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Archived Comments for: How new is the new philosophy of psychiatry?

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  1. The Maudsley Philosophy Group

    Robert Harland, Maudsley Hospital and Institute of Psychiatry, London

    15 November 2007

    Bill Fulford's OUP series is just one trend within this field.

    The Maudsley Philosophy Group formed by four trainees in 2002 was motivated by some of the same concerns that Damiaan Denys highlights. Working in an institution which in the UK led the 1990s Decade of the Brain we perceived a need in our own clinical and research careers to balance that perspective with one that recognised psychiatry as inherently being a conceptual discipline.

    What started as a small reading group covering Kant, Phenomenology, and some Philosophy of Mind became a grant for a regular series of monthly seminars and one international conference.

    Now that members of the group from 2002 are coming towards the end of their clinical training we have become more involved in teaching those below us. The group is now a registered charity which aims to continue the spirit of philosophical thinking within the Maudsley, IOP and wider profession.

    Speaking personally, the group has been as important to my development as a psychiatrist as any reading within the biological, epidemiological or psychological sciences. In fact it has provided a methodological tool with which I can approach both clinical and research material. I would see philosophy as an integral part of any apprenticeship in psychiatry.

    The new philosophy of psychiatry is not all new, but neither are the sentiments of Damiaan Denys. A growing number of psychiatrists have been seeing philosophy (both old and new) as a central concern of their subject.

    Competing interests

    None declared

  2. response to what is new

    Lindsay J. Webb, student

    15 November 2007

    I think, in some regard, that the new philosophy of psychiatry is a response to both the academic and clinical abandonment of the old philosophical psychiatry. Denys acknowledges a loss of philosophy as a tool for psychiatry, “reflecting, conceptual thinking, questioning, and criticizing have all virtually disappeared from common psychiatric education and daily clinical practice”. Yet, Deny also conveys the message that the “new” philosophy of psychiatry is nothing more than a revisiting of old practices, “the recent themes of the new philosophy of psychiatry are just an extension or repetition of earlier work of the last centuries”. Further, he argues that the “new”, in the new philosophy of psychiatry, is merely the abandonment of old philosophical practices in psychiatry. I half disagree.

    It seems to me, that the new philosophy of psychiatry attempts to be more accessible to both philosophers, as well as clinicians. What was accessible centuries ago to psychiatrists about philosophy and vice versa, is clearly, has Denys suggests, no longer available to modern clinical practice and philosophical discussion. So, the new philosophy of psychiatry responds to this inaccessibility by both 1) extending and revisiting old arguments (as Denys acknowledges), and 2) by building a scholarly and organized academic structure for which philosophers and psychiatrists can contribute more clearly to.

    The new philosophy of psychiatry in some part, focuses on the new psychiatry, and maybe also on the shift of academic philosophy to edge on analytical, rational and explainable problems, not problems of irrationality or socially constructed and normative definitions.

    It is not entirely the fault of psychiatry that philosophy is no longer used as a tool to scrutinize and explain the problems associated with mental disorder. Modern academic philosophers also are responsible for refusing to acknowledge mental illness as being a problem for philosophy at all. The new philosophy of psychiatry will benefit by focusing on these issues. The development of structured and supportive environments such as the Philosophy of Mental Health Programme at UCLAN and the Philosophy and Ethics of Mental Health Programme at Warwick do not exist in the United States, where a very popular undergraduate major is psychology. Surely, the existence of these environments alone, are relatively new.

    In conclusion, the “newness” of the philosophy of psychiatry is not that philosophy has been abandoned by psychiatry, but the “newness” lies in the response to such neglect. When we come back, we come back strong.

    Competing interests

    None declared

  3. A Philosophy for Philosophers?

    Richard Kanaan, Institute of Psychiatry

    15 November 2007

    Damiaan Denys laments the death of the ‘old’ philosophy of psychiatry, which was really an attitude of critical wonder; and while he applauds ‘the new’, he denies its novelty, and that it is really a useful replacement for the old. I, in turn, would applaud ‘the old’, but I wonder whether it ever really existed. That there was an Esquirol or a Jaspers tells us little about the routine practice of psychiatry there and then. Was there really a time when psychiatrists were trained in “naïve astonishment”? As someone who has trained entirely in the epoch of ‘the new’, I can only speculate – and report that our trainees are ravenous for philosophy, even amid the neuroscience.

    While I agree that the impact of academic philosophy on psychiatric practice is limited, I find myself unsurprised. Denys is right that philosophy is hermetic, but I don’t believe that this is any worse for psychiatry than for neuroscience. Efforts by neuroscientists to image moral reasoning or syllogisms or consciousness no more betray a grasp of philosophy than would a psychiatrist’s examination of the fixity of philosophers’ beliefs.

    It has always been the way of philosophy to adopt a position of superiority, to examine the principles and practices of a field of study. The limitation of this has equally always been that philosophers know less of the field than the practitioners of that field themselves. This is no less the case with the philosophy of psychiatry: with notable exceptions, it is populated by philosophers, not psychiatrists. I agree that there is an opportunity for phenomenology and the philosophy of mind to engage with the material of psychopathology, but this is an opportunity principally for philosophy, not psychiatry. The ‘new psychiatry’ is clear evidence of that opportunity – books, journals and philosophy jobs have all been created from it. What is much less clear is the benefit of this activity for psychiatrists. Our trainees may love wisdom, but will we teach them ‘the new’?

    Competing interests

    None

  4. Yesterday

    Gareth Owen, Institute of Psychiatry London

    15 November 2007

    Yesterday, I was working in a community mental health building in South London with a psychiatry team that is being re-arranged in accordance with concepts that have very little coherence. Staff literally do not understand what their team is supposed to be aiming at or whether their jobs will be maintained. Neither do their managers who are trying to interpret the multitude of policy directives that fall onto their desks from substantial heights.

    What everyone can agree on is that psychotic patients who do risky things need attention. And so it was that I, working with a patient who had attracted forensic interest, was afforded the time to attend to her old case notes - notes which went back to 1975.

    The notes were eye opening because they revealed something of the psychiatry of the Maudsley Hospital, London in 1975. Psychopathological detail was elicited, interrogated and discussed with a finesse and eye for distinctions that seemed entirely alien. The case was formulated with cross-sectional and longitudinal frames of reference and with a variety of explanatory systems in mind. Papers by Karl Jaspers, Kurt Schneider, Klaus Conrad and Aubrey Lewis were referenced in the case notes! The diagnosis – in this case paranoid schizophrenia - was discussed and debated as a concept.

    ‘What happened?’ I thought. What happened to that tradition of conceptual psychiatry, practiced by living psychiatrists with living patients? What happened to the ‘old philosophy of psychiatry’?

    I’m still not sure I have the answer. But what I do know is that it died. Sitting in that building yesterday it was clear that it had died – I knew because I caught myself romanticizing the past.

    We have a ‘new philosophy of psychiatry’. This ‘new philosophy of psychiatry’ has an impressive output which now includes a textbook. It is right that psychiatrists debate this because it will be coming to bookshops near them if it isn’t there already. I applaud PEHM for taking up the challenge of initiating this debate.

    It is interesting to draw parallels between ‘the new philosophy of psychiatry’ and the anti-psychiatry movement. Like the anti-psychiatry movement ‘the new philosophy of psychiatry’ comes primarily from outside psychiatry as a branch of medicine. It may be that psychiatry ignores it like it did the anti-psychiatry movement only to wake up a little late in the day to realize that it has influenced a lot of people who exert control over psychiatry. Unlike the anti-psychiatry movement ‘the new philosophy of psychiatry’ is not saying that mental illness does not exist – or if it is saying this it is saying it differently. It isn’t speaking with one voice and marching in one direction - it is characterized by a plurality of voices and a multitude of directions. It is also less journalistic than the anti-psychiatry movement. It seeks wide audiences but is written in more overtly academic and philosophical vocabularies by people with university posts.

    In trying to consider whether the ‘new philosophy of psychiatry’ is valuable to psychiatry I can’t help but come back to my position in the mental health building yesterday. Sitting there trying to grasp a case and knowing that clinical decisions lie ahead for me - decisions to do with the nature of that patient’s mental state, with medications that can alter that patient’s mental state and with mental health law that can effect that patient’s liberty.

    At one level we are operating so close to philosophical matters in psychiatry that the distinction between psychiatry and philosophy is hard to discern. This isn’t new. As Damiaan Denys writes it is inherent to psychiatric practice. At another level we are a long, long way away from philosophy. Sitting in that building being torn apart by socio-economic pressures, with real rather than theoretical problems and with deliberations which must, by necessity, end in decisions I felt that distance.

    That is the rub. Psychiatry is the stuff of true wonder and also the stuff of harsh realities. ‘The new philosophy of psychiatry’ if it does capture the wonder and if it does capture, or respect, the reality might have influence within psychiatry – live there so to speak. I think, however, that it is more likely that the influence will be outside psychiatry – in philosophy departments and in non-medical circles. I think it is too early to tell which way 'the new philosophy of psychiatry’ is headed. One possible cause for concern is that, unlike the ‘old philosophy of psychiatry’, it seems to have its locus outside psychiatry as a clinical decision-making discipline. If it evolves into an activity carried out by people who are not in touch with clinical problems it will become an academic pursuit thinking psychiatrists will not turn to for illumination.

    Whatever the fate of the ‘new philosophy of psychiatry’ psychiatry should not make the same mistake it did with the anti-psychiatry movement and try to turn the other way. It’s much better psychiatrists debate this sooner rather than later.

    Competing interests

    nil

  5. So what is new in the new philosophy of psychiatry?

    Richard Gipps, CASPD, Salomons, Canterbury Christ Church University

    16 November 2007

    I have often wondered whether R D Laing’s life might have turned out differently if he had found a more intelligent immediate audience for his existential inquiry The Divided Self. The early Laing was a scholar devoted not only to understanding the phenomenological depths of both schizophrenic illness and of psychoanalytical inquiry, but also to bringing to the English speaking psychiatrist the insights of such philosophically-informed continental psychiatrists as Minkowski (Laing, 1963). As it was, Laing’s audience became largely a popular one, he was excluded first from academic psychoanalytic circles and later from practicing ones, and – in my opinion – his writings soon lost their promising clarity and insight. If he had only found a more respectful yet philosophically intelligent ear, so my fantasy goes, perhaps he would have felt able and wanted to keep ploughing deep straight furrows through the fields of psychopathology, rather than sketching playful gestures on their surfaces.

    In many ways Laing was an exemplar of a tradition in psychiatry which aimed to use philosophical methods to directly shed light on the experience of their patients. The existential and phenomenological philosophical schools have always appeared to hold more promise for such a direct application. The focus of their analysis, after all, is directly on the lived experience of the person, of the kind of existence they enjoy, of the diverse forms this takes, and not, as the analytical schools have it, on the language and concepts used to describe the mind and the body. The distinction may well be an artificial one, and the real differences may have more to do with tacit metaphysical commitments (amongst analytical philosophers, a temptation to invent putative ‘mental entities and processes’ conjoined or ‘identified’ with a brain, rather than focus on the realities of being an intentional living being-in-the-world) and temperament (a greater tolerance for poetics and unclarity of expression in the phenomenological tradition). Nevertheless the reality is that, whilst the phenomenological tradition has surfaced fairly steadily over the years on the continent (think amongst many others of Minkowski, Straus, Binswanger, Boss, Laing and Tatossian, and more recently authors such as Thomas Fuchs and Giovanni Stanghellini), a comparable interest either from analytical philosophers in psychiatric concepts, or an interest in using analytical philosophy from within psychiatry itself, has been fairly lacking.

    What is new in ‘the new philosophy of psychiatry’ is, I would suggest, primarily the interest recently being taken by primarily English-speaking philosophers in psychiatry and by English-speaking psychiatrists in using philosophical methods. On the whole this work has been done in the Anglo-American analytical tradition, and many of the books in the International Perspectives series reflect this emphasis, although other writers for the series (such as Stanghellini (2004)), despite being of continental origin and using a phenomenological approach, have been written in English. Yet another important and new phenomenon for the philosophy of psychiatry, as for elsewhere in philosophy, has been the breakdown of the above-described divide between the analytical and the continental traditions. The new philosophy of psychiatry represents this erosion of the boundaries between the traditions – an erosion initiated by philosophers such as Charles Taylor and Richard Rorty – and its products can be found both within the series (Chung, Fulford & Graham (2007)) and without (in the work of Shaun Gallagher (2005) for example).

    It sometimes takes time for the intellectual value of good ideas to become acknowledged in the academic consciousness of an age. R D Laing’s most important intellectual contributions to schizophrenia did not reach any serious philosophical fulfilment until they were, thirty years later, taken up again and deepened in the philosophical psychopathology of Louis Sass (1994). Furthermore the understanding is now readily available that, to recycle the above farming metaphor, current psychiatric conceptions of conditions like schizophrenia and the empirical research they inspire have often looked like attempts to understand differences in the growth of corn by counting the heads on the stalks in the fields – rather than by investigating the root and soil structure underneath. Even psychiatrists known for their strongly biological perspectives have recently acknowledged that scientific reliability has too often been purchased at the expense of there being any real validity or true meaning in the understandings being employed (Andreason, 2007). So perhaps R D Laing could today have found a more congenial and intellectually adequate audience within psychiatry itself. Now that we have the International Perspectives book series, organisations such as the International Network of Philosophy and Psychiatry (www.inpponline.org), and philosophy contributing to the UK’s MRCPsych, the opportunity arises to use the methods of both phenomenological and analytical philosophy to plough deeply through the soil structure of psychopathology.

    Richard Gipps, PhD

    N. Andreason, (2007). DSM and the Death of Phenomenology in America: An Example of Unintended Consequences. Schizophrenia Bulletin, 33(1):108-112

    M. C. Chung, K. W. M. Fulford & G. Graham (2007). Reconceiving Schizophrenia. Oxford: Oxford University Press.

    S. Gallagher (2005). How the Body Shapes the Mind. Oxford: Oxford University Press.

    R. D. Laing (1960) The Divided Self. London: Tavistock Publications.

    R. D. Laing (1963). Minkowski and Schizophrenia. Review of Existential Psychology and Psychiatry 3, no. 3.

    L. Sass (1994). Madness and Modernism. Cambridge, MA: Harvard University Press.

    G. Stanghellini (2004). Disembodied Spirits and Deanimated Bodies: The psychopathology of common sense. Oxford: Oxford University Press.

    Competing interests

    None

  6. As the circle of science grows larger, it touches paradox at more places

    Matthew Broome, University of Warwick and Institute of Psychiatry, King's College London.

    17 November 2007

    Deny’s reply to Banner and Thornton is provocative and demonstrates some ambivalence as to the current relationship between psychiatry and philosophy. Clearly, Denys supports the interaction between psychiatry and philosophy but perhaps longs for a time when psychiatrists were able to draw upon their own philosophical sophistication, rather than recruiting a group of professional philosophers researching in ‘philosophy of psychiatry’.

    Denys is correct in that psychiatry has, until relatively recently, had close links with philosophy. As someone whose work is in the prodromal phase of schizophrenia, I remember being delighted that Feuchtersleben’s coining of the term ‘psychosis’ was based around his understanding of Schelling’s philosophy of nature. Such close links, however, have become less common: medical training is, perhaps, less tolerant of those who seek contact with alternate disciplines than in the past; however, until recently psychiatry was rather protected from this bias, and if anything those embarking on a career in psychiatry would typically have wider intellectual interests than other physicians. I would broadly agree with Denys’ historical account: psychiatry recently seems to have felt that it did not need philosophy anymore and became anxious if its trainees became interested in more conceptual issues. I would like to suggest that this is because psychiatry lost its own anxiety as to its status: in the 1990’s particularly, psychiatry developed a clear methodology and paradigm, and dare I say, its own unquestioned metaphysics. Psychopathological states were consequent upon altered cognitive or neuropsychological mechanisms, such mechanisms were located in certain anatomical areas of the brain, and these changes were further underpinned by neurochemical and genetic differences. Psychiatry, for a brief period, became a Kuhnian ‘normal science’. It was clear what we should be working on and other intellectual activity was a waste of time or could confuse the junior psychiatrist. It is only recently that the cognitive neuroscientific or neuropsychiatric paradigm has begun to run into difficulties that, again, philosophy becomes of crucial importance to both research and clinical psychiatrists. As Fulford and other writers have pointed out, it perhaps should not be surprising that the ‘new’ philosophy of psychiatry follows on the heels of the second biological psychiatry, given that Jaspers’ work was inspired by the limitation of the first period of biological psychiatry.

    Hilary Putnam, in the opening of his ‘Realism with a Human Face’, quotes Nietzsche ‘As the circle of science grows larger, it touches paradox at more places’ and it does seem apt that now for us, at the beginning of the 21st century, that philosophy is so relevant to us in psychiatry. The findings of cognitive neuropsychology, functional neuroimaging, and genetics have to be placed in a rational context alongside the experience of the suffering individual and the clinician who tries to make sense of what they say to them. I would argue against Denys and suggest that the ‘new philosophy of psychiatry’ has been characterized by strong and close collaboration between professional philosophers, clinicians and scientists and a growing interest in psychiatry from within ‘analytic’ philosophy. Further, given my philosophical interests into how one should study psychopathology scientifically, I agree that psychiatry can benefit greatly from the philosophy of psychology and the philosophy of neuroscience. Indeed, I am currently co-editing a volume with Dr Lisa Bortolotti, titled ‘Psychiatry as Cognitive Neuroscience: Philosophical Perspectives’. Philosophy of psychiatry is not anti-science by any means, but rather, should aid the best kind of science. I have been very fortunate to have been part of a philosophy group at the Maudsley Hospital for over 5 years: this group arose explicitly out of the anxiety we felt as trainees and junior researchers. Our philosophical interests have run in parallel with our empirical research and the group has been supported by senior academics such as Robin Murray. Indeed, the members of our group are more likely to be publishing scientific papers than those not interested in philosophy. Further, our philosophical studies have impacted on both our empirical and clinical work, and have lead to direct pieces of research being carried out. In addition to Robin Murray’s support to us locally, it is important to note that key psychiatric researchers internationally such as Nancy Andreason, Ken Kendler, Paul Mullen and Josef Parnas are increasingly turning to philosophy in their empirical work in psychiatry.

    Psychiatry remains for me the most fascinating branch of medicine and we have, as clinicians, to be able to hold ourselves upon to the ambiguity of our work: to simplify incoherently and falsely is to mislead ourselves and our patients. Instead, philosophy allows us to think about the very real, Kantian, problem that underpins all of our work: the relationship between freedom and natural laws.

    Competing interests

    Nil

  7. Critical thinking in clinical practice?

    Natalie Banner, University of Central Lancashire

    17 November 2007

    I am grateful for Prof. Denys’ thought-provoking response to Tim Thornton’s and my recent article which has, it appears, attracted a good deal of insightful commentary about the place of philosophical thinking in psychiatry. In replying to Denys, what primarily occurs to me is that we don’t seem to disagree fundamentally on any conceptual issue: the different attitudes we take towards the philosophy of psychiatry are characterised by our respective degrees of optimism about its utility and actual infiltration into psychiatric training and clinical practice.

    Given Denys’ allusion to past times when philosophical thinking was embedded within psychiatry, there appears to be no a priori reason why it should not be so firmly entrenched again. Target driven policies and pressure on resources regarding psychiatric care and treatment (in the UK at least) are probably more to blame for the loss of a critical, reflective attitude than any failure by either discipline to engage with the other.

    The main concern for the philosophy of psychiatry is, as I see it, the possibility that any incorporation of philosophical thinking into training or practice will merely be a gesture; another tick box in a long list of training requirements, without actually having any impact on the way clinicians go about their day to day practice. Philosophical theorizing about such things as the nature of mental disorder may be conducted by a group of interested participants who are genuinely enthusiastic about delving into the difficult conceptual issues their profession faces, but if this is perceived as a side-project that does not actually affect clinical practice the effort will, I think, have been largely in vain.

    Denys criticises philosophical writing as often being inscrutable and jargon-laden to an audience of psychiatrists (on which point I would reassure him that it is frequently just as impenetrable to philosophers themselves). However I would suggest that there are small but significant movements from within philosophy towards making philosophical theorizing and its results more transparent to an outside audience. Indeed, some of us are positively embracing the opportunity to apply a philosophical approach to conceptual difficulties within psychiatry, with a specifically problem-solving attitude that is intended to produce clear, practical consequences for psychiatric theory, policy and practice. Bill Fulford’s work on Values-Based Practice is but one example of this drive.

    The positive outlook of those responses from clinicians at the Institute of Psychiatry suggest to me that despite the heavy criticism levelled at psychiatry by many arguments in the IPPP series (among others) is not necessarily being taken as negatively as Denys implies. Indeed, the very fact that there has been such response from both philosophers and psychiatrists indicates that there is willingness on both sides to engage in the debate and gain from the expertise of other disciplines. I remain optimistic that the application of critical attitudes, reflection and philosophical theorising to conceptual and practical problems in psychiatry is achievable and that the discipline is continuing to gain momentum, despite the medicalisation of psychiatry’s subject matter and the enormous pressure on time and resources experienced by clinicians today.

    Natalie Banner

    PhD Research Student

    Institute for Philosophy, Diversity & Mental Health

    University of Central Lancashire

    Competing interests

    None

  8. Glass half empty or half full?

    Tim Thornton, University of Central Lancashire

    19 November 2007

    I am grateful to Damiaan Denys for the friendly tone of his critical response to Natalie’s and my paper and for his mention of my own contribution to the International Perspectives in Philosophy and Psychiatry book series, Essential Philosophy of Psychiatry.

    In fact, the friendly tone appropriately reflects a large measure of underlying agreement alongside surface disagreement. We all agree that philosophy and psychiatry can stand in a useful mutual relationship. We all agree that there has been a history of interrelation especially within the phenomenological tradition. (Natalie and I mentioned this in a preliminary way although it was not our topic.)

    But while Natalie and I saw grounds for optimism in the new developments in broadly Anglo-American philosophy of psychiatry, Professor Denys emphasises the grounds for pessimism in the diminution of philosophy within psychiatry itself. Aside from the suggestion that the rise of the new philosophy of psychiatry is the direct result of its loss within psychiatry – ‘Philosophy has left the psychiatric building. It is exiled from psychiatry, externalized and sequestered in the “new” philosophy of psychiatry’ – which seems unlikely, there is little substantial to disagree about. We see the glass half full (and the focus of our review was that full half), Damiaan Denys sees it half empty. All of us would like it to be fuller.

    So what practical steps can we take to improve matters? A recent discussion of the World Psychiatric Association’s Institutional Program for Psychiatry for the Person that took place in London suggested some possibilities. The main focus of the meeting, organised by Juan Mezzich (and the Department of Health), was to find ways to augment a narrow criteriological model of diagnosis with a broader, more explicitly person-centred, approach to psychiatric formulation. But in the meeting different views were also expressed (mainly by psychiatrists) questioning the general need for diagnosis and also pointing out the view of some service users that their conditions should not be seen in negative, pathological terms at all. Such debate, although leading to no quick answers, suggests a positive and practical way to improve our understanding of mental health and mental health care but also the positive practical steps that this might underpin.

    Professor Denys comments that most of the work of the new International Perspectives in Philosophy and Psychiatry book series is critical, for example ‘critically analyzing the conceptual foundations of academic psychiatry’. This is true and surely a good thing. What would be the point of a philosophical or conceptual engagement which was not critical, reflective, thoughtful? But he also suggests that such criticism, ‘coming from the outside’, is often perceived to be negative.

    It is worth noting that most of the authors or editors we reviewed are qualified psychiatrists (with a couple of clinical psychologists, also) so the criticism is not in the sense implied external to psychiatry. But if it is perceived by some to be negative that suggests that there is work to be done in examining the assumptions about change and development of psychiatric services and about the shared and divergent values of those involved. In this process there is an important role for the new philosophy of psychiatry.

    Competing interests

    None

  9. Philosophy and Psychiatry: Philosophizing reloaded

    Jann E Schlimme, Department for Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Germany

    20 November 2007

    First of all I want to thank Damiaan Denys for his article and I also have to confess that I wonder if the adjective “new” is really adequate. Furthermore I agree that it is necessary to reflect on the emerging field of “philosophy and psychiatry”, searching for its fundaments and asking questions like why is there such a momentum in this field right now. Why is it re-introduced (“reloaded”) just now? Basically I agree with his observation that philosophical thinking was more or less banished from the psychiatric discourse and psychiatric training in the last decade and with his observation that philosophical themes appear to be more easily connected with actual neurosciences than with everyday psychiatry, yet it is necessary to address philosophical problems in everyday psychiatry once again. Denys argues that the reason for this lies basically in our being human.

    Though it may appear as a simple repetition I want to focus on at least four reasons, not strictly belonging to only one of the broad interconnected themes: values, meaning and facts. These four reasons are fundamental to psychiatry and show why it is important for psychiatrists to be able to philosophize in their everyday practice. Maybe these four reasons can show that philosophy is not “a bridge too far” for practicing psychiatrists. Considering Denys line of argument I believe that he might agree with me regarding their importance. 1) If illness, sickness or disease means for the ill, sick or diseased person mainly the loss, fragility or questionableness of taken-for-granted realities and daylong implicitness, getting well affords basically achieving again reliability of one’s own everyday experience and reality. From a certain point of view this is exactly what philosophizing is trying to do: questioning the unquestioned taken-for-granted reality and coming back to an everyday implicitness on a new and “higher” level. 2) There is the longstanding and well-known phenomenon, that if a person gets well again, she will no longer need the doctor. To become dispensable seems to be accepted more easily when one is able to understand the other person’s perspective in a broader sense. 3) Normally we refer to “normal” without giving an account of this normality we are meaning. Certainly we as psychiatrists are asked to assure ourselves about the concept and content of normality we are referring to. To me it seems sensible to argue that we cannot come to an end with this reflection. Regarding, for example, the concept of personality disorders, we still like to refer to Kurt Schneider’s definition putting the first person perspective first, meaning that the diagnosis of a personality disorder relies basically on the subjective estimation of psychological strain regarding ones own personality (Schneider 1923). 4) Drawing on my experience of ten years of clinical practice in psychiatry I am convinced that many patients are far more philosophical than their doctors and that they are not satisfied with simple psychological answers. Our patients will ask important philosophical questions, whatever we may think of those questions. Of course one could say that we are not the ones to give answers to existential questions, but does not this reloading of philosophy in psychiatry show the existential need for such questioning? Are not the growing audiences attending international and national congresses and lectures proof of the desire to get some kind of reliable foothold in the world? What if we as “true” philosophers give way to those who give preliminary, dogmatic and single-minded answers? We can argue that this situation has become more prominent with actual neuroscience showing a) that we have to ask our questions very precisely and b) that there is really no chance to find, for examples, Kantian categories or the grammar of human language, in the NMR-scanner. Surely searching for (definite) answers to the questions life is asking us is a challenge, although we have to admit, since Immanuel Kant, that we are given ourselves as a task to perform on ourselves.

    Perhaps my four reasons focus on the following quotation from Karl Jaspers: “Yet if we cannot possess the truth as a whole and absolute truth in a matter-of-fact sense any more, possibly the process of searching is the truth in time, to live dying in this question is the highest and deepest truth, and maybe the completion of being true is a stadium of transience, not duration in time, is just like the ephemeral gaze of the eyes in which all is present.” (Jaspers 1947, 454) Of course one could say that I am talking more about philosophizing than about philosophy. Yet I would like to say, and I think that Denys would also agree with this statement: the emerging field of philosophy and psychiatry can do well without the adjective “new”, but psychiatry cannot do without philosophy.

    Literature

    Jaspers K. Von der Wahrheit (About truth). München. Pieper 1947.

    Schneider K. Die psychopathischen Persönlichkeiten (The psychopathic personalities). Leipzig, Wien: Franz Deuticke 1923.

    Competing interests

    The author declares that he has no competing interests

  10. Psychiatry and philosophy

    Rodrigo Carrillo, Other

    21 November 2007

    It is very interesting that today we try to make a marriage on this historic divorce. Psychiatry has divorced philosophy and I think it has to do with the positivism of the nineteenth Century. Positivism was like the Industry Revolution. It is very important to note that in the past physicians were also philosophers. I think that philosophy and psychiatry (also psychology) are two legs from the same body and we cannot separate them. If we do so, then we limp.

    Competing interests

    None declared

  11. Psychiatry's repressed past and its relevance for philosophy

    Helge Malmgren, Göteborg University

    22 November 2007

    Here are a few reflections stimulated by Denys’ thesis that the new philosophy of psychiatry is not really new, and some conclusions about how to make philosophy of psychiatry more relevant to psychiatric practice.

    One notable thing about the continental psychological and psychiatric theorists who were active before 1939 is that most of them combined deep neurological knowledge with a phenomenological approach to their patients. One well-known example of this combination is Sigmund Freud, but it also holds for many of the German speaking psychiatric pioneers such as Eugen Bleuler, Karl Jaspers and Claus Conrad. This double competence and double approach can also be found in later continental psychiatrists such as Henri Ey in France. Among other things, such an outlook implies an interest in the phenomenology of the organic mental disorders as documented, for example, in Ey’s monumental Traité des Hallucinations (1972). This combination of biology and phenomenology did obviously work, and one reason for this, I think, is that there was a simple (which does not mean: untrue) working solution of the philosophical mind-body problem around which was known to everybody in the game: a two-aspects or parallel theory (perhaps most explicitly stated by Freud). Within this general philosophical framework, and sometimes of course breaking out of it, there was an ongoing philosophical discussion among psychiatrists on how to improve our understanding of the mind-brain relationship.

    What happened in 1939? Well, there was a world war, which meant at least two things to continental psychology and psychiatry: some scientists and practitioners fled to Britain or the USA, and after the war there was a radical shift of scientific dominance from the German-speaking to the English-speaking community. The importance of the latter shift cannot be overestimated. Among other things, it is reflected in the fact that most of the later German and French literature in the field is not available to those who are limited to the English language. For example, the most important of the continental textbooks, Eugen and Manfred Bleuler’s Lehrbuch der Psychiatrie, came out in its 15th German edition in 1983 but none of the postwar editions have been translated into English. Of Ey’s work, only his philosophical treatise La Conscience (2d ed.: 1968) has been translated. I could give a host of other examples. The main exception to the absence of translations is of course Freud. But when it comes to psychoanalysis, the emigration from Austria and Germany of its leading figures may have meant a radical tradition break in another way. As argued by Jacoby in his fascinating little book The Repression of Psychoanalysis (1983), psychoanalysis was essentially taken over by American private psychiatrists who had little interest in pursuing natural-scientific investigations. So, the neurological connection which had been so strong in orthodox psychoanalysis was severed.

    Then, of course, came the psychopharmacological revolution in the 1950’s. Without doubting its beneficial effects for large groups of patients, I am sure that it had a deleterious effect on the science of psychopathology. With the new medications in your hand, a precise psychopathological diagnosis was no longer essential: if the first medicine doesn’t work, try the next one. I still remember my psychiatry teacher, around 1975, telling the story of a severely depressed patient who did not recover until she received haloperidol. This is not the kind of teaching that stimulates your interest for precise differential diagnosis.

    So, it can be argued, the art of diagnosis declined while the therapeutic arsenal grew. This trend may in itself have contributed to a felt need for a new clinical diagnostic system. It is also generally recognized that one of the motives behind DSM-III (1980) was the need for reliable research criteria in psychiatry. But another important driving force behind the new classification was the conflict between psychodynamic and biological psychiatrists in the USA, a conflict which was fueled by the psychopharmacological revolution and aggravated by the fact that the American psychoanalysts were not biological at all. DSM-III meant the end of the dominance of the psychoanalysts. One should also not underestimate the pressure from economic and administrative interests towards a smoothly working classification system. Perhaps one of the great mistakes of the authors of DSM-III was to suppose that one single classification could serve the needs of clinicians, scientists and economists at the same time. Be that as it may, DSM-III completed the break with the great continental tradition: clinical phenomenology was reduced to everyday observations of surface symptoms, and psychopathological theorizing was banned. Another striking feature is that the neurological connection was not reestablished when psychoanalysis was thrown out. Organic (neurological) psychiatry is the stepchild of DSM-III, and in this respect things have become worse in DSM-IV. Which in turn means that a main arena for studying brain-mind relations (and philosophizing about them) still lies abandoned.

    So, what relevance does my story have for today’s philosophy of psychiatry? Well, during the more than 35 years that I have been active in the field, I have repeatedly been reminded of two things. The first is that present-day psychiatrists seem not even to have been taught the simple two-aspects solution of the mind-body problem that was taken for granted by most of the old-school psychiatrists (at least as a starting-point for discussions). For example, they have difficulties in understanding that if you see a change in the brain of a patient (on fMRI for example), what you see could simply be the neural aspect of a mental process. It need not imply a non-mental cause: just think of the case where what we have caught on fMRI is a common reaction of grief. This lack of elementary philosophical insight (or, to be more neutral, this lack of a plausible working model of the mind-brain relationship) means that many discussions about the etiology and nature of mental disorders become extremely confused. The second thing I have noticed many times is that psychiatrists (and psychologists) have sought and found unnecessarily radical solutions to their philosophical troubles. In the words of a previous commentator, the heavy artillery has been brought in, and the philosophers have been all too eager to supply it. No wonder that, as Denys emphasizes, the criticism has been perceived as negativistic and destructive.

    Hence, my recommendations are simple: Translate the main works of the great continental psychiatrists - Eugen and Manfred Bleuler, Conrad, Ey and others - into English. Don’t forget to include their works on the phenomenology of organic mental disorders. Write elementary philosophical textbooks for psychiatrists. If your preferred philosophical theory has no strong support in the rest of the philosophy-of-psychiatry community, avoid marketing it among psychiatrists in general as the solution for psychiatry’s philosophical puzzles. And of course: continue and strengthen the promising interdisciplinary research which has, indeed, gained much force during the last 15 or so years.

    Competing interests

    No competing interests.

  12. Informal footnotes at the margins of Philosophy of Psychiatry

    Andrea Raballo, Department of Mental Health, AUSL Reggio Emilia, Italy

    26 November 2007

    It is only after looking at the long list of comments that Denys’ manuscript reveals most of its pleasant demystifying nuances (as well as the inadvertent extra-value of an implicit projective test). Once again, together with the inescapable polysemy of the notions of philosophy and psychiatry in all the breadth of their referential fields (not to mention the rich and allusive ambiguity of the adjective “new”), some of the critical articulations of the contemporary debate on the topic come to the surface. However, just bracketing the academic and fashionable implications of such phenomena (which closely mimic the broader reappraisal of the humanities in medical sciences), I would observe that most of the feeling of novelty is due to a fertile optical effect of de-historicization. Indeed it is only recently that the growing availability of English translations of continental authors of the last century has allowed the de-sequestering of such incredibly rich (yet largely unknown) material from the sometimes elite circuits of European national heritages. Thus, what is actually brand new is the explicit re-discovery (or in some cases the reformulation) of critical intersections between psychiatry and philosophy. The latter indeed is immanently grounded in the interpersonal-existential sides of both clinical practice and ethics, and is clearly essential for the continuous epistemic reorganization of psychiatry as a clinical neuroscience. Therefore, interpreting such a trend in a historical perspective does not reduce the salience of this interdisciplinary synergy, but helps to avoid the complementary sirens of romantic idealization and pragmatic neglect.

    Competing interests

    None

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