Queen’s University Department of Psychiatry

GRAND ROUNDS

Friday, October 18, 2013

Providence Care – Mental Health Services Amphitheatre

8:00 - 9:00

Gregory J. Walters, PhD Professor of Philosophy Saint-Paul University, Ottawa C. Cabrera, LMS, MSc, MRC Psych. Associate Professor Department of Psychiatry Queen’s University

“Empirical and Interpretive Psychiatry Today- Looking Back, Looking Ahead: A Centennial Celebration in Honour of

Karl J aspers's General Psychopathology”

These rounds are Royal College, Maintenance of Certification Accredited

Learning Objectives on reverse Upcoming Rounds – October 25, 2013 at PC- MHS Nov. 1, 8, 18, 22 & 29 at HDH Coff ee & Ref reshments will be available prior to rounds

Learning Objectives1. Jaspersian Echoes: Briefly survey Jaspers’s scholarly reception in North American psychiatry.

2. Looking Back: briefly identify the definition and tasks of phenomenology, outline, levels of medical practice in psychotherapy, and “complex unities,” “concrete enigmata,” and “the problem of a unified whole” in relation to understanding the human being as a whole.

3. Mental Health Stigma-Looking Ahead: briefly identify the problem of mental health stigma, some ethical considerations, and the contemporary relevance of Jaspers’s philosophy to emerging cognitive, emotional and physical enhancement technologies and Transhumanist philosophy.

I. JaspersianEchoes

Jaspers’s Echoes in North America

Echoes- DSM & Death of Phenomenology

Echoes- DSM-IV,ICD as reified categories

Echoes: “Antagonomia” &

“Idiomania”

Echoes- Perceptual Field Deficit

Echoes- Time Consciousness

Echoes- ‘Joint Reference’ Overcoming Biomedical Bias

Depressive Realism, the Cognitive Distortion Model and Existential Psychotherapeutic Methods

Echoes- Diagnosis & Ideal Types

Echoes- Perspectivism & Methods

II. Looking Back

General Psychopathology

The General Psychopathology

“Phenomenology” Defined (1912)“….Illustrative representation of individual experience (anschauliche Vergegenwärtigung individuellen seelischen Erlebens); an empirical method designed to define experienced mental states– i.e., subjective phenomena – within the narrowest possible confines; to distinguish between them; and to separate them terminologically.” Phenomenology accomplishes all this, “depending on the individual case, by the enumeration of a number of outward characteristics of the mental state, of the conditions under which it occurs, through vivid, illustrious comparisons and symbolizations, through a kind of suggestive representation,” which is based on empathy and which is supposed to enable the reader of a phenomenological description empathically to perceive the phenomenon described.” JASPERS, K. “Die phänomenologische Forschundsrichtung in der Psychopathologie” (1912) Zeitschrift für die gesamte Neurologie und Pscyhiatrie, No. 9, 1912, 391ff., translated in Ludwig B. Lefebre, “The Psychology of Karl Jaspers,” in P.A. Schillp, ed., The Philosophy of Karl Jaspers, 473

Tasks of “Phenomenology” (1913)Provide concrete descriptions of

individual psychic states and present them for observation.

Review the inter-relations of these, delineates them, differentiates them, and creates suitable terminology.

Patients’ self-descriptions are the chief help.

Close contemplation of an individual case teaches phenomena common to countless others.

What Conditions Determine Cognition in the Psychiatric Realm?

Erklärende Psychologie Part Three: Causal Connections of Psychic Life

Cause-Effect Relationships; Causal Scientific [Statistical] Explanation

Objective causal relationships are “always observed from the outside only.” Allgemeine Psychopathologie, 24

“Ascertainment of empirically existing cause and effect relationships which in themselves cannot be understood but are recognized as necessary.”

Example: Recognition of a connection between the deterioration of performance, on the one hand, and fatigue on the other hand.

Verstehende Psychologie Part Two: Meaningful Psychic Connections

Verstehen- “perception of mental phenomenon from within.”

Knowledge based on the intuitional comprehension of “understandable” processes.

Comprehension of meaningful psychological relations demonstrating an “inner causality” as opposed to the “outer [genuine] causality” discovered by explanation.

The Link With Different Levels of General Medical Therapy

(a) Doctor applies technical knowledge of cause and effect and through mechanical and chemical means repairs the disturbed connections in the apparatus of life.

(b) Submits the living being to certain conditions, of diet, environment, rest or exertion, training [cf. CBT]…facilitates the living being as a whole to help itself.

(c) Addresses herself to patient as a rational being…body-psyche unity (neurological, hormonal and morphological unitary structures)

The Link With Different Levels of General Medical Therapy

“…Once the individual has turned into an object, she can be treated by technical means, nursing care and skill, but the individual as herself can only discover herself through the mutual sharing of destinies.” (cf. self-concealment vs. revelation)

(e) The ultimate thing in the doctor-patient relationship is existential communication; doctor and patient are “fellow-travellers in destiny;” psychiatrist is neither “pure technician” nor “pure authority.” “There is no final solution.” Karl

Jaspers, The Nature of Psychotherapy, p.18.

Summation “Thus in therapy the widest polarities lie in whether the doctor turns to what can be discovered by science, that is, to the biological event, or whether he turns to the freedom of man. A mistake is made about the whole of human life, should the doctor in looking at persons let them be submerged in the biological event; so too should he convert human freedom into that sort of being which, like nature, is empirically there and can be used technically as an instrument of therapy. Life I can treat, but to freedom, I can only appeal. (Karl Jaspers, The Nature of Pyschotherapy, 20.

Part Six. The Human Being as a Whole

(c.) Philosophy in Psychopathology “If anyone thinks she can exclude philosophy and leave it aside as useless she will eventually be defeated by it in some obscure form or other. From this springs the bad philosophy in psychopathological studies. Only she who knows and is in possession of her facts can keep science pure and at the same time in touch with individual human life which finds its expression in philosophy.” (GP, Vol.II, 770)

Part Six.“The Human Being as a Whole”• Scientific obligation to integrate

philosophical anthropology with empirical facts of scientific psychopathology.

• Particular scientific facts must always square with the unified whole to which they belong.

• Various wholes prove to be “complex unities” for somatic and psychic investigation.

(c) The “Complex Unities” in retrospect and the problem of a unified whole (GP, 750ff)

I. The momentary whole in which experienced phenomena occurred was the state of consciousness.

II. The whole of the meaningful connections was the personality.

III.The whole of the causal connections was comprised in the several theories.

c. The complex unities in retrospect and the problem of a unified whole

IV. The complex clinical unities were the ideas: of the disease entity, of the Eidos, (Constitution, etc.); of the Bios (the individual life – as the whole of the person’s life in time).V. The communal and historical whole of the individual appeared as the state of his society, the objective culture, the historical epoch, the communal spirit as displayed in peoples, states and in the masses. (GP, 750ff)

False Conversions of Complex Unities into Absolutes “The momentary whole tends to be taken for the ultimate whole: the psyche is consciousness and nothing else; the performance as a whole is the only objectivity, the only object for science; the body-psyche unity is reality itself; milieu and culture are absolutes to partake in which is psychic reality; personality is the essence of the psyche, its meaningfulness is its Being; theories grasp the true reality; causal connections are the substance of things, the body is everything, the psyche is only a transit-station for hereditary connections; clinical reality consists of only disease entities, constitutions and the life history as a unit; the individual is a function of society and history.” (GP, 750 – 751)

(d) The concrete enigmata in retrospect

• Constitution

• Limits of Genetic Research

• Performances

• Limitation of understanding by biological events and by Existence itself• The unity of an individual life (the

Bios) and Chance [Luck](Jaspers, GP II, 752-754)

(d) The concrete enigmata in retrospect• Constitution (an insoluble problem)

• Limits of Genetic Research

• Performances

• Limitation of understanding by biological events and by Existence itself

• The unity of an individual life (the Bios)

Insoluble problems as a whole reduced to abstract principles:

• ‘Endlessness’

• ‘Individuality’

• ‘That which Encompasses all things’

The Encompassing Self• Ergo, psychopathological knowledge placed in

suspension [sic] at the boundaries of our knowing vis-a-vis the complex unities, the concrete enigmata, and “the Encompassing Self.”

• The GP anticipates the philosophical idea of the Encompassing: Subject-Being (Body, Intellect, Spirit/Mind (Geist), ‘possible Exiztenz’); Object-Being (World and Transcendence); non-reductionism of any one mode of human being.

Source: Nature Reviews| Neuroscience Vol.14, May 2013, 365-375.

III. Mental Healh Stigma-Looking Ahead

Søren Kierkegaard(1813–1855)

“Once you label me, you negate

me.”

• “Mark” or “Attribute;” reduces the other from “whole and usual” to “tainted and discounted;” “Less than fully human.”

• “Abominations of body” (Physical deformities)

• “Character blemishes” (Mental illness, addictions, government aid)

• “Tribal Identities” (Race, gender, religion)

• Stigma enacted in social interaction; Exclusion from full participation in society; Effects on identity are not Static

• Ebb and flow with “moral career” and larger societal context

Stigma in Mental Health

Stigma“co-occurrence of its components:”

Labeling

Stereotyping

Separation

Status loss

Discrimination

Power exercised

Public Stigma of Mental Illness

Stigma in Mental Health

Opening Minds: Anti-stigma,Anti-discrimination Program (2011)

Stigma in Mental Health

Prevalence of Personal Stigma Reported by (7% of sample; n >10,000) respondents treated

for emotional or mental health problemSurvey Item

(Self-reported impact on):

Family relationships

Romantic life

Work or school life

Financial situation

Housing situation

Weighted %

32.0%

30.%

27.5%

25.0%

18.0%Source: Paradigms Lost: Fighting Stigma

and the Lessons Learned. Ed. Stuart, H., Arboleda-Flórez, J., Sartorius, N. OUP, p.10.

Changing Directions, Changing Lives: The Mental Health Strategy for Canada

Mental Health Stigma: Ethical Considerations

UN Convention on the Rights of Persons with Disabilities): Access to treatment of mental disorders a human right.

The Principle of Human Rights"Act in accord with the generic rights of your recipients as well as of yourself." (Gewirth, 1996,19)

• Generic rights are rights to the generic features of action-- freedom and well-being-- which constitute the necessary conditions of action.

Mental Health Stigma: Ethical Considerations

• Stigma violates generic rights to freedom and well-being• “Well-being consists in having the various

substantive conditions and abilities that are proximately required either for acting at all or for having general chances of success in achieving one’s purposes through one’s actions.” (cf. Social Determinants of Health)• 3 Levels of Well-being: Basic, Nonsubtractive,

Additive

What is Transhumanist Philosophy?

Transhumanism is a contemporary life philosophy, a global cultural and intellectual movement that promotes “an interdisciplinary approach to understanding and evaluating the opportunities for enhancing the human condition and the human organism opened up by the advancement of technology.” (Max More, 2013)

Transhumanists Seek radical Extension of Human

Life ‘health-span’ Eradication of disease; elimination

of suffering; overcoming the “genetic lottery.”

Enhancement of human intellectual, physical, and emotional capacities by means of psychopharmaceuticals, genetics, molecular nanotechnology, artificial intelligence, and cryonics.

Therapy vs. Enhancement?Transhumanists aim not so much to cure

disease, but “reach beyond” health

Lift themselves above the norm

“one-sided triumph of willfulness over giftedness, of dominion over reverence, of molding over beholding?” (Michael Sandel 2012, 94).

Is there “Wisdom in repugnance?” cf. Procreative liberty, Human Cloning? (Leon Kass, 2013)

“Psychopathologie”“The belief that it was possible to develop methods which would enable us to comprehend man as a whole (as to constitution, character, body-type, and disease-entity) persisted, in ever new guises. Despite the fact that, within limits, all of them were fruitful, the supposed totality every time proved to be a totality within the one comprehensive totality of being human, never this totality itself. For the totality of man lies way beyond any conceivable objectifiability. He is incompletable both as a being-for-himself and as an object of cognition. He remains, so to speak, "open." Man is always more than what he knows, or can know, about himself.” Karl Jaspers, “Philosophical Autobiography,” in P.A. Schillp, ed., The Philosophy of Karl Jaspers, 13.

“Life I can treat,

but to FreedomI can only appeal.”

Karl Jaspers,

The Nature of Psychotherapy:

A Critical Appraisal (The University of Chicago Press, 1965 [1964]), 20.