CONCEPTUAL BASES OF PSYCHIATRY FOR THE PERSON
Psychological Perspectives on Psychiatry for the Person
Michel Botbol MDa, Yrjö O. Alanen MDb, Dusica Lecic Tosevski MD PhDc, Margit Schmolke PhDd
a Psychiatrist, Psychoanalyst, School of Psychologists, Paris Catholic University, France
b Professor of Psychiatry (Emeritus), University of Turku, Finland
c Professor of Psychiatry, Institute of Mental Health, School of Medicine, University of Belgrade, Serbia
d Psychologist, Psychoanalyst, German Academy for Psychoanalysis, Munich, Germany
Psychiatry for the person, psychological perspectives, subjectivity and intersubjectivity assessment, values-based psychiatry
Accepted for Publication: 19 January 2011
Human individual psychological development emerges in interaction with other persons, beginning with the infant-mother relationship and continuing with significant others in the environment nurturing the baby. A gradual developmental process culminates in two critical separation-individuation phases - the first one in early childhood and the other during adolescence – and leads to increasing independence of the subject and more mature relationships with other persons.
From a psychological perspective, person centred psychiatry has then to consider both the intra-subjective and the inter-subjective aspects of clinical situations when failure in the developmental process leads to severe psychopathological disorders.
In line with a contextualized definition of the person (“I am I and my circumstance”), person centred psychological approaches will have to focus both on the individual experience of the patient, including his subjectivity, and his experience involving the family and the social environment.
To understand and assess psychopathology one should take into account the following four psychological dimensions:
The patient’s experience of an illness and the effects of an illness on his/her personal and social life. This aspect could be called the phenomenological dimension (which includes psychological suffering, quality of life and similar processes). It is certainly subjective and can be considered as a core aspect of the mental disorder, defining both the patient’s clinical situation and his/her more global being in the world.
The psychological functioning underlying a disorder and the global organisation of psychological functions. This has to take into account not only the explicit symptoms but also the underlying normal or pathological personality within which they develop. This is not related only to the psychopathological elements but also to the overall organisation of the patient’s inner life. This aspect could be called the structural dimension.
The conscious and unconscious meanings of symptoms and other life events and the embedding of disorders in the patient’s narrative. We could call this the metaphoric or symbolic dimension. This dimension is essential for the individual’s appraisal of the disorder and for its treatment. In some cases, the elements of this dimension may have an etiological role. This specific subjective aspect should be considered in the design of the therapeutic approaches as they may be crucial to the therapeutic alliance.
The familial or environmental dimension: Clinicians find two groups of conditions that may require family- and environment-centred treatment. The first group is composed of acute crisis situations, especially when related to deaths in the family, including suicides and suicidal attempts which need empathetic support. A family-centred approach is also often needed for acute or prolonged family crises, often connected with anxious or depressive reactions. In divorce cases, a special attention should be given to the children’s mental state and needs for the future.
The second group of conditions requiring family- and environment-centred treatment involves persons with increased dependence on their closest human network. Children obviously belong to this group because of their dependence on the family. The same is also true for adolescents for whom a general goal of family therapy is often to support the individual development of the identified patient by clarifying the psychological boundaries between family members and to strengthen the adolescent’s contacts outside the family.
In adult psychiatry, this group of conditions may also include schizophrenia and other psychoses, substance abuse, severe eating disorders as well as borderline personality disorder. An insufficient individuation with an ensuing pronounced and ambivalent dependence on others is the common feature of patients experiencing these conditions. Old age patients and other dependent individuals may also be considered within this group.
In psychotic outbreaks, the general goals of family-centred treatment are usually twofold: to stimulate the individualized development of the patient and to support family members as they deal with the patient’s disorders. The experiences of joint meetings of the treatment team with patient and family members have shown that they have both an important informative function and therapeutic significance . In many cases, these joint meetings enhance the success of simultaneous or consecutive individual therapy.
The consideration of these four dimensions appears to be important for person centred conceptual and practical approaches in psychiatry. On the other hand, they are often ignored by conventional disorder-centred psychiatry. Carlos Berganza  has pointed out that the latter is one of the main limitations of the current standard classificatory systems on which much of modern psychiatry is grounded. John Strauss  has stressed the problems of reductionistic psychiatry by saying that “this has neglected attention to the importance of subjective factors such as feeling, meaning and will. It has left us ignoring a major part of human experience, left us with half a science”.
Unlike standard diagnostic criteria, these four dimensions are not only subjective but also holistic. The recognition and assessment of these dimensions requires improvements in the parameters and guidelines for the appraisal of evidence, beyond the rigidity and narrow scope of what is usually termed evidence based medicine (EBM), for the following reasons:
Their holistic perspective implies constant interactions between ill and positive aspects of health.
Their subjective components apply to the views of the professional, the patient and his family, and attention to the patient’s narrative and the professional’s empathy.
The methodological challenges to assess this holistic and subjective aspect of psychopathology have led many colleagues to favour the simplicity of the disorder-centred approach which however ignores important components of the clinical situation, in spite of their importance to understand the patient’s problems, to ground the clinician-patient relationship and to tailor the therapeutic approach to fit the patient’s needs.
For the psychiatry for the person perspective, one of the challenges is therefore to find a way to give enough room to the above mentioned psychological bases even though they can be accounted mainly through the patient’s narratives and the joint understanding of these narratives by both the patient and the professional in close interaction.
Also important for psychiatry for the person is to attend to human values in addition to traditional biomedical evidence considerations . Such a more encompassing perspective will bring psychiatry closer to the patients’ needs and increase effectiveness for both clinical care and health promotion. In fact, according to the Ottawa Charter, health is more than the mere absence of illness; it must also be formulated in positive terms and considered to be shaped on a daily basis in natural settings .
The above is consistent with the concept of “salutogenesis” , according to which a person can be at any point on the continuum of health and can move up and down on this continuum. Therefore persons are never totally ill or completely healthy. Furthermore, ill health and positive health must not be seen as the opposite poles in a linear scale, but rather as two overlapping and interrelated components of the whole concept of health . Moreover, mental health is increasingly seen as fundamental to physical health and quality of life and thus needs to be addressed as an important component of improving overall health and well-being [8, 9].
The psychological perspective of person centred psychiatry argues for employing a holistic framework, attending to subjectivity and inter-subjectivity, taking into consideration not only illness but the patient’s whole inner life, and contextualizing health and illness in terms of life history as well as family and social environment. Furthermore, this perspective posits that the above considerations are crucial for therapeutic effectiveness and for enhancing quality of life.
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