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date: 06 December 2019

Introduction: Cure and Care

Abstract and Keywords

This Section examines several moral dilemmas and epistemological aporias in clinical practice and shows how clinicians can benefit from the introduction of philosophical methods and discourse. The authors develop these issues having in mind emblematic mental disorders (e.g. depression, personality disorders, schizophrenia) and typical clinical situations (e.g. how to establish an effective therapeutic relationship with borderline persons, dream interpretation, cognitive-behavioural therapy). One important claim shared by the Authors is that a great effort has been made to ground psychiatry on evidence-based science, and to tie it to our growing understanding of the human brain. This is obviously an exceedingly important project, but it would be a mistake to assume that the central questions of psychiatry can be completely resolved through scientific inquiry. Science offers guidance for clinical practice only in light of our concepts and normative judgments.

Keywords: agency, autonomy, capacity, CBT, drugs, Freud, Heidegger, medicalization, "new" illnesses, placebo, psychoanalysis, responsibility, Therapeutic Alliance

This section examines several moral dilemmas and epistemological aporias in clinical practice and shows how clinicians can benefit from the introduction of philosophical methods and discourse. The authors develop these issues having in mind emblematic mental disorders (e.g., depression, personality disorders, schizophrenia) and typical clinical situations (e.g., how to establish an effective therapeutic relationship with borderline persons, dream interpretation, cognitive behavioral therapy (CBT)). One important claim shared by the authors and made explicit by Foddy et al., is that a great effort has been made to ground psychiatry on evidence-based science, and to tie it to our growing understanding of the human brain. This is obviously an exceedingly important project, but it would be a mistake to assume that the central questions of psychiatry can be completely resolved through scientific inquiry. Science offers guidance for clinical practice only in light of our concepts and normative judgments.

In Chapter 66, Pickard focuses on a philosophical and clinical conundrum: the combination of responsibility and blame as related to people with “disorders of agency” as severe personality disorder, addiction, and eating disorders. Clinicians know well that blame is a common emotion kindled by these patients, and that this is highly detrimental since it may trigger feelings of rejection and self-blame in them, which bring heightened risk of disengagement from treatment, distrust and breach of the therapeutic alliance, and potentially self-harm. Clinicians should hold these persons responsible and accountable for behavior and at the same time compassion and empathy should be maintained. To do so, two sorts of blame should be sorted out: “detached” and “affective.” Detached blame consists in judgments of blameworthiness, and involves accountability and answerability. It encourages responsible agency. Affective blame consists in negative reactions and emotions, whether rational or not, which the blamer feels entitled to have. Effective treatment requires responsibility without affective blame: without a sense of entitlement to any negative reactive attitudes and emotions one might experience.

What is autonomy is the focus of Rodoilska’s contribution (Chapter 67). Defining “autonomy” is a crucial topic in practical neuropsychiatric ethics since patients with severe mental disorders, and especially schizophrenic and manic–depressive (“bipolar”) psychoses, often refuse treatment, and it can be especially difficult to establish if such refusals are made by completely autonomous agents, given the effects that mental disorders can have on a person’s (p. 1132) mental capacities. Autonomy can be defined from at least four major philosophical angles. The first relates autonomy to agency and free will, and defines it in terms of motivational states, such as identification, endorsement, or acceptance. A second approach explores it as related to particular values, such as self-respect. A third one sees autonomy in terms of rational agency and moral responsibility and concentrates on the links between responsiveness to reasons and effective control over one’s life. Finally, autonomy as a central topic in bioethics is examined in connection to informed consent and decisional capacity. Rodoilska endorses a view of autonomy as primarily an agency concept and applies it to some paradoxes of depression.

The “medicalization” and extensive use of psychiatric drugs to treat a growing list of psychopathological conditions claimed to afflict people who would have been considered normal even in the recent past is one of the biggest changes in first-world lifestyles since the 1970s. Foddy et al. (Chapter 69) argue that this raises serious ethical and epistemological problems: Are “new” illnesses “invented” merely to promote the interests of pharmaceutical companies? Are these new clinical diagnoses in effect value judgments disguised as objective scientific categories? And, if psychotropic drugs threaten to disrupt a person’s identity, or disconnect emotion from circumstance and self, will these extensive use of medical treatments in subclinical population affect our sense of being a person and the very philosophical concept of “person”?

A closely related topic is the main focus of Chapter 68 by Svenaeus: How do antidepressant drugs affect the self? The author begins with distinguishing the groups of traits that belong to personality (temperaments, ways of acting, habits, skills, emotional dispositions, enduring preferences and values, and character traits) from the different layers of selfhood (pre-reflective embodied self, reflective self, and narrative self) and then argues that if personality disorders and neuropsychiatric disorders (developmental disorders) are clearly related to personality traits of the self (the person), there are other mental disorders that seem rather to be disorders, not of personality, but of the self itself. The effects of the new antidepressants must be thought of in terms of changes in self-feeling or, more precisely, of “self-vibration of embodiment.” Some patients go through the experience of “becoming themselves” while on Prozac, whereas others have the experience of “losing themselves,” despite feeling better on the drug. Antidepressant medication represents a way to change this mood profile in a way that is more direct than the ways of psychotherapy, and the effect in question is not limited to alleviating the suffering. It will also have some effects on self and personality, since the temperament and emotional dispositions of the person are, indeed, basic to selfhood.

Similar worries about the ways drugs (including placebos) may affect identity and the self are discussed by Jopling in Chapter 70, which debunks some of the myths surrounding placebo effects through a survey of some of the discoveries that have been made in the last fifty years about placebo effects in medicine. It then looks at how placebo effects make an appearance in psychiatry and psychotherapy, particularly in the case of treatments of depression that involve psychoactive medication and/or talk therapy. Following this is a survey of some of the leading definitions of the placebo effect, as well as a survey of some of the leading explanatory theories. The chapter concludes with a discussion of some new directions in placebo research: namely, open-label placebos and the evolutionary origins of placebo effects.

(p. 1133) The last three chapters are focused on “psychological” issues. The concept of care is closely linked to that of the unconscious. Heidegger and Freud, arguably the two greatest “meta-physicians” of the twentieth century, sought to develop a comprehensive account of the human condition and its affliction of the contemporary human situation. Challenging the science of their time, both sought to develop a new science of the human being to serve as the theoretical foundation for psychotherapeutic practice and its application. Heidegger inspired the development of various forms of existential analysis while Freud generated his immensely influential theory/practice of psychoanalysis. Askay and Farquhar (Chapter 71) show that, beyond differences, there is an intimate belonging together of Freud’s and Heidegger’s views since both have grasped concealment—the unconscious dimension—as a fundamentally important realm of human existence. Heidegger offers a unified account of the hidden ontological dimension of human existence, while Freud offers an account of those hidden conditions through our bodily being. Taken together, they afford a considerably complete account of the human condition, and its relation with meaning, freedom, and autonomy.

In Chapter 72, Gipps discusses four objections to CBT: (1) various CBT formulations conflate the formal relations between different aspects of the same state with causal relations between discrete inner states; (2) some CBT models construe emotionally laden perspectives too much as occurrent inner processes, and too little as a subject’s attitudes; (3) such attitudes can sometimes be misdescribed in CBT models as beliefs—when what we really have to deal with here are feelings; (4) CBT models can underplay the significance of changes in the form of (a subject’s ownership of) such attitudes when they focus instead on changing their content. Gipps explains that his purpose is not to critique the CBTs en bloc, but instead to scrutinize some ways in which some CBT theories may be inflected in ways that go against what it means to be an emotionally alive human subject. The CBT practitioner is perhaps not aware of what she is really doing with the patient. By helping the patient to give articulate structure to his fears, to think, to be nourished by reality contact, and to distinguish fearful fantasy from genuinely representational belief, the CBT practitioner can be understood as doing far more than helping the patient to regulate his emotions and test out his cognitions: she is perhaps helping to restore her patient’s subjectivity.

In Chapter 73, the final chapter of the section, Hopkins brings together psychoanalysis and neurobiology through evolutionary and attachment theories. Psychiatry is liable to tension between a clinical approach that concentrates on the lived experience of mental disorder and a neurobiological one that focuses on the brain in which such experience is realized. Accounts of mental disorder provided by Freud and his successors should not be taken as alternatives to a more adequate neurobiology of mental disorder. Building on clinical as well as anthropological and biological evidence, he puts conflict at the heart of human life. Human beings belong to an astonishingly social but also lethally group-aggressive species. Hopkins sorts out two basic kinds of conflicts: between incompatible emotions and desires, felt toward one and the same person, and between parts or aspects of the self. These emotional conflicts, in turn, seem rooted in evolution, together with the “moral” emotions that go awry in mental disorder as well. Our brain is equipped to deal with conflicts: it has a conflict-mitigating function. It regulates our own emotion by internal representations of ourselves as in relation to members of our own species. Important forms of mental disorder seem rooted in conflicts, and in the fictive experiences by which the brain tries to regulate it.