placed into archives for further studies.
But the nagging questions remain and will remain for some, and probably a long time: is psychiatry really a science? Or is it just a collection of "professional" opinions, mixed with convenient labels and outdated jargon? What is "sane" and what is "insane"? And how far should the justice go in its modern "humane" stance?

"Grete Faremo, Norway’s justice minister, has said that it plans to establish a committee to examine the role of forensic psychiatrists. She told Norwegian daily Aftenposten on April 13 the committee would have a “broad mandate” that would examine three key questions: What is sanity? What is the role of the forensic psychiatrist? And how do we take care of security when an insane man is sentenced?
“Much suggests that the medical principle is inadequate,” said Faremo. “It is a historic step we are now taking. It is an important step in light of the terrible incident and the trial we face and in consideration of people's sense of justice.”
“This is a big thing,” says Abrahamsen. “If it hadn’t been for Breivik, we wouldn’t have discussed this.”

References and Links

Psychiatry May Also Face Scrutiny at Norway Killer's Trial - NYTimes.com

Breivik trial: Norwegians rethink role of psychiatry in courts - CSMonitor.com

Breivik Trial and The Crisis Of Psychiatry As Science - Links


Friday, April 27, 2012

Response to Dr. Wessely

Response to Dr. Wessely

Normality or psychopathology of belief or belief system is determined first of all by the intrinsic qualities of belief in question. It is not determined by the fact that belief is shared or not shared: "Delusions are beliefs that are not only wrong, in the sense of not corresponding to the world as we know it, but they must also not be shared with others of the same cultural background."
There are many delusional beliefs that are or were shared, and some of them on a rather large scale. For example, the ancient Maya believed, that for the sun to rise they had to offer human sacrifices (of their best and brightest) every day, otherwise all kind of life on earth would come to a halt. This belief was shared very widely in precolumbian Maya culture, which does not make it less delusional.
Breivik's ultra nationalist anti-immigrant ideology is shared by great many people of various cultural backgrounds. The goal of his forensic psychiatric evaluation is to assess his own particular belief system, with all its peculiarities and idiosyncrasies, in order to determine its nature, qualities and psychopathological aspects, regardless of other similar beliefs. In the end, it was him, not others, who took these ideas to their logical (or rather illogical and "sick") extreme, although the (possibly facilitating) role of "significant others" in his case still has to be determined.
Neither the "monstrosity" and "grievous consequences" of his actions nor "popular misconceptions" should cloud the picture. The most important factor in his forensic psychiatric assessment is the presence or absence of identifiable and diagnosable mental illness and the degree of its causal relationship with the crime. In my opinion, whatever it is worth, psychopathological qualities of Breivic's beliefs: their highly systematised, structured, all embracing "world view" quality, along with their unshakable, messianic conviction and "call for action", indicate with high degree of probability the presence of Delusional Disorder, mixed, persecutory-paranoid type, and the direct and overwhelming causal connection of his psychopathology with the criminal act.
The cognitive aspect in psychopathology of Delusional Disorders (abnormalities and/or dysfunctions in concept selection, elimination and confirmation), indicating possible subtle but decisive organic involvement is much under-researched area, probably due to our neglect or inattention to biological aspects of these disorders and overestimation of its psychodynamic aspects. Delusional jealousy, secondary to chronic alcoholism (a very discrete and specific syndrome) is the case in point.
"The... misconception... that the purpose of psychiatry is to “get people off”" might be as wide spread as any other misconception, which does not make it any less of a misconception. The historically formed legal concept of "NGRI: not guilty by reason of insanity" is a witness to humanity and rationality on a  part of a society; not to mention other, less important but present factors, such as political and social convenience, expediency and cultural traditions. (E.g.: Disraeli to Queen Victoria: "Only a madman can think about assassinating your Majesty..."). Modern psychiatry, very likely, was born out of the M'Naghten rules, as some psychiatric historians suppose.
And last, but certainly not least, is the difficult and complex subject of "Schizophrenia", its clinical concept (and/or misconcept) and diagnosis (and/or misdiagnosis). The diagnostic label of "Schizophrenia" became so wide spread and all encompassing (because it is so easy to apply, and is applied almost indiscriminately), as to loose its meaning and clinical value. In our rush to nosological (and reimbursement) parity with the rest of medicine we jumped over our heads too soon, introducing the (man made) diagnostic criteria based "nosological" system, which leads to premature ossification and codification of clinical concepts and experience, impeding the independent minded research greatly and precluding the normal development (albeit slow and lagging) of psychiatry as a medical science. Is it not more correct and probably clinically more productive, especially in the field of psychopharmacology, to return to syndromologically based classification system and to try to define, refine and research these historically formed clinical syndromes further, before rushing to judgements about their pseudonosological "pigeon holes"?
This is what Breivic trial, along with other issues, brings to the front. And these issues deserve a deep and long thought.

Michael Novakhov, M.D.

References and Links

Anders Breivik, the public, and psychiatry : The Lancet

Anders Breivik, the public, and psychiatry : The Lancet

The Lancet, Volume 379, Issue 9826, Pages 1563 - 1564, 28 April 2012
doi:10.1016/S0140-6736(12)60655-2Cite or Link Using DOI


Sanity - Wikipedia, the free encyclopedia

In The Sane Society, published in 1955, psychologist Erich Fromm proposed that, not just individuals, but entire societies "may be lacking in sanity". Fromm argued that one of the most deceptive features of social life involves "consensual validation."[3]:

It is naively assumed that the fact that the majority of people share certain ideas or feelings proves the validity of these ideas and feelings. Nothing is further from the truth... Just as there is a folie à deux there is a folie à millions. The fact that millions of people share the same vices does not make these vices virtues, the fact that they share so many errors does not make the errors to be truths, and the fact that millions of people share the same form of mental pathology does not make these people sane.[4]

Fromm, Erich. The Sane Society, Routledge, 1955, pp.14–15.

sane society - Google Search

Erich Fromm - From Wikipedia, the free encyclopedia
Sunday, May 13, 2012

Mike Nova: I support Dr. Frances' idea about founding some new... interdisciplinary body for establishing current scientific criteria, principles, parameters and most adequate working models for clinical mental health (psychiatric) diagnosis

Last Update: 9:20 AM 5/13/2012

Mike Nova: I support Dr. Frances' idea about founding some new, superpsychiatric (possibly under combined umbrella of all the appropriate agencies that he mentioned) interdisciplinary body for

Establishing current scientific criteria, principles, parameters and most adequate working models for clinical mental health (psychiatric) diagnosis,

which should include efficient participation of philosophers, neuroscientists, geneticists, biologists, psychologists, sociologists, specialists in forensic behavioral sciences and lawyers.

Maybe, with a little help from our friends the "heavenly gate" to a new, broader scientific paradigm in psychiatry will crack open; a little.

And this might lead to true and real (not imaginary, as a product of the wishful thinking), scientifically revolutionary "paradigm shift". Any new paradigm in psychiatry (just like in any other scientifically oriented ideational activity, according to Kuhn) has to be significantly broader than the previous one, incorporating the new body of knowledge, disciplines and theories in a new conceptual framework, resolving the "anomalous contradictions" of the old paradigm which becomes conceptually inadequate to contain them.

This new paradigm must also fit into the larger current paradigmatic systems of scientific and cultural beliefs, and the present lively debate about the meanings and the essence of psychiatric diagnosis is one, and maybe the best indication that the old paradigm "does not fit", that it is scientifically (which is not synonymous with medical practice) - inadequate.

It is also interesting to observe that the battle for this new paradigm is waged in a mainstream media, which might also indicate "the revolutionary situation" expressed as a heightened public awareness and concerns which are absolutely justified, legitimate and significant.

James Phillips - Key Concepts: Hermeneutics - Philosophy, Psychiatry, & Psychology 3:1

James Phillips - Key Concepts: Hermeneutics - Philosophy, Psychiatry, & Psychology 3:1

Philosophy, Psychiatry, & Psychology 3.1 (1996) 61-69

Key Concepts: Hermeneutics

James Phillips

Keywords: psychoanalysis, philosophy of science, nosology, classification
Hermeneutics is a concept whose breadth and significance have continued to grow in contemporary thought--and in psychiatry. Since its scope can be best appreciated through an historical overview of its development, I will begin there and then proceed to a discussion of its place in psychiatry. Derived from the Greek verb hermeneuein, which means "to interpret," and the noun hermemeia, "interpretation" (and both associated with the god Hermes), the word was first used in the seventeenth century to mean biblical exegesis (Palmer 1969). The Protestant Reformation created a need to interpret the scriptures without the aid of church authority, and with the plurality of possible interpretations for any biblical text, a need arose to establish the principles of correct interpretation. Hermeneutics was the study of such principles. While the scope and content of the hermeneutical enterprise have changed vastly since these beginnings in biblical exegesis, the concept of hermeneutics retains its initial reference to the art and science of interpreting. In Palmer's words, "Whenever rules and systems of explaining, understanding, or deciphering texts arise--there is hermeneutics" (1981, 458).
The scope of hermeneutics was broadened significantly in the nineteenth century through the philosophers Friedrich Schleiermacher and Wilhelm Dilthey, who moved the focus of hermeneutical understanding from texts to all human productions--verbal and nonverbal, historical and current. For Dilthey the task was to respond to the nineteenth-century challenge that all knowledge must follow the model of the burgeoning physical sciences. He sought to secure for the humanist or cultural disciplines such as literature and history (the Geisteswissenschaften) a status that was different from but on par with that of the physical sciences (the Naturwissenschaften). To accomplish this he set about formulating the principles of understanding in each of the two kinds of disciplines. The methodology of understanding in the cultural sciences was modeled on the interpretation of a text and became the expanded notion of hermeneutics.
For Dilthey the core difference between the natural and cultural sciences lies in their respective objects of study--on the one hand an object in the world, on the other hand another person--and in the way we understand each. He summarized the difference with his categories of "explanation" (Erklären) and "understanding" (Verstehen). "The sciences explain nature, the human studies understand expressions of life" (1924, 144). Explanation [End Page 61] in the natural sciences comprehends its object through causal connections; it "knows" its object from the outside. The object remains alien to the human scientist. In contrast, understanding "knows" its object, a human being or a human production, from the inside. That is, I can know the inner life of another person because I also am a person. This is not a knowledge of causal connections but rather of a network of meanings, analogous to the network of meanings by which I understand myself (Dilthey 1883/1989).
Two points must be underlined about Dilthey's treatment of hermeneutics as the methodology of understanding in the humanities. The first is that the understanding does not take place through introspection or intuition. I do not understand myself through introspection, and I do not understand the other through intuition. Rather, it is the nature of life to express itself, and it is through an understanding of these objectifications of inner life that we understand ourselves and others. Hermeneutics is then the study and method of understanding human expression. For Dilthey the triad of "life, expression, and understanding" defines the field of the human sciences. The second point is that because human life, lived experience, is temporal, the categories by which we understand man and human productions will have to involve this temporality. Self-understanding in the present, for instance, involves a historical reflection on those fixed expressions of others that form our common past.
Hermeneutic methodology as developed by Schleiermacher and Dilthey generated a series of unique concerns that characterize the hermeneutic approach to understanding. The first is that of the hermeneutic circle or round. At each level of hermeneutic investigation--a literary text, a historical monument, a person's life--there is a part-whole structure in the understanding of meaning networks that is different from the causal analyses of the natural sciences. That is, in the meaning gestalt that comprises a novel, for instance, the part is understood in terms of the whole and the whole in terms of the part. We are not inclined to say that one chapter causes another but rather that it is related to it, and to the whole novel, in such-and-such ways. The same is true of the coherence of a human life. The apparent contradiction of the hermeneutic circle--understanding part and whole in terms of the other--is overcome by the way in which we in fact do plunge into a work, somehow grasping the part and the whole in terms of one another and at the same time. Other specifically hermeneutic concerns are a focus on the historical and psychological context of the author or agent and an emphasis on the individuality of the object of study.
The ever-widening scope of hermeneutics was taken to a new level in the twentieth century by the philosopher Martin Heidegger and his pupil Hans-Georg Gadamer. While influenced by his reading of Dilthey, Heidegger moved beyond hermeneutics as the method of the human studies and in his Being and Time (1927/1962) gave it an ontological dimension by describing understanding and interpretation as essential features of man's (Dasein's) being. He could then say both that Dasein is hermeneutic in his very nature or being and that he, Heidegger, in his analysis was offering a "hermeneutic of Dasein."
It was left to Gadamer to develop the full implications of Heidegger's ontological reformulation of hermeneutics. He did this in his magnum opus, Truth and Method (1960/1975). For Gadamer the emphasis in hermeneutics falls on historicity. The interpreter does not interpret and understand from an Archimedean point but is always immersed in his or her own historicity. Hermeneutics is an encounter between the researcher of the present, aware of his or her historically conditioned categories of understanding, and a past that presents itself for interpretation. From this perspective the very notion of an "historical object," separate from myself as the interpreter, does not make sense. In Gadamer's words, "a text is understood only if it is understood in a different way every time" (1975, 275­276). In Truth and Method this process of hermeneutic understanding is described as a "fusion of horizons." A horizon is "the range of vision that includes everything that can be seen from a particular vantage point" (1975, 269). Abstractly, there is a horizon of the present, the categories of understanding which we cannot see beyond, and [End Page 62] a horizon of the historical epoch that is being studied, the standpoint of the historical figure. But this is an abstraction. We do not disconnect ourselves from the past. The horizons of present and past overlap and fuse into one great horizon. Finally, the fusion of horizons is framed in terms of what Gadamer calls the logic of question and answer. The text engages us in a dialogue about its subject matter. The text, as a response to an implicit question, challenges us to address the same implicit question that it has confronted. Hermeneutic understanding of the past is then not a simple reconstruction of the context in which the historical text emerged; it is rather a conversation with the tradition in which the issues that exercised the particular epoch continue to exercise us.
The direction in which Heidegger and Gadamer took hermeneutics has been debated in recent decades. However, this debate does not represent the final chapter in our historical overview of hermeneutics. That distinction goes to the recent changes that have occurred in the philosophy of science. What has been called the "post-empiricist philosophy and history of science" (Hesse 1980) was initiated with the publication of Thomas Kuhn's enormously influential The Structure of Scientific Revolutions in 1962 (1962/1970). Kuhn challenged the traditional view of scientific progress as unidirectional and progressive with his distinction between "normal science," in which science advances incrementally within the established procedures, and "revolutionary" science, in which anomalies occurring in the accepted practices prompt scientists to question those practices and, in breaking with the usual procedures to accomodate the anomalies, create new norms by which science is done. The moment of crisis thus occurs when an innovative scientist encounters a problem that cannot be resolved within the current disciplinary matrix. Science then becomes revolutionary as new norms and a new disciplinary matrix are formulated. A significant part of any scientific tradition is the existence of exemplary problem-solving models--paradigms in the sense that Kuhn wishes to reserve for this term (1977, 293)--that provide training exercises and standards for students working within a particular disciplinary matrix. The discovery that generates the new disciplinary matrix will also generate new exemplars or paradigms for doing science. Of great significance is the fact that the terminology of the earlier tradition is not commensurate with the one that replaces it, and some kind of translation is therefore called for.
With his theory Kuhn rejected the traditional view that later scientific theories offer "progress" or a more truthful representation of reality and replaced it with the more modest position that later theories offer better solutions to certain puzzles. From this he drew the logical conclusion that progress in science is similar to, not different from, progress in nonscientific fields. In science as in the humanities the practitioner works out of a particular perspective and does not fully transcend his or her own history. In his first book Kuhn acknowledged borrowing notions of progress from the humanist disciplines, and in his later writings he declared his method to be hermeneutic. "What I as a physicist had to discover for myself, most historians learn by example in the course of professional training. Consciously or not, they are all practitioners of the hermeneutic method. In my case, however, the discovery of hermeneutics did more than make history seem consequential. Its most immediate and decisive effect was instead on my view of science" (1977, xiii).
With Kuhn's assertion that scientific progress is historically contingent and thus hermeneutic, the rigid Diltheyan opposition of science and the humanities was shown to be invalid. The perspectivism that was felt to be unique to the human studies was found in the natural sciences as well. With the collapse of a rigid distinction between hermeneutics and the scientific method, Kuhn's conclusions called for a revised understanding of hermeneutics. This was accomplished by the philosopher Richard Rorty in his (also quite influential) Philosophy and the Mirror of Nature (1979). Rorty argued that hermeneutics is not at all about the difference between science and the humanities but rather about incommensurability in any domain. Echoing Kuhn's conclusion that there is no single "correct" scientific account of reality, Rorty issued a challenge to [End Page 63] "epistemological foundationalism" in philosophy--that is, the conviction that one can reach a neutral ground from which to judge differing positions in epistemology. Rorty generalized Kuhn's distinction between normal and revolutionary science to that of normal and abnormal discourse in any discipline. Normal discourse is that in which there is agreement about terms and rules of adjudication. A disagreement can be resolved by reasonable people. Abnormal discourse, on the other hand, is that in which there is not agreement about terms and rules of adjudication. Abnormal discourse means incommensurability, and hermeneutics is now simply the effort to communicate, and continue to communicate, in the face of incommensurability. As a corollary of this redefinition of hermeneutics, "objectivity" for Rorty no longer carries an ontological claim of correspondence to reality but refers simply to the agreement among discussants.
As we turn from this historical review to the matter of hermeneutics in clinical theory and practice, it will prove useful to distinguish hermeneutics in psychoanalysis from hermeneutics in general psychiatry. The discussion regarding psychoanalysis has been fairly explicit (Phillips 1991; Strenger 1991), while the discussion concerning hermeneutics in general psychiatry remains inchoate and often more implicit than explicit.
The consideration of hermeneutics in psychoanalysis has transpired in three stages. The first was the challenge issued to traditional psychoanalysis three decades ago by psychoanalytic theoreticians like George Klein (1976) and Merton Gill (1976), who, while not working formally within the European hermeneutic tradition, questioned psychoanalysis' status as a natural science and argued that it had more to do with the understanding of meaning and purpose than with causal analyses. This effort to reformulate psychoanalysis rested on making a distinction between the clinical theory and the metapsychology in Freud's writings. The metapsychology was judged to be a superstructure of pseudoscience, while the clinical theory was considered to retain what is important in psychoanalytic experience. For Klein especially, the clinical theory is an explanation of behavior in terms of meanings, purposes, and intentions that is linked "more closely to the humanistic disciplines than to a natural science" (1976, 30). This effort to purify psychoanalysis of its pseudoscientific, metapsychological trappings is thus quite close to Dilthey's view of hermeneutics in the human sciences.
A second stage in the treatment of hermeneutics in psychoanalysis was the formal assimilation of psychoanalysis to the hermeneutic disciplines by the major philosophers Jurgen Habermas (1968/1971)--together with his associate Karl-Otto Apel (1979/1984)--and Paul Ricoeur (1965/1970, 1969/1974, 1981). It is to be noted, however, that while each of these philosophers argued for the hermeneutic status of psychoanalysis, each argued also that psychoanalysis is only partially a hermeneutic discipline, that it also contains features that are better treated with the categories of the natural sciences. For Ricoeur this means that the patient is not only someone involved in a network of meanings but also someone caught up in a field of mechanistic forces. The patient is thus to be treated both like a text to be interpreted and like an organism that is subject to causal mechanisms. For both Ricoeur and Habermas, then, psychoanalysis becomes a paradigm of the disciplines that contest any rigid separation of the hermeneutic and scientific methods.
A third stage in the hermeneutics/psychoanalysis discussion is represented by a more open recognition of hermeneutic principles by working psychoanalysts. A significant document in this regard is the final 1994 issue of The International Journal of Psycho-Analysis (Tuckett 1994). For the 75th Anniversary Edition of the Journal the editors organized a symposium on the subject of "The Conceptualization and Communication of Clinical Facts in Psychoanalysis." Given the assumption of virtually all the articles in this 300 page issue that there are no theory-free facts in psychoanalysis, this document might be regarded as the official death notice of positivism, and the official birth announcement of hermeneutics in psychoanalysis (Phillips 1995). Within the psychoanalytic community, Roy Schafer (1983, 1992) has stood out as the psychoanalytic theoretician who has most openly and articulately espoused a hermeneutic point of view. He has encompassed [End Page 64] all the complexity of the hermeneutic discussion in his writing: on the one hand a treatment of psychoanalysis as involved in the interpretation of meaning that carries the older view of hermeneutics, and on the other hand a discussion à la Kuhn and Rorty that addresses the theoretical pluralism--with competing and possibly incommensurable models--that has beset psychoanalysis. Focusing on the analyst's reworking (along with the patient) of the presenting narrative into a more psychoanalytically framed narrative, Schafer recognizes, one, that narratives are meaning structures and not force fields, and two, that the narrative developed by each psychoanalyst will be determined by the model from which he or she is working.
The consideration of hermeneutics in clinical psychiatry is more varied than the discussion in psychoanalysis. To begin with, hermeneutics entered psychiatry early with Karl Jaspers' adoption of Dilthey's concept of understanding (Verstehen) as the primary mode of comprehension for some psychiatric conditions, such as reactive states and some of the neuroses (Jaspers 1963). Then there is the fact that issues central to hermeneutics have emerged in psychiatry throughout the modern era, albeit not always in the explicit language of hermeneutics. One route of entry has been general medicine, where a humanist tradition has always accorded the "art" or "craft" of medicine a status equal to that of the "science" of medicine, and where a considerable literature in the philosophy of medicine has associated the "art" dimension with the hermeneutic tradition (Wulff, Pedersen, and Rosenberg 1986; Leder 1990). The same humanist tradition has of course been present in modern psychiatry and has given voice to aspects of clinical psychiatry that are here being labeled hermeneutic. In contrast, then, to the case of psychoanalysis, where it is relatively easy to review the major signposts in its dialogue with hermeneutics, the dialogue in general psychiatry has been more complex, and we will have to settle for a representative sampling of its encounter with hermeneutics.
It will aid our discussion to bear in mind the distinction made above between hermeneutics in the older sense, focused on the uniqueness of the human studies as contrasted with the positive sciences, and hermeneutics in the sense developed by Kuhn and Rorty, focused on the differences among researchers in any discipline. A particular discussion in psychiatry may emphasize one or the other of these approaches.
To begin with the older hermeneutic tradition, its Jasperian expression has been sustained throughout the decades, most forcefully in recent years by Schwartz and Wiggins (1987, 1988), who have argued for the continuing relevance of Jasper's use of ideal types (borrowed from Weber) in psychiatry, as well as Jaspers' distinction between conditions that require a causal, disease-oriented explanation and those that lend themselves to interpretative understanding of meaning structures. Also in this tradition are the publications of McHugh and Slavney (1986, 1987) on perspectives in psychiatry, in which they differentiate a life-story perspective (a dimension of meaning) from a perspective of disease. While these writers all provide a contemporary voice for the tradition of Dilthey and Jaspers, they also point to the limitations of a Diltheyan hermeneutics resting on a rigid distinction between causal explanation and interpretation of meaning. As they note, we cannot in fact divide psychiatric conditions neatly into those that call for a purely causal approach and those that require a meaning-oriented approach. We do find much to talk about with our schizophrenics and bipolars, and we find biological vulnerabilities in our neurotic and personality-disordered patients. Rather than holding on to the neurotic and personality disorders as meaning-oriented conditions and turning over the major psychotic disorders to the biologists, the task of hermeneutics is to sort out, in each of these groups, where is the place for understanding of meaning and where is the place for causal explanation.
But while it is not useful to maintain a rigid distinction between disorders on the basis of "cause" versus "meaning," a case can still be made--contra Kuhn and Rorty--for the uniqueness of the human studies, including psychiatry--and thus for the continuing relevance of Diltheyan hermeneutics. Unlike the object of scientific investigation, the object of the human studies comes [End Page 65] pre-interpreted. That is, people have ideas about themselves before we reinterpret them. Charles Taylor has developed this theme at length, distinguishing psychology from the natural sciences by virtue of the fact that the "object" of the former, human beings, are "self-interpreting animals" (Taylor 1985). Anthony Giddens has described this feature of the human studies as a double hermeneutic (Giddens 1977). That is, the human subject is always involved in self-interpretation, and this interpretation is then subjected to a second-level interpretation by the "professional" interpreter.
The application of these issues to clinical practice in psychiatry can be spelled out a bit. In situations in which questions of biological disorder, causal mechanisms, etc., are minimal, the clinical experience may take place virtually entirely at the level of psychodynamics and meaning structures. Much of the hermeneutic discussion in psychoanalysis is applicable here. The patient brings in a life-story, a self-interpreted narrative, that is intimately involved with his or her suffering. How the patient organizes his or her world meaningfully and what makes him or her suffer are virtually the same question. The goal of the therapy becomes then the reorganization of these meaning structures. With and through the therapist a new set of meanings, a new narrative, is developed.
In contrast to this situation is that in which there is a heavy biological loading in the patient's condition. The obvious examples are schizophrenia and bipolar illness. In this kind of clinical experience, issues of meaning are still relevant albeit different. The illness, although biologically loaded, still means something to the patient; it comes pre-interpreted. Questions of meaning and psychodynamics are thus relevant to how the patient regards the psychiatric condition. An obvious issue--and one that is evaluated differently in each case--is the extent to which the patient can take distance from the illness and talk about it. Is the meaning the patient gives the illness somewhat independent of the illness or is it a product of the illness? In still other terms, is the patient's thinking always thought-disordered? There is an obvious difference between a schizophrenic who can discuss his or her illness and another whose thinking is so invaded by the illness that such discussion is not realistic. It is also the case that a seemingly more disturbed schizophrenic may be more able to take distance from the illness than a character-disordered patient who cannot step back from his or her lying and self-deception. It is the clinician's task to sort out these questions, since issues like compliance with treatment hinge on them.
In contrast to this discussion arising out of the Diltheyan tradition in hermeneutics, a different set of issues emerges in association with the sense of hermeneutics that I am associating with the names of Kuhn and Rorty. Conscious of the radical historicity of any psychiatric enterprise, hermeneutics now becomes the art of recognizing (and exposing) different perspectives and assumptions, the art of promoting "conversation" among the different perspectives, and finally the art of navigating among the perspectives and models in the concrete situation, with the ability to switch from one model to the other and to integrate them into an optimal treatment plan.
One aspect of this hermeneutic inquiry is the question whether we can formulate definitions of mental illness (and of particular psychiatric conditions) that are not value-laden. In this regard Fulford has attempted to demonstrate the inevitable injection of current values into any conception of mental illness (Fulford 1989, 1991). Another aspect of this hermeneutics is the effort to bring multiple perspectives to bear on the individual patient. An example is Engel's work with the biopsychosocial model (Engel 1977, 1980), in which he attempts to make room for these three dimensions in the understanding and formulation of each clinical case. In still another approach to this hermeneutics of multiple perspectives, namely the tacking among different models, Sadler and Hulgus (1991) have offered an exemplary exposition of hermeneutics in action, showing with a specific case study how different theoretical orientations generate different data and different treatment protocols, but also how a flexibility in switching from one model to the other can result in a successful, more nuanced treatment.
Nowhere in contemporary psychiatry does this hermeneutics of historicity, of multiple perspectives, [End Page 66] and of the exposure of hidden assumptions, emerge more forcefully than in the area of diagnosis. It is appropriate then that the first AAPP sponsored monograph should be entitled Philosophical Perspectives on Psychiatric Diagnostic Classification (Sadler, Wiggins, and Schwartz 1994). Indeed, psychiatric nosology and the DSMs provide a vast arena for what are, explicitly or not, hermeneutic deliberations. The progression from one DSM to the next is itself a strong reminder that these are historical documents that do not transcend their historical conditions. Hermeneutic considerations are engaged at the opening bell with the famous (or infamous) statement that the DSM's diagnostic statements are atheoretical. The notion of an atheoretical diagnosis is, of course, an oxymoron hermeneutically. Appropriately, the statement has been challenged vigorously (Agich 1994; Goodman 1994). Then there is the hidden bias in favor of biologically based illnesses, as well as that in favor of individual pathology, as opposed to family or societally located disorders. Issues such as a multi-axial approach, the particular axes of DSM-III and DSM-IV, a categorical versus a dimensional approach, the use of operational definitions and diagnostic criteria, the privileging of reliability over validity, and of objective signs and isolated symptoms over subjective unities of experience--all are decided in a manner that is inevitably arbitrary and value laden. All must be the subject matter of ongoing discussion, for there is nothing inherently right about the position taken by the DSMs regarding any of these issues. Regarding the DSM-IV, one can take either of two positions: that it represents the best conclusions of a group of historically conditioned experts engaged in conversation à la Rorty about how best to classify psychiatric disorders; or that it represents the prejudices of a group of experts who currently hold power in the psychiatric establishment. Certainly we want it to be more the former than the latter. The position we cannot take is that the DSM-IV--or any other possible diagnostic system--is, purely and simply, the truth. Which is to acknowledge that we cannot transcend the hermeneutic discussion.
Finally, in addition to the two dimensions of hermeneutics in psychiatry just presented, I would like to underline a third aspect of a hermeneutic orientation, namely that of psychiatry as practical knowledge. Remember, after all, that psychiatry like the rest of medicine is involved in the treatment of individuals; all psychiatric theory and knowledge ends up, figuratively speaking, at the bedside. This aspect of hermeneutics has been emphasized by Gadamer, for whom hermeneutics involves not only understanding and interpretation but also application. For him application is not an add-on that may or may not accompany understanding and interpretation; the three form an indissoluble unity. Hermeneutic understanding is thus in its essence practical. To understand and interpret something is to see its relation to praxis. It is because of this integration of application into the process of understanding and interpretation that Gadamer accords to legal and theological hermeneutics a priority over literary hermeneutics as models of understanding in the human sciences. And it is this issue of application and praxis that brings Gadamer (1960/1975, 278) to Aristotle's Nicomachean Ethics and the latter's notion of "practical knowledge," or phronesis--for Gadamer an early forerunner of hermeneutics.
According to Aristotle (1941), what is unique about practical knowledge is that it deals in particulars--how a particular man should act in a particular situation. Practical knowledge always involves a dialectic of the general principle and the particular case, and practical wisdom is precisely the ability to accomplish this application. Finally, Aristotle notes that since each kind of knowledge enjoys the degree of exactness that its subject-matter allows, practical knowledge, because it deals with particulars, admits of only inexact knowledge.
The relevance of these ideas to psychiatric practice is clear; psychiatry is practical in the sense both of Gadamer and Aristotle. Psychiatric theory is oriented toward application and practice, and the psychiatrist is dramatically engaged in a dialectic of the general and the particular. The latter is indeed even more true of psychiatry than medicine (which Aristotle takes as an example of practical knowledge). If the internist can at times legitimately remain at the level of the universal, treating the patient as a case of such-and-such illness, this is rarely true of the psychiatrist. Treating [End Page 67] the patient, for instance, as a borderline, rather than as this person with this life and borderline pathology, will not make for good treatment. Knowing the diagnosis is generally a small part of knowing (and treating) the patient. This is of course the reason why courses and chapters on "The Treatment of Diagnosis X" are always of limited value. Finally, following Aristotle, we must recognize that the practical, individual-directed nature of psychiatric practice renders psychiatry an inexact science. It is as inexact as people are different. As practical knowledge, this inexactness is not a defect that can be overcome with more progress in the field.
In concluding this review I would like to summarize what I consider the major features of a hermeneutic orientation in psychiatry. (1) A hermeneutic approach will focus on those conditions, and those aspects of any condition, that call for an interpretation of the meaning structures that play a significant role in the condition. It will also evince a sensitivity to the boundaries between meaning-oriented and other explanatory modalities. (2) This approach will emphasize the historicity of any theoretical point of view, any diagnostic system, and any therapeutic modality in psychiatry. This involves a recognition that there is no value-free or presuppositionless orientation in this field. One of the challenges of the hermeneutic effort is to promote "conversation" among the differing approaches, both at theoretical level and at the level of treatment of the individual patient. (3) The hermeneutic approach will subordinate the universal to the particular--that is, theory takes second place to the understanding and care of the individual patient. Psychiatric knowledge is thus practical and organized for treatment of the individual patient. (4) Finally, as a practical discipline, directed toward the care of the individual patient and allowing an inevitable plurality of perspectives in the provision of that care, psychiatric knowledge is finite, limited, and subject to ongoing revision.
James Phillips, Associate Clinical Professor of Psychiatry, Yale School of Medicine, New Haven, CT 06520, USA.


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