Madness versus badness: the ethical tension between the recovery movement and forensic psychiatry

The mental health recovery movement promotes patient self-determination and opposes coercive psychiatric treatment. While it has made great strides towards these ends, its rhetoric impairs its political efficacy. We illustrate how psychiatry can share recovery values and yet appear to violate them. In certain criminal proceedings, for example, forensic psychiatrists routinely argue that persons with mental illness who have committed crimes are not full moral agents. Such arguments align with the recovery movement’s aim of providing appropriate treatment and services for people with severe mental illness, but contradict its fundamental principle of self-determination. We suggest that this contradiction should be addressed with some urgency, and we recommend a multidisciplinary collaborative effort involving ethics, law, psychiatry, and social policy to address this and other ethical questions that arise as the United States strives to implement recovery-oriented programs.     

?Psychische St?rung�� als Begr��ndung f��r staatliche Eingriffe in Grundrechte des Individuums

When dealing with ?old cases?? of preventive detention as well as retrospectively ordered preventive detention, a continuation of confinement should be possible if the offender involved suffers from a ??mental disorder?? which constitutes the danger of future serious violent or sexual crimes. In this psychiatric article it will be explained that the terms ??mental illness?? and also ??mental disorder?? must retain an empirical scientifically definable psychiatric content in order not to instigate deception. They must also be functionally defined in each judicial environment (police law, social law, civil law and criminal law) with respect to the capabilities of the individual which are impaired by the mental disorder. Such an approach could prevent a misuse of psychiatry for purely political security purposes.     

On the legitimacy of psychiatric power

The author examines the existential, historical, and political roots of psychiatric power, locating them, respectively, in the universality of guilt feelings and the desire to escape them, in psychiatry (replacing religion) as an institution offering surcease from such (and similar disturbing) feelings, and in the alliance, in modern societies, between psychiatry and the state. Clinical psychiatry and psychoanalysis, each in its own distinctive way, have served to legitimize the uses of psychiatric power. Liberty from coercive psychiatry requires destroying the legitimacy, and hence power, of coercive psychiatric principles and practices.     

Psychopharmacological enhancement: a conceptual framework

The availability of a range of new psychotropic agents raises the possibility that these will be used for enhancement purposes (smart pills, happy pills, and pep pills). The enhancement debate soon raises questions in philosophy of medicine and psychiatry (eg, what is a disorder?), and this debate in turn raises fundament questions in philosophy of language, science, and ethics. In this paper, a naturalistic conceptual framework is proposed for addressing these issues. This framework begins by contrasting classical and critical concepts of categories, and then puts forward an integrative position that is based on cognitive-affective research. This position can in turn be used to consider the debate between pharmacological Calvinism (which may adopt a moral metaphor of disorder) and psychotropic utopianism (which may emphasize a medical metaphor of disorder). I argue that psychiatric treatment of serious psychiatric disorders is justified, and that psychotropics are an acceptable kind of intervention. The use of psychotropics for sub-threshold phenomena requires a judicious weighing of the relevant facts (which are often sparse) and values.     

Political conservatism and variety‐seeking

In this research, we document and explain a counterintuitive effect of political ideology on variety-seeking. Although political conservatives have a higher desire for control, which exerts a negative effect on variety-seeking, they also have a stronger motivation to follow social norms, which exerts a positive effect on variety-seeking. Three studies demonstrate that conservatism is positively related to variety-seeking due to social normative concerns and rule out an alternative explanation of heightened self-expressive motives among conservatives. This research provides preliminary evidence of how political ideology may explain differences in product choices.     

The attack of psychiatric legitimacy in the 1960s: rhetoric and reality

During the 1960s there was a sustained attack on psychiatric legitimacy. Thomas S. Szasz was the most vituperative and best-known critic, but he was by no means alone. Individuals and groups from both extremes of the political spectrum were united in their belief that psychiatry was not a legitimate medical specialty, but one that was devoted to protecting its authority as well as enforcing societal norms associated with an unjust society. The attack on psychiatry, of course, did not occur in a vacuum; numerous social and intellectual currents played major roles. To comprehend such attacks and their consequences requires an understanding of the larger societal context as well as the changes that transformed psychiatry in the post-World War II years.     

Sense and nonsense in the social psychiatry concept

The term social psychiatry was justified when coined as a name denoting a psychiatric sub-discipline in order to promote the development of this specific aspect of psychiatric research and practice which, at the time, ran counter to established theory. At present, however, social psychiatry is in danger of becoming isolated, of developing in the boundary regions of psychiatric practice, and thus failing to fulfil its actual role of permeating psychiatry as a whole. The term social psychiatry is regarded as an expression of this isolation and should be avoided.     

论保密义务与诚信原则

尊重患者隐私,保守执业秘密,是医师的道德义务,也是法律义务,保密义务的理论基础在于诚实信用原则.为此,医疗活动中应引入体现伦理道德要求的诚信理念,从道德和法律两方面规范医师的行为,并且建立以法律规范为主的规制模式.     

Psychiatry under tyranny: A report on the political abuse of Romanian psychiatry during the ceausescu years

Romanians suffered incredible deprivations of every sort during the decades of Communist dictatorship. Most of the country’s 1,000 psychiatrists, and most of their patients, were victimized by the political system. A few psychiatrists actively engaged in practices amounting to torture. Many, however, became willing or unwilling participants in the political abuse of their profession. Such political abuses were fostered by abusive legislation and abusive law enforcement by the secret police. Abuses included: mass detentions in psychiatric hospitals of dissidents and political undesirables; abusive interpretation of the laws in detaining persons not suffering from mental illness; false, politically motivated diagnoses and treatment; and detention in secret facilities. While there are honest efforts to come to grips with the past, to compensate victims of psychiatric abuse, and to institute proceedings against abusers, there is also much resistance to reform. Reform-minded Romanian psychiatrists deserve the support of their western colleagues in the effort to restore Romanian psychiatry. In particular, professional colleagues all over the world are asked to comment on the draft law currently pending before the Romanian parliament, which is intended to restore the rule of law to the practice of psychiatry in Romania. Report of a consultative mission to Bucharest, on behalf of the Geneva Initiave on Psychiatry, 7 June to 12 June 1992, by Nanci Adler, Historian-Sovietologist, Geneva Initiative on Psychiatry, Amsterdam, The Netherlands; G.O.W. Mueller, Distinguished Professor of Criminal Justice, Rutgers — The State University of New Jersey, U.S.A.; Mohammed Ayat, Professor of Criminology and Penal Law, Université de Fes, Faculté des Sciences Juridiques, Economiques et Sociales, FEs, Morocco. The Geneva Initiative on Psychiatry is a nongovernmental, nonprofit organization, dedicated to the introduction and preservation of ethical practices in the psychiatric profession, in accordance with medical ethics, the Universal Declaration of Human Rights, and U.N. standards and guidelines. Headquartered in Amsterdam, the organization is currently providing technical and financial assistance to the newly established free, independent, democratic psychiatric associations in Russia, Ukraine, Romania, and other countries. The General Secretary of the organization is Robert van Voren; the board is composed of professionals from some twenty countries. This article was based on meetings at governmental and parliamentary offices, nongovernmental organizations, and embassies as well psychiatric institutions with, among others, the following persons: Dr. Lucian Alexandrescu, V-P Radu Ciuceanu, Mr. Comsa, Proc. Gen’l. Ulpiu Cereceanu, Mr. Nistor Cristea, Mr. Dinu Ianculescu, Prof. Dr. George Ionescu, Miss Cristina Luzoscu, Dr. Zaharia Nicolae, Mr. Iancu Petrescu, Dr. Dan Prelipcianu, Min. Mircea Ionescu-Quintus, Dr. Aurel Romila, Av. Nicolae Stefanescu-Draganesti, Dir. Dr. Tomescu, Dr. Alexandru Trifan, Dr. Valeriu Tuculescu, and numerous victims, diplomats, and Romanian citizens.     

Relevance of education and intelligence for the political development of nations: Democracy, rule of law and political liberty

Political theory has described a positive linkage between education, cognitive ability and democracy. This assumption is confirmed by positive correlations between education, cognitive ability, and positively valued political conditions (N = 183 − 130). Longitudinal studies at the country level (N = 94 − 16) allow the analysis of causal relationships. It is shown that in the second half of the 20th century, education and intelligence had a strong positive impact on democracy, rule of law and political liberty independent from wealth (GDP) and chosen country sample. One possible mediator of these relationships is the attainment of higher stages of moral judgment fostered by cognitive ability, which is necessary for the function of democratic rules in society. The other mediators for citizens as well as for leaders could be the increased competence and willingness to process and seek information necessary for political decisions due to greater cognitive ability. There are also weaker and less stable reverse effects of the rule of law and political freedom on cognitive ability.     

Patients' desire to participate in decision-making in psychiatry: a questionnaire survey in Japan

Japanese national sentiment has been described as paternalistic, which has potentially wide-ranging implications for the manner in which psychiatric patients should participate in medical decision-making. To examine the extent and possible determinants of the desire to participate in medical decision-making among Japanese people, we distributed a packet of questionnaires to 747 (nonmedical) university students and 114 of their parents. The questionnaires included an imaginary case vignette of psychotic depression. The participants were asked whether they would want various types of medical information, i.e., diagnosis, aetiology, treatment, outcomes, medical charts, etc., disclosed to them were they in such a psychiatric condition. Also included was the 1995 Scale for Independent and Interdependent Construal of the Self by Kiuchi. More than half of the participants wanted all the types of medical information disclosed to them. Those participants who wanted to have all types of information disclosed to them (n = 413) as compared to those who did not want to know at least one type of information (n = 445), tended to be male and to have an educational background in psychiatry (9.7% vs 5.4%) as well as an assertive attitude as indicated by a higher score on Independence on the Scale for Independence and Interdependent Construal of the Self. These results suggest that the Japanese in this sample are more likely to want to make an autonomous contribution to the psychiatric decision-making process and that less desire for information can be predicted by some demographic and personality factors.     

The Psychology of Moral Conviction

This paper reviews current theory and research that indicates that attitudes held with strong moral conviction (‘moral mandates’) represent something psychologically distinct from other constructs (e.g., attitude strength, partisanship, or religiosity), and that variance in moral conviction has important social and political consequences, such as increased intolerance of attitudinally dissimilar others, difficulties in conflict resolution, increased political participation, willingness to accept violent means to achieve preferred ends, strong ties to positive and negative emotions, and inoculation against the usual pressures to obey authorities, obey the law, or to conform to majority group influence. The normative implications of these findings are both reassuring (moral convictions can protect against obedience to potentially malevolent authorities) and terrifying (moral convictions are associated with rejection of the rule of law, and can provide a motivational foundation for violent protest and acts of terrorism). Implications and directions for future research are discussed.     

Complexity of ethical decision making in psychiatry

Psychiatric residents and psychiatrists have little difficulty in making judgments about a clinical course of action to take with patients. However, making ethical clinical decisions is more challenging, because psychiatric residents are usually provided little formal training in ethics. Further, many ethical dilemmas are complex, requiring knowledge of the psychiatric profession's ethics code, moral principles, law, and practice standards and of how they should be weighed in the decision-making process. The purpose of this article is to demonstrate this complexity in regard to the identification of potential ethical dilemmas, understanding the issues that these dilemmas raise, and formulating potential solutions to them. Two common but important areas of treatment in which ethical dilemmas arise (informed consent and competence of care) are used as examples for our presentation. The article demonstrates that to successfully engage in ethical analysis in psychiatry is impossible without substantial formal training in the process.     

Constraining the Ruler: On Escaping Han Fei's Criticism of Confucian Virtue Politics

One of Han Fei's most trenchant criticisms against the early Confucian political tradition is that, insofar as its decision-making process revolves around the ruler, rather than a codified set of laws, this process is the arbitrary rule of a single individual. Han Fei argues that there will be disastrous results due to ad hoc decision-making, relationship-based decision-making, and decision-making based on prior moral commitments. I lay out Han Fei's arguments while demonstrating how Xunzi can successfully counter them. In doing so, I argue that Xunzi lays out a political theory restricting the actions of the ruler through both the use of ritual and law, which allows him to develop a theory that legitimizes government while at the same time constraining itself. Xunzi's political theory makes important strides in its attempt to recognize the importance of the ruler as a moral exemplar while also restricting his control in the political process.     

Perceptions of South Florida Hispanic and Anglo Catholics: From Whom Would They Seek Help?

Hispanic and Anglo Catholics in South Florida who attended Sunday services (N = 473) were surveyed to determine their help-seeking preferences for moral concerns, mental disorders, and practical life/family problems. Respondents were asked to indicate whether they would seek help from a priest; a priest with a degree and license in one of the helping professions (clinical social work, psychology, psychiatry, or mental health counseling); a layperson with a degree and license in one of the helping professions (clinical social work, psychology, psychiatry, or mental health counseling); or if they believed they could deal with the situation without external assistance. The findings suggest that Anglo Catholics prefer assistance from a person who was credentialed in one of the helping professions, whereas Hispanic Catholics would seek help from a priest with or without a background in the helping professions.     

Sociophysiology as the Basic Science of Psychiatry

The medical specialty of psychiatry should possess a basic science in which pathologies are considered deviations from normal brain physiology. Historically, psychoanalytic pathogenesis was considered separately from brain physiology. It was not scientific because observations could not be refuted. Countering this, Eli Robins's legacy stemmed partly from his having been damaged by a psychoanalyst. It eschewed pathogenesis. Attempting to integrate psychiatry with medicine more generally, Robins and colleagues refocused on empiricism, although they acknowledged the brain's centrality. Here I hold that the term biology used in the context of psychiatry should broadly encompass social facets of organismal function. The term “sociophysiology” may best describe the central basic science of psychiatry because it alludes to brain functions used for the person's social realm. Disruptions of such functions result in deviant behaviors and unpleasant feelings which psychiatrists diagnose and treat. Future study encompassing top-down and bottom-up research should include genome-neural-behavioral analyses.     

Neurophilosophical perspectives of neuroimaging in forensic psychiatry—giving way to a paradigm shift?

Forensic psychiatry is concerned with the relationship between psychiatric abnormalities and legal violations and crimes. Due to the lack of available biological criteria, evaluation and therapy in forensic psychiatry have so far been restricted to psychosocial and mental criteria of offenders' personalities. Recent advances in neurosciences allow a closer approach to the neural correlates of personality, moral judgments and decision-making. We propose to discuss the introduction of biological criteria in the field of forensic psychiatry and to establish rules as to what extent such biological criteria will be a better and more reliable choice in judging mentally ill criminals by using all available information that can be obtained by biological means. Psychosocial and subjective criteria in forensic evaluation will be more and more accomplished by biopsychosocial and objective criteria. The responsibility of having committed a criminal act will no longer be exclusively defined by judging free and voluntary decision-making, but rather by brain-behavior relationships. What is often referred to as psychosocially determined mental processes thus could be complemented by estimating the degree of biopsychosocially determined neural processes. We conclude that such a process could contribute to a paradigm shift in forensic psychiatry, which will have profound implications for offenders, forensic psychologists and psychiatrists, the law and society in general.     

Critics and dissenters: reflections on "anti-psychiatry" in the United States

During the 1970s various professionals and social activists adopted an explicitly anti-psychiatry position which was perceived by many as a new phenomenon. Hostility to psychiatry actually predates the establishment of psychiatry as a profession in 1844, and organized opposition to psychiatric practices appeared in the late nineteenth century. The deinstitutionalization of the 1970s, which was aided by development within psychiatry, had a strong anti-psychiatry component, but the novel aspect was the organization of ex-mental patients themselves. By the 1980s the decline of psychiatric power, dissension among ex-patients, and new social trends vitiated the anti-psychiatry movement.     

社会规范的跨文化比较

对中、日、美三国的社会规范进行了比较研究。被试为北京1434人,大阪608人,洛杉矶1409人。在3方共同研讨基础上编制了统一的调查问卷,共67个项目。采用SPSS 10.0软件对结果进行了多元统计、解析。结果表明：（1）三国国民的社会规范的基本维度是一致的,包括伦理道德、价值取向、法律规章和社会习俗4个维度。其中,伦理道德和价值取向组成内控规范,法律规章和社会习俗组成外控规范。（2）中日两国的社会规范都是以内控规范为主,外控规范为辅。中国人在内控规范中,以伦理道德为主,价值取向为次;在外控规范中,法律规章为主,社会习俗为辅。而日本人的内控规范中却以价值取向为主,伦理道德为辅。（3）美国人的社会规范以外控为主,内控为辅。在外控的两大维度中,法律规章为主,社会习俗为次;在内控规范中,以价值取向为主,伦理道德为辅。尽管三国之间有着相同的规范维度,但组成各规范维度的具体规范,既有超越特定文化的共同规范,又存在着依存于特定文化的特殊规范。社会规范的文化差异是导致管理冲突的根本原因。     

Madness or Mental Illness? Revisiting Historians of Psychiatry

Is madness medical disease, problems in living, or social labeling of deviance? Does the word merely refer to behavior peculiar enough to be disturbing? Are the mad mad because of mental, physical, or environmental vulnerabilities? No one knows the answers to these questions because there is no scientific validation for any theory or specific causes of madness. Nonetheless, a view of madness as medical/bodily disease has been receiving concrete and rhetorical support from the government mental health bureaucracy, Big Pharma, mental health lobby groups, the organized profession of psychiatry, hundreds of thousands of providers of mental health services and countless books and articles. This article explores the role that medicalized language and its use by seven noted historians of psychiatry (Norman Dain, Albert Deutsch, Gerald Grob, Roy Porter, Charles Rosenberg, Andrew Scull, and Edward Shorter) might have played in shaping the contemporary view of madness as mental illness. The evidence we uncover suggests that historical “facts” about madness, much as psychiatric “facts” supporting the disease model, are shaped by belief, bias, error or ambiguous rhetoric rather than the facts of the matter.