Person-Centred Care in Psychiatry

Self-Relational, Contextual and Normative Perspectives

Gerrit Glas

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9780429516115
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

One of the paradoxes about psychiatry is that we have never known more about and better treated mental disorders, yet there exists so much unease about the practice of mental healthcare. Patients feel still stigmatized, psychiatrists are struggling with their roles in a rapidly changing system of healthcare, there is lack of consensus about what mental disorders are and what the focus of psychiatry should be. Person-Centred Care in Psychiatry: Self Relational, Contextual and Normative Perspectives offers a distinctive approach to two important linked conceptual issues in psychiatry: the relation between self, context, and psychopathology; and the intrinsic normativity of psychiatry as a practice.

Divided in two parts, this book shows how the clinical conception of psychopathology and psychiatry as normative practice are intrinsically connected, and how the normative practice model can be conceived as a natural extension of the analysis of the web of relations that sustain illness behaviour as well as professional role fulfilment.

Person-Centred Care in Psychiatry brings these topics together for the first time against the backdrop of unease about scientistic tendencies within psychiatry in an interconnected discussion that will be of interest to academics and professionals with an interest in the philosophy of psychology, psychiatry and mental health-care.

1

PSYCHIATRY IN NEED OF PHILOSOPHY

1.1 Paradoxes and concerns

One of the paradoxes of the current state of mental healthcare is that we have never known more about mental disorders and simultaneously been more uncertain about the science as well as the practice of psychiatry.

This is remarkable. Psychiatry as a science is flourishing. Over the last three decades, there has been an enormous increase in empirical research on the genetic, neurobiological, psychological, and social determinants of mental disorder. At the same time, mental healthcare has improved significantly, at least in most Western countries. There are more treatments and there exists much more refined differentiation in the way healthcare is delivered. Reform in legislation and in the organization of care has led to greater patient autonomy, more control over the process and outcomes of therapy, more transparency in decision making, and more patient participation at all levels of policymaking.

Yet, these improvements have not diminished the unease about psychiatry, as a science and as a practice. Psychiatry as a science is haunted by discussions about a proper system for diagnosis and classification. There is no consensus on what mental disorders “are.” Researchers have discovered many determinants of mental illness, but most of them lack specificity and are related to more than one psychiatric disorder. In addition, scientific leaders have differing views on where psychiatry as a science should be heading; for example, toward a variant of biomedical reductionism and a reunion with neurology (Insel & Wang 2010) or toward a science of the mind-brain-in-context as a branch of complexity theory (Thompson 2007), to mention only two extremes.

No wonder psychiatrists are struggling with their professional roles and their identity. Some of them see the prototypical psychiatrist as a hospital-based medical specialist with a focus on the neural underpinnings of mental problems. Others prefer a role as networker and negotiator at the interface between science and society. Still others look for hybrid constructions, in which the psychiatrist is a mix of expert, negotiator, and health advocate.

With respect to mental healthcare as a practice, there are also many tensions and uncertainties. The field is struggling with its acceptance in society. There is strong agreement about the need for evidence-based psychiatric treatment. However, despite this need and all the efforts to fulfill it notwithstanding, treatment results have not dramatically improved over the last two or three decades. This also holds for stigmatization. An enormous amount of effort has been put into anti-stigma programs. Nevertheless, stigmatization has hardly decreased. People with mental disorders still hide their problems. They still feel that having a mental problem is something they should feel ashamed and culpable of.

It is the aim of this chapter to show that most of these practical, conceptual, and moral concerns can be grouped together under three fundamental themes. A second purpose is to highlight one dominant response to the challenges, which is scientistic. The scientistic response seems attractive and convincing at first glance, but it is, in fact, inadequate, as I will show. The final goal of this chapter is to briefly introduce the philosophical framework I work within, which draws on core ideas developed by the Danish philosopher Sören Kierkegaard (1848), the French philosopher Paul Ricoeur (1990), and the Dutch philosopher Herman Dooyeweerd (1953–1958). Ricoeur and Dooyeweerd belong, together with Karl Jaspers, to the first and most vocal opponents of scientism. From Kierkegaard and Ricoeur, I borrow the notions of self-relatedness and self-referentiality to investigate the nature and implicit normativity of the patient’s relationship to his or her illness and the professional’s attitude toward the fulfillment of his or her professional role. Dooyeweerd’s systematic philosophy functions as a conceptual resource for the formulation of a heuristic framework of normative principles that play a role within the different contexts of psychiatry. Other philosophers who significantly influenced my ideas about the normative aspects of professional and institutionalized practices are Alasdair MacIntyre (1984) and Charles Taylor (1989).

1.2 Fundamental conceptual issues and their inner connection

Instead of presenting an exhaustive list of the current practical, conceptual, and moral problems in psychiatry and providing arguments on how to conceptually group them together, I simply suggest that most of these problems belong to three general conceptual themes. I indicate these themes briefly here and provide more detail in the remainder of this chapter:

1. The nature of psychopathology, especially considering its context dependence and its relatedness to the self.
2. The value-ladenness of psychiatry as a clinical practice.
3. The role and status of scientific knowledge, especially in view of the nature of clinical knowledge.

1.2.1 Self-relatedness and context dependence of psychopathology

Mental illnesses do not exist in and of themselves. They are neither Kantian things-in-themselves—beyond what we can grasp with our senses—nor are they material entities (things, events, or processes) located somewhere in space-time; and neither are they only mental constructions that help us organize the world. However, mental illnesses do indeed exist. They exist not only in the mind of the psychiatrist, but first in the lives of the patients who experience them. Terms such as psychosis, anxiety, depression, and addiction refer to a variety of categorically distinct phenomena within the patient, including feelings, thoughts, inclinations, and non-intentional behaviors. These phenomena occur in patterns or regular combinations of features. These regularities and patterns form the basis for psychiatric nomenclature.

The science of psychopathology attempts to grasp these patterns and regularities by relating them to explanatory factors (determinants, risks, and vulnerabilities). The search for patterns, regularities, and explanatory factors inevitably leads to simplifications. Individual details are put between brackets. Like any other science, psychopathology focuses on general patterns. This is what we call “abstraction”: the carving out of a pattern and regularity as a first step toward the discovery and formulation of explanatory hypotheses. In philosophy of science, abstraction is usually referred to as “reduction.” I use both terms to refer to the same cognitive act of carving out an aspect, part, or set of features of the object under study. Ideally, this carving out is determined by a hypothesis or theory. Abstraction is the first stage in the testing of this hypothesis or theory.

A well-known issue in this context concerns the transition from abstraction to reification. Abstraction, as we have seen, refers to the artificial pulling out and setting aside of an aspect, part, or set of features in order to explain patterns or regularities. Ideally, there is no moment during the process of abstraction that the artificiality of this process and of the abstracted entity is ignored. Reification, however, “forgets” this artificiality. Instead of viewing the aspects, parts, or sets of features as being divorced of their holistic context, it considers them as things in themselves and sometimes even as the whole thing.

To reify means to make (facere) a thing (res) of something. For example, in the field of psychopathology, one might say that panic disorder “is” a disturbance in the brain’s serotonin metabolism. The presence of this disturbed serotonin metabolism is indeed an important empirical finding in patients with panic disorder. The disturbance forms a part of panic disorder as a clinical phenomenon. However, the entire clinical picture involves much more than altered serotonin levels. To assert that panic disorder essentially consists of a disturbance of the brain’s serotonin metabolism is to commit a mereological fallacy, as Bennett and Hacker (2003) would refer to it. A mereological fallacy is a logical error which occurs when a part (from the Greek meros) is treated as if it were the whole. In this case, the serotonin abnormalities (a part) are being taken as an adequate description of panic disorder (the whole). Mereological fallacies usually lead to reification of the abstracted part and to an abstract view of the entire phenomenon, in this case, panic disorder. However, every patient suffering from panic disorder can tell that it involves much more than altered serotonin levels. Reification is also sometimes referred to as “substantialization” (making a substance of something) or “absolutization” (making something absolute, a thing-in-itself, apart from its relationships with other things), or, in German, Verdinglichung (making a concrete thing of an abstract entity).

From the above, it is no large step to understand why, during the process of abstraction, scientists tend to put between brackets both the context in which psychopathology evolves and the relationships among the symptoms and the self of the patient. After all, these relationships are important sources of individual variation in the presence and expression of symptoms, and variation is an impediment to the reconstruction of patterns and regularities, which is the goal of the process of abstraction. The scientist is usually not interested in the way depression affects a person’s self-image or interferes with highly personal contextual issues, such as functioning as a parent. However, these factors are, of course, crucial in the clinical treatment of depression.

The tendency to abstract from the context and from the patient as a person is further enhanced by psychiatry’s indebtedness to the somatic concept of disease, which focuses on states within the individual, i.e., on symptoms and underlying causal processes, determinants, and latent variables. Symptoms are typically seen as the expression of an individual’s state, which is viewed as the disease in the proper sense. This strategy of conceptualizing disease does not leave much room for a contextually sensitive and self-relational view of psychopathology. When abstraction subsequently culminates in reification, the separation between psychopathology, on the one hand, and context and self, on the other, becomes a fact.

What do I mean by a contextually sensitive and self-relational view of psychopathology? With respect to context sensitivity, it is, to begin with, clear that the nature and severity of psychiatric symptoms are often at least partially determined by environmental factors. Problems in memory and attention may long remain unnoticed, but not in situations that are cognitively demanding. The delusions of a computer game addict differ from those of an elderly widow. It is, furthermore, important to notice that the mental healthcare system itself is also a major contextual contributor to variation in the presence and expression of symptoms. The availability of facilities, treatments, and other forms of support shapes the way patients present their complaints. The context sensitivity of the expression of psychiatric symptoms is even more evident when examined from a developmental perspective. Children must learn to verbalize what they feel. Behind every symptom, mental or bodily, doctors must presuppose a socialization process that exerts much influence on the expression of symptoms.

The adjective “self-relational” refers to the fact that patients relate to their symptoms and that symptoms have an impact on how a patient relates with him or herself, with his or her disorder, and with their environment. Later in this book, I discern different ways of self-relating. For now, it is sufficient to recognize two points: First, that mental problems almost always have an impact on how the patient relates to him or herself; and second, that there are some symptoms that intrinsically refer to aspects of the self. I believe the first point is obvious. Persons who under normal circumstances have an average level of self-confidence may feel totally insufficient when depressed. In such cases, depression interferes with the way one relates to oneself. The second point, the immediate and intrinsic reference to aspects of the self, is particularly relevant for the understanding of emotions and certain dispositions (e.g., character traits). For example, anxiety not only points to danger outside myself but also to something in me, i.e., to an aspect of myself that is vulnerable toward the kind of threat that provokes the anxiety. Emotions have an intrinsic self-referentiality: They refer intrinsically to an aspect or aspects of the person experiencing them. This self-referring occurs alongside reference to the object of emotion, which is typically external to the person experiencing the emotion. Anger refers to situations in which I feel insulted or attacked. But the fact that a situation can have such an impact on me indicates also something about me, i.e., that I can be insulted and attacked on this point. Much of the variation in the expression of emotion depends on the enormous spectrum of human vulnerabilities. Most of these vulnerabilities are, of course, within the range of normality.

One of the greatest problems in current psychopathology is that leading systems of diagnosis and classification such as the International Classification of Diseased (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) offer little room to do justice to the context sensitivity of symptoms and the self-relational aspects of psychopathology. These classification systems play a crucial role in diagnosis and treatment planning, but they can hardly be said to capture all that the individual patient needs. What patients need is often not so much determined by the nature and the severity of the symptoms as by the impact of these symptoms on the self-image of the patient and on context-dependent demands. One of the reasons for lack of satisfaction with the mental healthcare system is the blindness of most current diagnostic systems to the context-boundedness of mental problems and to their embedding in the I–self relationship of the patient.

1.2.2 The value-ladenness of clinical practice

Psychiatry is both a science and a practice. As a practice, it refers to norms, preferences, criteria, interests, and values. In the typical case, two people meet: the professional and the patient. The two parties communicate based on their own explicit and implicit assumptions. These assumptions play a role in what is said and left unsaid. Ideally, the patient and the professional succeed in establishing a shared view, or reconstruction, of the patient’s problems and their possible solutions. This reconstruction entails an idea about what is most urgent and needs immediate attention. It provides a coherent picture of all relevant factors contributing to the patient’s problem. The collaborative effort of patient and physician ideally leads to a 3-D view of what is going on and what should be done (Glas 2010). This 3-D view offers perspective; it identifies what is in the foreground and what is in the background; it sheds light on the relevance of the different elements that play a role in the patient’s situation. Ms. A with panic disorder suffers immensely from the intensity of the anxiety, but her primary reason for seeking help is her agoraphobia, which prevents her from going to work. She doesn’t dare leave her home unaccompanied and thus fears losing her job. Here, the efforts of the therapist are directed first at the agoraphobia. Mr. B with moderately severe depression has recurrent suicidal thoughts that disturb him, but he suffers most from lack of sleep and waking early in the morning. He feels exhausted, and the exhaustion is so intense that it leads to a disquieting experience of powerlessness and lack of control. The psychiatrist, therefore, first focuses on restoration of a normal sleeping pattern. These preferences are based on what people deem valuable. Ms. A prefers exposure therapy for her agoraphobia because having work is an important value in her life. Mr. B values normal sleep above alleviation of his suicidal thoughts because exhaustion gives him an intense experience of lack of control.

Norms, preferences, interests, values—they not only play a role at the level of practical decision making but also in a broader sense. They are present in implicit working models in the minds of clinicians (and patients), e.g., in the ideas they have about the nature of mental disorder and the proper role of the psychiatrist. Values help shape one’s ideas about professionalism and professional identity. They are transmitted via residency training programs, role models, and culture in the organization. Values determine one’s responses to the institutional dynamics within mental healthcare and to the societal role of psychiatry. These issues are dealt with in more detail later in this book. We will also systematize the different normative aspects at stake here. For now, it is enough to note that the practice of psychiatry is value laden in many respects.

The value-ladenness of psychiatric practice seems obvious. There is, nevertheless, much unease about it. Why is that? Why is it that even within the psychiatric community, there is so much ambivalence about the fact that value negotiation is at the heart of psychiatric consultation (Woodbridge & Fulford 2004)? Why are ethics and moral reasoning still so underrepresented in residency training programs?

I suggest that it is the underlying model of medical practice that plays a role here. What seems decisive is the assumption that medical problems have a hard, objective core and a soft, subjective margin. Under this model, scientific knowledge about the origin, course, and treatment of diseases belongs to the objective core, whereas values, preferences, patient interests, and clinical intuitions belong to the soft margin. Insofar as practices are built on this underlying assumption, they are inclined to favor evidence-based treatment protocols and to distance themselves from the soft aspects of psychiatry. This occurs by either ignoring these aspects or by describing them as belonging to a prescientific form of psychiatry.

Clearly, the objective-core-soft-margin concept of psychiatric care easily leads to a technical conception of professionalism. Let me briefly outline this technical—or even better, technicistic—conception as a contrast to the idea of psychiatry as a person-centered and value-oriented practice (an idea defended in this book). I am aware that I am sketching an extreme and that, in daily practice, the positions are seldom as pronounced as depicted here. Nevertheless, pointing out an extreme at one end of the spectrum helps clarify the idea of person-centered and value-oriented psychiatry at the other end of the spectrum. According to proponents of the technicistic view, it is the task of the professional to apply scientific knowledge as purely and detachedly as possible by using techniques (pharmacotherapy, psychotherapy, and so on). The knowledge itself is value free, and the application of it should be as well, according to this view. This is because th...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of illustrations
• Preface
• 1. Psychiatry in need of philosophy
• PART 1: Self, context, and psychopathology
• PART 2: Psychiatry as normative practice
• References
• Index