The Concepts of Psychiatry
A Pluralistic Approach to the Mind and Mental Illness
Publication Year: 2007
Published by: The Johns Hopkins University Press
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We read books from our own professional vantage points and with our own aims—if we’re beginners, to learn; if we’re practitioners, to refresh our knowledge; if we’re investigators, to seek confirmation or refutation of opinions. Of late, I read psychiatric texts to help me see into the future. I want to know where we are going and how we might get there. In this pursuit, most recent books have disappointed me. They...
Preface to the Paperback Edition
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The debates and dilemmas discussed in this book have been a century in the making. The issues raised are real today and will remain so for years to come. Unfortunately, it is still the case that psychiatry is murkily eclectic, uncertain of what it stands for, unable to clearly explain its basic views to outsiders, and engaged in tense conflict...
Preface to the First Edition
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Seymour Kety once told a parable that summarizes much of what I seek to do in this book. Kety was a biologically oriented psychiatric researcher, the first scientific director of the National Institute of Mental Health (NIMH), and a pioneer in establishing genetics research, particularly in schizophrenia, in the 1950s and 1960s. In 1960 Kety...
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PART I: Theory: What Clinicians Think and Why
1 The Status Quo: Dogmatism, the Biopsychosocial Model, and Alternatives
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What do we do in psychiatry and why? This is a question not asked often enough. Much is taken for granted. At a basic level, psychiatrists do one of two things. One activity is often subsumed under the heading of psychotherapy. Externally, psychotherapy consists of formal meetings, usually weekly, of an hour’s duration, over an extended period of time (usually six months or longer). These external...
2 What There Is: Of Mind and Brain
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A common view in modern analytic philosophy is that the purpose of philosophy is the logical analysis of conceptual arguments. This perspective has little in common with other versions of the goals of philosophy, such as building metaphysical systems of thought (Hegel), seeking epistemological certainty (Descartes), or providing support for ethical (Kant) or religious (Aquinas) systems. Understood this way, we can make...
3 How We Know: Understanding the Mind
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For a psychiatrist to understand a patient, to grasp the contents of her mind, seems fraught with so many difficulties. Karl Jaspers’s clinical experiences convinced him of this. He saw the problem of one human, as subject, trying to understand another human, as object, to be nearly impossible to understand. Jaspers did not...
4 What Is Scientific Method?
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In the late nineteenth century, when some believed that Darwinism had undermined religious faith, the English mathematician W. K. Clifford made the above startling pronouncement, adding, “It is sinful” to hold such beliefs. In one pithy statement, he captured the spirit of the new age: he turned the concept of sin against religion. It was now literally sinful to believe, rather than to disbelieve. This was a challenge...
5 Reading Karl Jaspers’s General Psychopathology
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Certain books, such as Karl Marx’s Capital, Charles Darwin’s Origin of Species, or Freud’s Interpretation of Dreams, are often discussed and rarely read. There must be a reason for this. Length, outdated language, the seepage of ideas from great books into the general culture—all these no doubt play a part. But there is a danger in relying on discussions about great books without having read them: each discussion...
6 What Is Scientific Method in Psychiatry?
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I believe that Karl Jaspers has provided the most tightly reasoned analysis of scientific method for psychiatry. One might summarize his contribution in this regard in two main ideas: methodological pluralism and the understanding-explanation dichotomy....
7 Darwin’s Dangerous Method: The Essentialist Fallacy
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My discussion of scientific method has touched little on the groundbreaking work of Charles Darwin. The philosopher Daniel Dennett has suggested that philosophy, psychology, and other disciplines would also benefit from taking seriously the ideas of Darwin. Yet I have not discussed what arguably could be the single most influential theory in modern biology: evolutionary theory. Dennett (1995) argues...
8 What We Value: The Ethics of Psychiatry
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In the psychoanalytic heyday, ethical discussions about psychiatry were rare. Freud insisted that he was simply engaging in medical science and that medicine was value-free. The only value, if any, for physicians was the general goal of preserving life and ridding people of disease. Patients in psychoanalytic psychotherapy generally were...
9 Desire and Self: Hellenistic and Eastern Approaches
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In psychiatric training, as one learns to do psychotherapy, one soon realizes that there is an ethical component to psychotherapy. The therapist is intimately involved with trying to understand what the patient values, what the patient does in life, and why he does it; and what might be different. Freud denied that psychoanalysis was value-laden or that...
PART II: Practice: What Clinicians Do and Why
In the first half of this book, I have tried to explain how psychiatry has to answer certain problems in ontology, epistemology, and ethics: what exists in psychiatric practice, how do we know about it, and how do we value it? Yet, to answer these questions...
10 On the Nature of Mental Illness: Disease or Myth?
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What is mental illness? Is it a disease entity, as in the standard medical model, or a myth, as in postmodern critiques, or something in between? A discussion of mental illness needs to begin with a discussion of illness in general, followed by specific matters related to psychiatric conditions. In this chapter I review this general issue conceptually, and in the following chapters I discuss specific types of classification...
11 Order out of Chaos? The Evolution of Psychiatric Nosology
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In the eighteenth century, there was only one mental illness: insanity. The diagnosis of insanity meant roughly what clinicians currently mean by the word psychosis or what is referred to colloquially by “crazy.” Insanity denoted that patients had somehow lost touch with reality, often with delusions or hallucinations or with severe melancholia or states of elation. Although these symptomatic states were described, and had been for ages dating back to the Greeks, physicians who treated these...
12 A Theory of DSM-IV: Ideal Types
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The DSM system in psychiatry is a convenient straw man for all sides of the diagnostic discussion. Even by its name, DSM-IV seems like the kind of arid cookbook approach to human beings that produces shudders in our collective humanistic spines. Why should we categorize the richness of humanity into these labels? And on what basis...
13 Dimensions versus Categories
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Categorical knowledge involves all-or-nothing qualitative phenomena; that is, something either belongs to category X or to category Y. An example is pregnancy; one either is or is not pregnant. Dimensional knowledge is continuous and is characterized by possessing or experiencing more or less of something. An example is blood pressure. Every living human has blood pressure; in some it is high, in some low, and...
14 The Perils of Belief: Psychosis
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The definition of psychosis is tendentious. This can be disheartening: if, after all, we cannot agree on what psychosis means, how can we claim to diagnose it, much less treat it? Superficially, one would expect psychosis to be the simplest thing to diagnose. Even the unversed, when faced with the “crazy” person who talks to himself...
15 The Slings and Arrows of Outrageous Fortune: Depression
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Neurologists are sometimes criticized for admiring disease rather than treating it. Psychiatrists have never been subject to similar indictment. If anything, psychiatrists have gone to the other extreme, downplaying diagnosis for years and seeking “great and desperate cures” (Valenstein 1986) for that one illness: insanity. The philosopher Michael...
16 Life’s Roller Coaster: Mania
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He was thin, a bit too thin for health. He looked bedraggled by life, pulled from Kansas to Washington, D.C., leaving his wife and children behind. “I left it all because I was manic,” he said, with an air of disgust. Who was he disgusted with? “I wish someone would have just grabbed me by the scruff of the neck and said, Hey, don’t make any life decisions; you’ve lost your judgment...
17 Being Self-Aware: Insight
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Thus far I have surveyed the traditional subject matters of psychiatry: psychosis, depression, mania, personality, nosology. One phenomenon has been touched on that underlies all those discussions; it is, to my mind, the central phenomenon of psychiatry: insight. The term here refers to the perspective that an individual maintains toward her own psychological state. If one knew, from a God’s-eye perspective, so to speak...
18 Psychopharmacology: Calvinism or Hedonism?
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The advent of relatively safe and effective medications has transformed psychiatry. But, instead of simply treating diseases, will we try to “improve” normality in the future? One of the issues that have become prominent with the availability of many new and well-tolerated antidepressant medications is the question, Who should be treated? The treatment-enhancement distinction is a problem of health care ethics that involves devising the right approach...
19 Truth and Statistics: Problems of Empirical Psychiatry
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Many of us, as clinicians and as citizens, have an uneasy relationship with statistics. As clinicians we may not understand the more complicated methods: multiple logistic regressions and Bonferroni corrections sound as foreign to us as medical lingo does to statisticians. We also fear, perhaps, that statistical truths may not translate into clinical truths (with some justification, as we shall see). As citizens, we may feel that...
20 A Climate of Opinion: What Remains of Psychoanalysis
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In the public mind, psychiatry is still identified with Sigmund Freud. It might appear surprising, then, that I have avoided a lengthy discussion of Freud’s work until now. This is because, in my opinion, what is useful in Freud needs to be placed in the context of the previous chapters. W. H. Auden famously concluded that Freudianism was not simply a theory but had become a climate of opinion...
21 Being There: Existential Psychotherapy
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The “existential” school of psychiatry has three main branches, based on different aspects of its philosophical fathers. The first, based on Edmund Husserl, emphasizes the phenomenological reduction; Karl Jaspers worked in this tradition, which formed the mainstream of Continental psychiatry for decades. The second, resting on the early Martin Heidegger, emphasizes the existential structure of each...
22 Beyond Eclecticism: Integrating Psychotherapy and Psychopharmacology
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In psychiatric education, eclecticism is a popular professed approach, implying theoretical lack of bias and an evenhanded biopsychosocial approach. However, with the economic pressures of managed care and the influence of advances in empirical research, some observers have noted a drift in psychiatric teaching programs toward biological approaches, with a concomitant decline in psychotherapy...
PART III: After Eclecticism
23 Bridging the Biology-Psychology Dichotomy: The Hopes of Integrationism
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In chapter 2, where I discussed current philosophies of mind, the basic dichotomy that I described was the split between dualism and monism. Until the twentieth century, dualism was commonly accepted, the basic idea being that mind and brain are separate and generally unrelated entities. Contemporary philosophy is greatly influenced by the advances of science, however, and most philosophers would likely accept...
24 Why It Is Hard to Be Pluralist
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The danger of advocating pluralism is the “So what?” problem. Readers might be inclined to ask that question when I suggest the benefits of pluralism. Especially when pluralism is set against the term dogmatism, most persons would not want to identify themselves with the latter. But I use the word dogmatism as shorthand: in reality it is always dogmatism about something. Thus, in politics, one...
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Psychiatry rests on philosophical questions and assumptions. The main purpose of this book has been to raise questions and discuss concepts, rather than to provide answers. No single theoretical framework has been suggested that will satisfy those who seek a single ideology. Philosophers may find this a weakness, but it is only so if one accepts that such is the purpose of philosophy: system...
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Page Count: 368
Illustrations: 8 illus.
Publication Year: 2007