IntroductionBorderline personality disorder patients are often subjected to inpatient compulsory care due to suicidal behaviour. However, inpatient care is usually advised against as it can have detrimental effects, including increased suicidality.AimTo investigate what motives psychiatrists have for treating borderline personality disorder patients under compulsory care.Materials and MethodsA questionnaire survey was distributed to all psychiatrists and registrars in psychiatry working at mental health emergency units or inpatient wards in Sweden. The questionnaire contained questions with fixed response alternatives, with room (...) for comments, about the respondents’ motives for practising compulsory care of borderline personality disorder patients. The responses were analysed quantitatively with descriptive statistics, and comments were analysed with qualitative descriptive content analysis.ResultsThe psychiatrists’ views were divided on when it was justified to treat borderline personality disorder patients under compulsory care, as were their views on borderline personality disorder patients’ decision competence. When there was an assessed risk of harm, 53% were positive to compulsory care of decision-competent borderline personality disorder patients and another 31% because they considered the patients to be decision incompetent in such situations. Adding the risk of harm caused many respondents to alter their assessment of the patient from decision competent to decision incompetent.ConclusionThe large variations in doctors’ opinions indicate that the care of borderline personality disorder patients is arbitrary. Further, the assessed risk of harm increases the use of compulsory care, even though such care is advised against in clinical guidelines, has questionable legal support, and could lead to an increased suicide risk over time. (shrink)

The psychiatrist, Dr. Charles B. Nemeroff of Emory University, is the most prominent example to date in a series of disclosures that is shaking the world of academic medicine and seems likely to force broad changes in the relationships between doctors and drug makers.

This paper is a critique of a paper by Robert Lipkin [1]. Arguments for the following claims are put forward: (1) that what is essential to the psychiatric relationship is what we want it to be for utilitarian reasons; (2) it would not be to our advantage to allow the medicalization of morality; (3) what we should expect from the psychiatrist is prudential advice, not moral advice, and that Lipkin has a confused view about the relationship between these two areas; (...) and (4) we should not allow the psychiatrist to restrict individuals on moral grounds, but only on public safety grounds. (shrink)

Psychiatrists' accounts of clinical significance in depression Clinical significance is a crucial element in the diagnosis of mental illness, yet, it is practically untheorised and significantly under-researched. This article takes up the question of how the criterion of clinical significance is translated into psychiatric practice. More particularly, it examines how psychiatrists account for the threshold between health and depression. The paper is anchored in the constructionist view of discourse underpinned by the assumptions of critically oriented discourse analysis. It (...) is based upon a convenience sample of 39 semi-structured interviews with specialist-psychiatrists in south-western Poland. There is no discursive space for clinical significance in psychiatrists' accounts. There is no boundary, no decision to be taken as to whether the symptoms are clinically significant. Depression, invariably constructed in terms of diagnostic criteria, is always represented as fully developed, appearing out of thin air, with no period of falling ill. The article raises the issue of the validity and usefulness of psychiatric diagnosis. (shrink)

Mandating psychiatric evaluation for patients who request physician‐assisted suicide may not offer the clearcut protection from possible coercion or other abuse that proponents assert. Competence itself is a complex concept and determinations of decisionmaking capacity are not straightforward, nor is the relationship between mental illness and decisionmaking capacity in dying patients clearly understood. And casting psychiatrists as gatekeepers in end‐of‐life decisions poses risks to the profession itself.

Over the course of an illustrious career, the late Bernard Diamond established himself as the preeminent forensic psychiatrist of the century. _The Psychiatrist in the Courtroom_ brings together in a single volume Diamond's pivotal contributions to a variety of important issues, including the nature of diminished capacity, the fallacy of the impartial expert, the predictability of dangerousness, and the unacceptability of hypnotically facilitated memory in courtroom proceedings. Ably introduced and edited by Jacques M. Quen, M.D., a close colleague of Diamond's (...) and leading historian of forensic psychiatry, these writings enable experts and neophytes alike to track Diamond's evolving positions while clarifying where current legal and psychiatric opinion converge -- and diverge -- on a host of critical topics. For the forensic specialist, _The Psychiatrist in the Courtroom_ is not only an invaluable reference work but a compassionate reminder of the clinician's obligation to protect patients in legal proceedings. And in an age when clinicians are increasingly called into court, the book will be no less valuable to psychoanalysts and other mental health professionals eager for an introduction to the intricacies of judicial reasoning. Then, too, owing to Diamond's clinical acumen, the book is a compelling human document. With great erudition and deep compassion, Diamond tackles these and other knotty questions, always with an eye to clarifying the legal and clinical implications of the answers. By combining superb clinical gifts with an incisive understanding of legal principle, Diamond produced a seminal corpus whose relevance to discussions of therapeutic ethics and to legal debates will continue well into the next century. (shrink)

Questions about when to limit unhelpful treatments are often raised in general medicine but are less commonly considered in psychiatry. Here we describe a survey of U.S. psychiatrists intended to characterize their attitudes about the management of suicidal ideation in patients with severely treatment-refractory illness. Respondents (n = 212) received one of two cases describing a patient with suicidal ideation due to either borderline personality disorder or major depressive disorder. Both patients were described as receiving all guideline-based and plausible (...) emerging treatments. Respondents rated the expected helpfulness and likelihood of recommending each of four types of intervention: hospitalization, additional medication changes, additional neurostimulation, and additional psychotherapy. Across both cases, most respondents said they were likely to provide each intervention, except for additional neurostimulation in borderline personality disorder, while fewer thought each intervention would be helpful. Substantial minorities of respondents indicated that they would provide an intervention they did not think was likely to be helpful. Our results suggest that while most psychiatrists recognize the possibility that some patients are unlikely to be helped by available treatments, many would continue to offer such treatments. (shrink)

In 1961 in Japan, the son of a hospitalized man suffering from severe pain after a stroke mixed a cup of milk with insecticide and arranged for his unsuspecting mother to give this to the patient, who had requested that his son assist him in dying. The son could not endure his father's condition and killed him in order to show his love.

Psychiatric ethics as professional and biomedical ethics -- The distinctiveness of the psychiatric setting -- Psychiatric ethics as virtue ethics -- Elements of a gender-sensitive ethics for psychiatry -- Some virtues for psychiatrists -- Character and social role -- Case studies in psychiatric virtues.

Machine generated contents note: -- Part I -- 1. Portrait of the psychiatrist as a young man 1927-1960 -- 2. Portrait of the psychiatrist as an intellectual. Laing's early, notebooks, personal library, essays, papers, and talks -- 3. Laing and psychiatric theory -- 4. Laing and existential-phenomenology -- 5. Laing and Religion -- 6. Laing and the Arts -- Part II -- 7. Laing in the Army -- 8. Gartnavel Hospital and the 'Rumpus Room' -- 9. Individual patients at Gartnavel (...) -- 10. Laing at the Southern General Hospital -- 11. Laing in London -- 12. The Divided Self. (shrink)

Combining theological and medical perspectives is indispensable for the historical study of the interconnections between mind, body, and soul. This article explores these relations through the history of Finnish psychosomatic medicine, and uses published and archival materials to examine the intellectual biography of the Finland-Swedish theologian turned psychiatrist Asser Stenbäck (1913–2006). Stenbäck's career, which evolved from priesthood to psychiatry and politics, reveals a great deal about the tensions between religion and medicine, the spiritual and scientific groups that impinged upon psychosomatic (...) medicine, and ideas on how health and Christian morality were interconnected. The biographical approach is adopted to unearth the values encoded in medical concepts, and through this, to point towards another, underexplored dimension of the health–religion relationship. In addition to their emotional aspect, religious doctrines are intended to organise life and give it meaning. Stenbäck's ideas tied these experiential and normative spheres together by defending an irrationalist substratum of the world in the secular age of medicine. His work illustrates how the inner experience of faith can become both medically and politically purposive. It is worth combining these perspectives in historical research as well in order to better understand how the theological, medical, and political worlds are in dialogue when it comes to human problems. (shrink)

This second paper explores psychiatrists’ ethical obligations in the face of the failure of the social contract – inherent failures in distributive justice, the failure of the sovereign and the reconstitution of the social contract in post-conflict societies. Such situations present many sources of ethical tension between the professional ethical obligations of psychiatrists to their individual patients and to their society.

Relationships between patients and psychiatrists are shaped by a complex array of factors. The clinical experience centers on diagnostic and treatment decisions occurring in the context of a structured relationship that is regulated by principles of professional ethics and personal boundaries. At the same, however, patients and psychiatrists are unique and autonomous agents with emotional responses to one another that may evoke a wish for a personal friendship or other sorts of personal relationships that are outside the bounds (...) of the usual professionally defined structures. Negotiating the tension between the need for professional regulation and the desire for developing a friendship with certain patients can present clinical and ethical challenges in psychiatric practice. Pragmatist reasoning can help the psychiatrist and patient to successfully negotiate the dilemma that may arise when either or both of them wishes to develop a personal friendship but still adhere to the ethical tenets of the patient/psychiatrist professional dyad. (shrink)

The research questions was: 'How do psychiatrists describe their responses to patients' suicidal deaths in the light of a published model of consolation?' The textual data (n = 5) was a subset of a larger (n = 19) study. Thematic analysis showed a main theme, 'unburdening grief', and six themes. Embedded in the results is a story about suffering that reveals that, through ethical reflectiveness, a meaning of suffering can be recreated that unburdens grief and opens up new understandings (...) with and among disciplines. This can help to prepare health professionals to respond to people who suffer because of suicidal death. (shrink)

These two papers consider the concept of social justice and the ethical obligations psychiatrists may have in its regard. In this first paper, the concept of social justice is defined in terms of the successful function of the social contract. Basic conceptions of justice are then considered.

Experiences of moral distress encountered in psychiatric practice were explored in a hermeneutic phenomenological study. Moral distress is the state experienced when moral choices and actions are thwarted by constraints. Psychiatrists describe struggling ‘to do the right thing’ for individual patients within a societal system that places unrealistic demands on psychiatric expertise. Certainty on the part of the psychiatrist is an expectation when judgments of dangerousness and/or the need for coercive treatments are made. This assumption, however, ignores the uncertainty (...) and complexity of reality. Society entrusts psychiatrists to care for and treat those among its most vulnerable members: persons deemed to have a severely diminished capacity for autonomy due to a mental disorder. Simultaneously, psychiatrists are held accountable by society for the protection of the public. Moral distress arose for psychiatrists in their efforts to fulfill both roles. They described an ‘outsider/insider’ status and the ways in which they attempted to cope with moral distress. (shrink)

An important question in the philosophy of psychiatry is: what is the proper method of psychiatric diagnostic reasoning? Let us call this the Methodological Question. In this paper, I criticize the answer that proponents of phenomenological psychiatry have given to this question and present an alternative. I argue that their answer fails to meet several adequacy conditions for a theory of psychiatric diagnostic reasoning. I then show how my own answer to the Methodological Question – the Model-Based Account of diagnostic (...) reasoning – meets these adequacy conditions. I conclude that the Model-Based Account of diagnostic reasoning is preferable to the Phenomenological Account. (shrink)

Lacan, despite being largely ignored and misunderstood in Anglo-American analytic philosophy, brings psychoanalytic theory into close contact with the philosophy of mind and psychiatry as illuminated by the continental tradition. He draws on Freud, phenomenology, existentialism, and structuralism to construct a subtle theoretical approach to the psyche according to which our engagement in discourse and our existence in the world combine to generate a many layered structure of meanings and influences that forms us. This allows him to focus on the (...) nature and role of language and our discursively constructed self-conceptions both in the therapeutic encounter and in the maladies of the psyche. The relevance of Lacan's thought for analytic philosophy of psychiatry can be explored by pursuing his links to Freud, his complex treatment of issues in the philosophy of language, and a subtle blend of existentialism and continentally inspired naturalism that paints the contours of the unconscious mind in operationally compelling terms. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Importance of What Psychiatrists Care AboutJohn M. Talmadge (bio)Keywordspost-traumatic stress disorder (PTSD), psychotherapy, Frankfurt, veteransChristopher Bailey's account of his conversation with Colin, an unhappy man who feels regret about the absence of heroism in his own life, is both poignant and evocative. The emptiness that Colin feels illustrates aspects of the human condition central to definitions of psychotherapy for the past century or so. In this brief (...) commentary, I have three observations. First, the life of the therapist intertwines, however briefly, with the life of the patient. The light brought by the therapist may be like a candle, beacon, or flashbulb. Regardless of the therapist's strategic decisions and elected action, the patient may still end up in the dark. Second, I believe that this vignette illustrates the value of Professor Harry Frankfurt's ideas as expressed in his essay, “Freedom of the Will and the Concept of the Person.” And third, the tortuous journeys of psychotherapy may frighten and excite even the most temperate, contemplative clinician. In this third realm, where therapists create strategies for conversations about life, I also want to mention the work of Otto Rank.We have only a glimpse of Colin's life, but Dr. Bailey raises an issue of universal importance in helping others. The concept of moral heroism dates from the stoics, but the twentieth century merged psychology, theology, and philosophy in addressing the importance of significance, self-affirmation, and anxiety.Colin feels as though he has missed an opportunity for heroism, and Dr. Bailey is trying to help him feel better. Setting aside the technical problems imposed by a clinical setting, let us stipulate that there are two distinct aspects of psychiatric care: one is medical, formal, and biological; and the other is interactive, personal, and philosophical. With regard to the former, the psychiatrist is uniquely qualified to assist with medication, refinement of diagnosis, and remediation of illness. Regarding the latter, the psychotherapist may see the patient as an object, treated behaviorally, which is not necessarily bad or wrong, and solutions may be fairly procedural and simple. Dr. Bailey, however, sees Colin's problem as somewhat deeper than that, and I agree.Having a theory of human nature is one thing, but being in a relationship with another person requires action as well as contemplation. Like the parable of the two monks meeting in the forest, one turns to the other and says, “I’m lost.” The other monk replies, “I am also lost!” After a moment, the first says, “I don’t know the way out, but I know some ways that don’t lead out.” The second monk thinks for a moment and adds, “Me too. Perhaps we can find the way out together.” [End Page 241]When Harry Frankfurt (1988) first wrote about the importance of what we care about, he observed that conscious beings (as opposed to young children, who have not fully developed the capacity for self-reflection) exhibit conflicts of will. The concept of the person, he says, includes more than the nature of our knowing (epistemology) and the matter of our behavior (ethics). Those who are uniquely human have the capacity to consider and understand what they really care about, what matters most. In an elegant lecture series he sums this up as “taking ourselves seriously, and getting it right.” His work is valuable, not only for his keen insights and observations, but also because his thought is so accessible to those of us who are not trained philosophers.Frankfurt rightly points out that philosophy has largely neglected the study of personality, leaving that to the psychologists and social scientists. He never ventures into the world of diagnosis and treatment, and rightly so; he defines his interests narrowly and effectively, assuming for the sake of his arguments that he is describing someone not burdened by mental disease or defect. At the same time, he engages head-on the complexity of life and personal will. He offers a way to think about human will, but he does not say what we should necessarily do, nor for that matter when we should intervene, when it comes to the will of... (shrink)

The main thesis of this paper is that mental health practitioners can legitimately infer that a patient's given condition is a case of mental disorder without having diagnosed any specific mental disorder. The article shows how this is justifiable by relying either on psychopathological reasoning, on 'intentional' analysis or possibly on other modes of reasoning. In the end, it highlights the clinical and philosophical consequences of the plurality of modes of 'inferences to mental disorder'.

Freud's philosophical anthropology is in fact little more than an amplified psychiatry. For Freud, the human being is in essence a sick animal. In this paper, I discuss the possibility of founding this "anthropological turn" on evolutionary biology. On the one hand, it is shown that Freud's own attempted "evolutionary psychiatry" failed because of his very limited knowledge of Darwinism and his awe for Haeckel and Lamarck. On the other hand, I argue that more recent attempts to reconcile psychoanalysis and (...) evolutionary biology do not always provide a solid biological foundation for the Freudian philosophical project, despite the fact that they are—from a Darwinian point of view—tenable. This is so because, generally speaking, these theories consider psychopathologies either as adaptations or as accidental disorders, and not as inevitable but dysfunctional parts of human nature, like Freud did. (shrink)