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.     

Gewalttaten psychisch Kranker

Only a minority of mentally ill persons become conspicuous due to acts of violence. Nevertheless, from time immemorial there has been a certain fear of the alleged unpredictability of the mentally ill, particularly of people who suffer from a psychosis. The creation of psychiatry as an independent medical discipline was designed from the very beginning to separate people deemed to be dangerous from society and to detain them in institutions in order to heal them, to make relevant improvements or to keep them indefinitely. The movement of dehospitalization since the 1970s, which in turn was a consequence of revolutionization of treatment options through modern neuroleptic and antidepressive drugs, led to a distinctive separation between general psychiatry and forensic psychiatry, institutionally (general psychiatric institutions with periods of hospitalization of a few weeks and psychiatric forensic committment lasting many years) as well as increasingly more in scientific discourses; however, a close cooperation is necessary for healthcare treatment, which meets the requirements of patients and also public security. In this respect general psychiatry must still undertake substantial safety reponsibilities, which it can learn from forensic psychiatry, whereas forensic committment must rapidly acquire the therapy experience of general psychiatry.     

The triumph of American psychiatry: How it created the modern therapeutic state

Over the past 170 years, American psychiatry has progressively asserted its authority over a larger segment of the American population. From the mid-1800s to the end of World War II, psychiatry had authority over the asylum population, which markedly increased in the first half of the twentieth century due to the influence of eugenics, an ideology that argued the ‘mentally ill’ had to be segregated from society. After the war, American psychiatry adopted Freudian conceptions of mental disorders, which enabled it to begin treating people in the community who were ‘neurotic’ in some way, which dramatically expanded its influence in society. Then, in the 1970s, when many in American society were questioning psychiatry’s legitimacy as a branch of medicine, the American Psychiatric Association (APA) responded by adopting a disease model for diagnosing mental disorders, which it set forth in the third edition of its Diagnostic and Statistical Manual. There were no scientific discoveries that led to this new model, but soon the APA was informing the American public that mental disorders were diseases of the brain, and that psychiatric drugs helped fix those diseases, ‘like insulin for diabetes.’ The APA, in concert with pharmaceutical companies, has successfully exported this belief system to much of the developed world. In order to break free of this ‘therapeutic state,’ the public needs to understand the history of how it came to be, and see the social injury it has caused.     

Embracing the other: Revisiting the epistemological foundations of family systems therapy

Family systems therapy originated in the 1960s, 1970s, and 1980s through the work of innovative thinkers and clinicians. However, despite the creative contributions of the mentioned colleagues and of later innovations in family therapy theory and practice, it seems as though the dominant culture of establishment psychiatry in the United States (and in most Western countries) to this day has not seriously incorporated relationships, social context, or community connectedness into the treatment of individuals with psychiatric diagnoses. For the “psychiatric” patients diagnosed according to the DSM-5, the dominant underlying epistemological perspective is the medical “scientific” paradigm. Within this approach there is a dearth of reflections about the truthfulness of so-called “empirical facts” and a lack of skepticism about the techniques of “measurement” of the psychiatric illness. The alternative, relationship-oriented, context-sensitive, and community-connected thinking paradigm is highlighted here in contrast to the “psychiatric” foundation. This paradigm consists of (a) the awareness that all human Subjects (including “psychiatric” clients) are constituted as such by their relational connection to others; (b) the awareness of our sensitivity to and embeddedness in a socio-economic, cultural, and racial context; and (c) the awareness of our involvement in and connectedness with many kinds of communities.     

Frantz Fanon in the Time of Mad Studies

Abstract

Amidst renewed interest in the psychiatric writings of Frantz Fanon, this article reads his work against the background of contemporary mental health advocacy and scholarship. Epitomized in the emergent field of Mad Studies, whose origins lie in anti-psychiatry and psychiatric user/survivor movements, this body of scholarship espouses a discourse of madness as identity and culture. While Fanon continues to be disassociated from or (occasionally) associated with anti-psychiatry, this article elaborates elements in his work that animate such ambiguity. It proposes that Fanon and Mad studies be put in a relation of mutual critique.     

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.     

Psychiatry,language and freedom

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

A critical engagement with the DSM-5 and psychiatric diagnosis

Classifications in psychiatry can result in the reification of hypothetical approaches, arbitrary categorisation and social injustice. This article applies a social constructivist approach to critique the DSM-5 as a neurobiological model of psychiatric diagnosis which ignores psychosocial factors such as poverty, unemployment and trauma as causes of mental distress. It challenges the universality of psychiatric diagnosis and proposes that cultural psychiatry's framing of ‘culture-bound syndromes,’ or ‘cultural case formulation’ guidelines, is oversimplified. Use of the DSM in the South African context risks perpetuating injustice by labelling and stigmatising people who have in the past been racially stigmatised by apartheid. In culturally diverse South Africa, psychiatric diagnosis should take into account alternative explanatory models that provide a more balanced view of the complex and dynamic relationship between biological and sociocultural forces in the manifestation of psychopathology.     

Behavioral assessment of imipramine effects in a depressed child

A 7-year-old boy was diagnosed as suffering from childhood depression by two independent psychiatric evaluators who employed the Research Diagnostic Criteria. Multifaceted behavioral observations were performed on target behaviors which were identified as major problematic areas of functioning related to the child's depression. The behavioral assessment strategy included daily monitoring of on-task and disruptive behavior in the classroom, enuresis, and overall hygienic, social, and compliance behaviors as a means of identifying the specific drug-induced effects of an anti-depressant, imipramine. The assimilation and application of behavioral assessment strategies within child psychiatry have been slow and tenuous. Reasons for the resistance include theoretical differences and misconceptions among psychiatric personnel, who, although open to objective evaluations, may wish to employ nonbehavioral treatments such as pharmacologic agents. The primary purpose of this study was to demonstrate the viability of behavioral assessment as an integral adjunct to pharmacologic treatment in a psychiatric setting as a means of gauging the efficacy of a psychiatric intervention. Issues regarding the role of behavioral assessment in psychiatry and, in particular, pharmacologic interventions with depressed children are examined and discussed.This study was supported, in part, by NIMH Grant MH 30915.     

The making of contemporary American psychiatry, part 1: patients, treatments, and therapeutic rationales before and after World War II

This article, the 1st in a 2-part series, uses patient records from California's Stockton State Hospital to unearth the midcentury roots of contemporary American psychiatry. These patient records allow the authors to examine 2 transformations: the post-World War II expansion of psychiatry to include the diagnosis and treatment not only of psychotic patients but also of nonpsychotic patients suffering from problems of everyday living, and the 1950s introduction of the first psychotropic drugs, which cemented the medical status of these new disorders, thus linking a new therapeutic rationale to biological understandings of disease. These transformations laid the groundwork for a contemporary psychiatry characterized by voluntary outpatient care, pharmacological treatment of a wide range of behaviors and distress, and a doctor-patient relationship and cultural acceptance of disease that allow psychiatric patients to identify themselves as consumers.     

The psychiatrist Heinroth--a critical reflection

Heinroth (1773-1848) belongs to the founders of psychiatry in Germany. He represented an idealistic, spiritualistic psychiatric school that had a strong leaning towards materialist ideas. He believed that mental disturbances were caused by guilt and sin. But, besides these speculations, he also expressed views that led to view psychiatric and psychotherapeutic insights. One of these was his postulated psychogenesis of mental disturbances. His thoughts on the importance of social, biographical and psychosomatic factors also contributed to the development of psychiatry.     

Prevention of admission and continuity of care

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

Beitrag der Neurowissenschaften zur forensischen Psychiatrie

Forensic psychiatry is a subspecialty dedicated to the interface between psychiatry and law. It uses paradigms and knowledge from general psychiatry for diagnostics, assessment, therapy and research under consideration of the special requirements of legal aspects and framework conditions; therefore, scientific development in forensic psychiatry is substantially dependent on scientific progress in psychiatry and thus nowadays also in neurosciences. Neurobiological hypotheses on the neuronal foundations of psychiatric diseases have been established, for example the dopamine hypothesis for schizophrenia, in a manner that led to important therapeutic advances in the treatment and long-term quality of life for affected persons. Analogous advances should not be withheld from forensic psychiatric patients, who are doubly affected by the disease and the accompanying limitations in their rights to freedom, which is why research in this field must be driven forwards. Clear advances in knowledge of the neurobiological foundations of forensic psychiatric illnesses have, for example, already been made in the field of pedophilia and psychopathy. Based on studies of investigation populations, such neuroscientific knowledge on the neurobiological principles of forensic psychiatric diseases, however, requires a carefully concerted communication with respect to dissemination in the media as well as in the interpretation of individual cases, for example in court. This is of great importance in order to prevent simplifying misconceptions and to avoid a subsequent loss of trust in the scientific process. Therefore, training of the new generation of forensic psychiatrists in the understanding and communication of scientific methods of modern forensic psychiatric neuroscience is of great importance for the societal impact and further advancement of the discipline.     

Thoughts and feelings and things: A new psychiatric epistemology

Epistemology — the study of knowledge — is a philosophical discipline with close ties to psychiatry. When epistemologists address specific questions about how knowledge is actually realized by human beings, their philosophy must be informed by empirical studies of the sort psychiatrists now take up in a variety of forms. As this paper describes, psychiatrists can likewise improve their understanding of human psychology through a deeper appreciation of philosophical analysis in epistemology.The aim of this article is to introduce a unifying framework within which the experience from different approaches to psychiatry — (1) the conceptual schemas of cognitive psychiatry, (2) the mental structures of psychoanalytic psychiatry, (3) the categorical forms of existential psychiatry, and (4) the neural pathways of biological psychiatry — can all be applied productively to the central question of epistemology. By establishing a broad understanding of the problem of knowledge, this new view of epistemology is developed within the idiom of each psychiatric approach. In addressing themselves to a unitary problem, these diverse psychiatric approaches are themselves revealed, not as competing points of view, but as complementary views of a single subject. The result is a new epistemology that can not only bring the insights of psychiatry to philosophy, but can also contribute to the care of patients when psychiatrists bring this broader view to their clinical work.     

Symptom modelling can be influenced by psychiatric categories: choices for research domain criteria (RDoC)

Psychiatric researchers typically assume that the modelling of psychiatric symptoms is not influenced by psychiatric categories; symptoms are modelled and then grouped into a psychiatric category. I highlight this primarily through analysing research domain criteria (RDoC). RDoC’s importance makes it worth scrutinizing, and this assessment also serves as a case study with relevance for other areas of psychiatry. RDoC takes inadequacies of existing psychiatric categories as holding back causal investigation. Consequently, RDoC aims to circumnavigate existing psychiatric categories by directly investigating the causal basis of symptoms. The unique methodological approach of RDoC exploits the supposed lack of influence of psychiatric categories on symptom modelling, taking psychiatric symptoms as the same regardless of which psychiatric category is employed or if no psychiatric category is employed. But this supposition is not always true. I will show how psychiatric categories can influence symptom modelling, whereby identical behaviours can be considered as different symptoms based on an individual’s psychiatric diagnosis. If the modelling of symptoms is influenced by psychiatric categories, then psychiatric categories will still play a role, a situation which RDoC researchers explicitly aim to avoid. I discuss four ways RDoC could address this issue. This issue also has important implications for factor analysis, cluster analysis, modifying psychiatric categories, and symptom based approaches.     

The professionalization of psychology within the apartheid state 1948-1978

When the National Party came to power in South Africa in 1948 it inherited an ageing colonial psychiatric system underpinned by British-based mental health legislation promulgated in 1916. This situation remained substantially unchanged until the late 1960s, despite the apartheid government's far-reaching attempts to restructure other aspects of the social landscape. The 1966 assassination of South Africa's prime minister by a schizophrenic parliamentary messenger led directly to a series of commissions of enquiry into the management of mental health services, followed by new mental health legislation in 1973 and the compulsory registration of clinical psychologists. The increasing professionalization of psychology, and the apartheid state's policy in relation to the profession, are considered in the light of local and international influences. Unlike the Nazi and Soviet governments, the apartheid state did not seek to create a new psychology and psychiatry in its own image but was instead motivated by a desire to emulate Western models and to identify and control the dangerous individual.     

How new is the new philosophy of psychiatry?

In their recent paper, Natalie Banner and Tim Thornton evaluate seven volumes of the Oxford University Press series “International Perspectives in Philosophy and Psychiatry,” an international book series begun in 2003 focusing on the emerging interdisciplinary field at the interface of philosophy and psychiatry. According to Natalie Banner and Tim Thornton, the series represents a clear indication that the interdisciplinary field of philosophy of psychiatry has been flourishing lately. Philosophers and psychiatrists face a “new philosophy of psychiatry”. However, the optimism which the “new” philosophy of psychiatry celebrates is precisely the exiling of philosophy from the foundations of psychiatry. The 150 year old belief that psychopathology cannot do without philosophical reflection has virtually disappeared from common psychiatric education and daily clinical practice. Though the discipline of psychiatry is particularly suited to contributions from philosophy, the impact of philosophy on psychiatry nowadays remains limited. With some exceptions, philosophical papers are embedded in a philosophical context inscrutable to ordinary psychiatrists. Much current philosophical work is perceived by psychiatrists as negativistic. I would encourage the field of psychiatry to incorporate once again basic philosophical attitudes which render possible true dialogue with philosophy and enrich both disciplines. The views developed here should not discredit the value and importance of Natalie Banner and Tim Thornton’s paper and the excellent series “International Perspectives in Philosophy and Psychiatry.” As Jaspers said “Everybody inclined to disregard philosophy will be overwhelmed by philosophy in an unperceived way”.     

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.     

The establishment of the department of psychiatry in the Mount Sinai Hospital: a conflict between neurology and psychiatry

A conflict between neurology and psychiatry and controversies about psychoanalysis played an important role in the establishment of psychiatry in the general hospital. This article reviews the impact of this conflict on the establishment of an independent Department of Psychiatry in the Mount Sinai Hospital in New York during the first half of the twentieth century. A unique opportunity is provided to consider the relationships and personalities of the individuals involved, as well as economic, social, and scientific factors, including the introduction of psychoanalysis as a major psychiatric treatment.     

?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.