In this new addition to the Collège de France lecture series, Michel Foucault's historical enquiry into the uses and techniques of power and knowledge finds itself directed towards a study of the birth of psychiatry. Psychiatric Power shows not only how Western society's division of the "mad" from the "sane" began, but also how society, medicine, and law and their treatment of the "mad" developed into what we now recognize as modern psychiatry, and how modern social and (...) political attitudes towards madness developed. A seminal work by this leading thinker of the modern age, Psychiatric Power builds on Foucault's published writings while opening new vistas within historical and philosophical study. (shrink)

Lectures at the Collège de France, 1973-1974. Ed. Jacques Lagrange, trans. Graham Burchell, intro. Arnold I. Davidson,. Extract from Chapter One, 7 November 1973.

The author examines the existential, historical, and political roots of psychiatric power, locating them, respectively, in the universality of guilt feelings and the desire to escape them, in psychiatry (replacing religion) as an institution offering surcease from such (and similar disturbing) feelings, and in the alliance, in modern societies, between psychiatry and the state. Clinical psychiatry and psychoanalysis, each in its own distinctive way, have served to legitimize the uses of psychiatric power. Liberty from coercive psychiatry (...) requires destroying the legitimacy, and hence power, of coercive psychiatric principles and practices. (shrink)

Psychiatric abuse, such as we usually associate with practices in the former Soviet Union, is related not to the misuse of psychiatric diagnoses, but to the political power intrinsic to the social role of the psychiatrist in totalitarian and democratic societies alike. Some reflections are offered on the modern, therapeutic state's proclivity to treat adults as patients rather than citizens, disjoin rights from responsibilities, and thus corrupt the language of political-philosophical discourse.

Pedagogy, power and practice ethics: clinical teaching in psychiatric/mental health settings Often, baccalaureate nursing students initially approach a psychiatric mental health practicum with uncertainty, and even fear. They may feel unprepared for the myriad complex practice situations encountered. In addition, memories of personal painful life events may be vicariously evoked through learning about and listening to the experiences of those diagnosed with mental disorders. When faced with such challenging situations, nursing students often seek counsel from the clinical (...) and/or classroom faculty. Pedagogic boundaries may begin to blur in the face of student distress. For the nurse educator, several questions arise: Should a nurse educator provide counseling to students? How does one best negotiate the boundaries between ‘counselor’, and ‘caring educator’? What are the limits of a caring and professional pedagogic relation? What different knowledges provide guidance and to what differential consequences for ethical pedagogic relationships? This paper offers a comparative analysis of three philosophical stances to examine differences in key assumptions, pedagogic positioning, relationships of power/knowledge, and consequences for professional ethical pedagogic practices. While definitive answers are difficult, the authors pose several questions for consideration in discerning how best to proceed and under what particular conditions. (shrink)

The power of routine and special observations: producing civility in a public acute psychiatric unit This study directly addresses controlling aspects of psychiatric nursing practice, which are currently marginalised in practice and research. We first consider the discursive tensions surrounding the mandated goal of social control in public acute psychiatric units, particularly referring to those units located within medical hospitals. We attest to the enduring social control mandate in psychiatric nursing and explore ways in which (...) it is enacted.Specific nursing practices of ‘doing the obs’ while scanning the ward and ‘special observations’ are investigated as important activities of social control, based on findings from an ethnographic study in one acute psychiatric unit in Australia. These practices are acknowledged as key modes of nursing surveillance. Contrary to past work, they are regarded as productive for engendering civil conduct among patients in acute psychiatric settings. We reframe these activities of surveillance as liberal therapeutic practices in themselves, to the extent that they assist patients to achieve treatment goals and promote self‐surveillance and self‐control. Instead of effacing practices of control, we encourage nurses to discriminate between more and less liberal modes of control in everyday practice and to build their skills in liberal controlling strategies. (shrink)

In the wake of their heightened role in addressing the emotional challenges of United States soldiers during World War II, American psychiatrists increasingly argued that their knowledge of human nature, based on interpretation of unconscious processes, was a powerful tool in effecting changes in society. As they turned to training an adequate supply of psychiatrists to meet expanding demand, educators in psychiatry residency programs faced questions about whom to entrust with the power of psychiatric interpretation, how educators’ knowledge (...) about trainees’ own unconscious processes should be harnessed, and how much to adhere to strict psychoanalytic doctrine in training. During the 1970s, social and cultural upheavals outside and inside psychiatry began to dismantle the grand claims of the postwar generation of psychiatrists, while shifts in the 1980s led educators to focus more on seemingly objective educational measures. Trainees’ and critics’ serious questioning of authority and structures in American society, and within psychiatry training programs, was perhaps as much of a factor – if not more – in the shift away from an emphasis on the interpretive power of psychoanalysis in favor of more eclectic and ultimately biological approaches in academic psychiatry. (shrink)

Police and pastoral power: governmentality and correctional forensic psychiatric nursing Since 1978, the federal inmates of Canada have had access to a full range of psychiatric care within the penitentiary system. Several psychiatric units are now integrated into the correctional services of Canada. This paper presents the results of a grounded theory doctoral study undertaken in a multilevel secured psychiatric ward within the Canadian federal penitentiary system. The author describes and discusses the results of qualitative (...) data that emerged from his fieldwork. The concept of governmentality, as defined by the late French philosopher Michel Foucault, constitutes one of the major theoretical tools that were helpful in analyzing these data. Police and pastoral power, two dimensions of the security apparatus of governmentality, were found to be useful in understanding and characterizing nursing practice caught between the penal and the psychiatric dispositifs. A Foucauldian perspective allows one to understand the manner in which forensic psychiatric nursing is involved in the governance of mentally ill inmates through three forms of power — sovereign, disciplinary and pastoral — which have posited nursing practice as a strategic tool of the correctional services. This research consists of a study of nursing practice in an extreme setting that deserves a radical analysis. (shrink)

The issue of power has become increasingly important within psychiatry, psychotherapy and mental health nursing generally. This paper will suggest that the work of Michel Foucault, the French philosopher and historian, has much to contribute to the discussion about the nature, existence and exercise of power within contemporary mental health care. As well as examining his original and challenging account of power, Foucault's emphasis on the intimate relationship between power and knowledge will be explored within the (...) context of psychiatry and mental health nursing. This is to say that the paper will investigate Foucault's account of how power and knowledge are central to the process by which human beings are ‘made subjects’ and therefore how ‘psychiatric identities’ are produced. In doing so, it will be suggested that Foucault's work can not only make a valuable contribution to contemporary discussions about power and knowledge, but can also provide a significant critique and reconceptualization of the theoretical foundations and associated diagnostic and therapeutic practices of psychiatry and mental health nursing. (shrink)

For much of the 20th century, scholars of American and European applied psychology and psychiatry have concerned themselves with the concepts of progress and power. In an effort to revisit the character of 19th-century psychiatry and to use the results as a means of evaluating 21st-century practice, this paper explores the relationship between power and progress in two popular but chronologically distinct approaches to caring for the mad: 19th-century moral treatment and late 20th-century psychiatric rehabilitation. Using the (...) theoretical framework of Foucault (1979), moral treatment (as developed by Thomas Story Kirkbride, for example, [1854] 1973) and psychiatric rehabilitation (as developed by William A. Anthony and colleagues, for example, Anthony, Cohen, and Farkas 1990) are compared for the degree to which each is structured by disciplinary interests and technologies. Based on this textual analysis, important differences emerge. Not only do these differences cast moral treatment in a new, and perhaps more positive light, but they also shed light on how disciplinary structures might affect a psychiatric approach's ability to carry out expressly humanitarian goals. To the extent that both propositions are accurate, the traditional view equating psychology and psychiatry's progress with a diminished reliance on power is brought into question. (shrink)

Underlying Foucault’s accounts of asylums, hospitals, prisons, and schools was a continuing concern with power and knowledge. In the field of mental health, his preoccupation with power relations and the construction of narratives of exclusion and repression in the History of Madnesshave led many scholars to consider Foucault an anti-psychiatrist. They question the book’s historical data, which prioritize power relations and political analysis over the actual experience of doctors and patients, undermining its scientific worth. Even thinkers sympathetic (...) to Foucault’s ideas argue that, despite the cultural discontinuities that he sought to foreground in his historical analysis, he nevertheless offered a continuous narrative of confinement and exclusion as a result of the oppressive powers of reason. But for Foucault, power is not unilateral, dominant, and oppressive, but distributional. Power is not a substance or a property one can claim to possess. It is not a political structure, a government or a dominant social class. Power is mobile, unstable, and reversible and is not blind but is determined by an internal logic. There is a form of rationality behind the exercise of power, and when that form of rationality is undermined, power loses its foundations. This can be observed in current forms of psychiatric practice, where psychiatric power is in fact being undermined while apparently being ever more closely inscribed in social practices. (shrink)

This essay focuses on three moments in Foucault's lifelong engagement with the pressing political question of the relationship between power and the subject. The first moment involves Foucault's examination of madness and Foucault's account of the relationship between the social‐institutional and conceptual exclusion of madness and the constitution of the rational subject in modernity, as this is articulated in the History of Madness (HM). The second moment focuses on Foucault's later account of subjection and normalization, as presented in Foucault's (...) famous genealogical works, Discipline and Punish (DP) and History of Sexuality (HS). Foucault's lectures on Psychiatric Power (C‐PP) serve as a bridge between these first two moments. The third moment involves Foucault's exploration of technologies of the self in the context of ancient Greek and Roman ethics. There is a movement to Foucault's thought from madness as the condition of impossibility of thought to disciplinary subjection to the Stoic idea of conversion. (shrink)

THE TARGET OF ERICA LILLELEHT'S interesting comparison between 19th-century moral treatment and 20th-century psychiatric rehabilitation is contemporary psychiatric rehabilitation. Using Foucault's (1979) Discipline and Punish as her critical foil, she argues that psychiatric rehabilitation is "an approach to madness fraught with paradox." The paradox lies in the fact that the techniques of psychiatric rehabilitation can be practiced in a manner that contradicts its professed humanitarian intentions; notably, liberating the mad from "resource dependency and segregated living." The (...) lesson to be drawn from this paradox is that "our practices, may be shaped and reformulated to serve goals of which we are only dimly aware." The resulting "mindfulness" is supposed to make us more careful and critical of what to count as success and progress in psychiatric treatment... (shrink)

Background Research has shown that moral distress negatively impacts nurses, patients, and organizations; however, several scholars have argued that it can be an opportunity for positive outcomes. Thus, factors that may mitigate moral distress and catalyze positive change need to be explored. Research aim The purpose of this study was to explore the relationships among structural and psychological empowerment, psychiatric staff nurses’ experience of moral distress, and strategies for coping with moral distress. Research design A descriptive cross-sectional correlational study. (...) Participants and research context A total of 180 registered nurses working in psychiatric hospitals in Japan participated. This study examined relationships among key variables using four questionnaires to assess structural and psychological empowerment, moral distress for psychiatric nurses, and coping strategies. Statistical analyses of correlations and multiple regressions were conducted. Ethical considerations The study was approved by the institutional review board at the author’s affiliated university. Findings Psychiatric nurses perceived moderate levels of structural and psychological empowerment, and their experiences of moral distress were related to low staffing. Structural empowerment was negatively related to the frequency of moral distress but not the intensity. Contrary to expectations, psychological empowerment was not found to mitigate nurses’ moral distress. Multivariate regression analyses revealed that the significant predictors of moral distress were the leaving issues unresolved coping style, the problem-solving coping style, and a lack of formal power, which explained 35% and 22% of the variance in the frequency and intensity of moral distress, respectively. Conclusions In psychiatric hospitals in Japan, nurses experience moral distress that compromises the quality of care they provide. Therefore, formal support for nurses in voicing and investigating their moral concerns is required to bestow formal power by establishing a ward culture that includes shared governance. (shrink)

Bluhm et al. (2023) interviewed psychiatrists, patients with depression, and members of the public and concluded that participants recognized multiple categories of invasiveness, including emotiona...

The Oxford Handbook of Psychiatric Ethics is the most comprehensive treatment of the field in history. The volume is organized into ten sections which survey the scope of the text: Introduction, People Come First, Specific Populations, Philosophy and Psychiatric Ethics, Religious Contexts of Psychiatric Ethics, Social Contexts of Psychiatric Ethics, Ethics in Psychiatric Citizenship and the Law, Ethics of Psychiatric Research, Ethics and Values in Psychiatric Assessment and Diagnosis, Ethics and Values in (...) class='Hi'>Psychiatric Treatment. Written and edited by an international team of experts, this landmark book provides a powerful and compelling review of psychiatric ethics in the 21st Century. (shrink)

This paper examines the planning process and architecture of two public psychiatric institutions built around 1900 in Trieste and Lower Austria. From 1864, the building of new asylums was the responsibility of Crown land governments, which by the end of the nineteenth century had emerged as sites of power and self-presentation by minority groups and new political parties. At the same time, the area of asylum planning was establishing itself as a branch of asylum psychiatry and promoting the (...) idea of the asylum as model settlement, contributing to social reform. I analyse the interaction of psychiatrists, architects and government officials involved in planning the two institutions in the context of Crown land governments’ self-positioning within the empire and internationally . The Trieste asylum planners were working for a government controlled by Italian nationalists, but their desire for a ‘modern’ asylum turned them towards German models. The Christian Social government in Lower Austria sought to supplant Germany as the leader in this branch of science. The spatial arrangement and visual articulation of the two asylums is interpreted in the context of the interaction of psychiatry and the politics of regional autonomy. (shrink)

Psychiatrists encounter persons from diverse cultures who profess experiences (e.g., communicating with spirits) that evoke intuitions of abnormality. This view might not be shared with the person or her/his cultural peers, raising questions concerning the justification of such intuitions. This article explores three positions relevant to the process of justification. The relativist position transfers powers of judgment to the subject’s peers yet neglects individual values and operates with a discredited holistic view of culture. The clinical-ethnographic position remedies this by suspending (...) judgment subject to understanding the individual in a sociocultural context yet finds objections with the universalist-scientific position: objective standards exist and could justify intuitions of abnormality cross-culturally. This article argues that the claim to objectivity is value-laden, reflecting instead a brand of normality and relationship to reality further upheld through epistemological utility and valued technological progress. In conclusion, it is suggested that the clinical-ethnographic position takes personal values and context seriously, both of which are crucial for responsible clinical practice. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:'Psychiatric Dasein'Christopher Heginbotham (bio)Fulford and Colombo's pioneering work (2004)in linguistic analysis offers valuable insights and 'deconstructs' the often inter-related concepts of mental disorder and treatment. Their paper describes a combined philosophical and empirical research program developed to study "the role models of disorder in the community care of people with long-term schizophrenia" (2004, 130). They claim that the approach supplies a key explanatory insight into the nature of (...) the problem presented by models of disorder, a characterization of models, contributions to research design, a theoretical framework—a 'models-grid,' and a basis for turning theory into practice. These claims are not unreasonable in the context of the specific objectives of the research design, but do not necessarily cover everything of importance in the way models are used to describe mental disorder. In particular, this brief response proposes the need to develop an understanding of psychiatric Dasein—mental disorder as presented in the world.Fulford and Colombo are surely right in their claim that representations of mental disorder are high-level concepts not dissimilar to other high-level concepts such as time. These are concepts that we seem to have little difficulty using in day-to-day practice but have great difficulty defining. In their discussion of this point, they suggest that little progress has been made in relation to models of mental disorder over the previous fifty years, that there is a considerable volume of theoretical literature that has had little impact on practice.This assertion does not appear to do justice to the significant progress that might be argued to have occurred in psychoanalytic theory, psychodynamic therapy, and other metapsychological developments of the last fifty to one hundred years. Many of these developments have changed markedly our perceptions of mental disorder. Some treatments, it is true, may not have direct relevance or applicability to serious psychotic behavior, although that is contentious; there are psychoanalytic psychotherapists working with people with schizophrenia who would claim success. Recent developments in cognitive-behavioral therapy allied to other treatment modalities, such as careful use of low-dosage medication, have had therapeutic impact in enabling people with schizophrenia to 'manage their voices' and to understand the complex nature of their own thought processes.Fulford and Colombo also suggest that after this half century of work much of the development of practice has been largely abortive. Is this correct? It is true that we continue to struggle with an understanding of what we mean by mental disorder, which is made much worse, as the authors say, by the multiplicity of definitions of mental illness, models of mental disorder and practical approaches to treatment and management. Multidisciplinary and multi-agency developments of the last twenty years especially have, on the one hand, been a powerful approach to recognizing the multifaceted nature of mental disorder, but, on the other, have tended to a potential fragmentation of effort that has undermined [End Page 147] the necessary focus on the needs of the individual patient.Threefold ExpansionIt is here that perhaps an addition or expansion can be made to Fulford and Colombo's approach. That addition is, to borrow a phrase used by Hilary Putnam for the title of one of his books, a 'three fold cord.' The term comes originally from Ecclesiastes 4.12: "..a threefold cord is not quickly broken." (Putnam subtitles his book, Mind, Body and World, echoing, probably unintentionally, Heidegger's threefold structure of 'Being-In' [Dreyfus 1991. 163]).First, there have been many attempts 'informally' to understand the interplay of differing mental disorders in the operation of multidisciplinary teams. The development of community mental health teams and more recently Crisis Resolution and Out-Reach teams has required staff from varying professional backgrounds and agencies to find some common ground and to negotiate across their various professional, philosophical, and nosological boundaries. These negotiations have not been easy. A first element of the threefold expansion may be to incorporate (or strengthen) an organizational and group dynamic in the model (see, for example, de Board 1978; Hinshelwood 1987)Second, theoretical and practical work by professionals trained in psychoanalytic disciplines have sought to understand the nature of multidisciplinary community provision for people... (shrink)

This thesis investigates the nature of psychiatric disorders, and to what extent they can form a basis for classification, explanation, and treatment interventions. These questions are important in the light of the “crisis of validity” in psychiatry, according to which current diagnostic categories do not pick out real disorders. I address the questions by defending an account of psychiatric disorders that can better accommodate social aspects and non-epistemic values than the symptom-based model of the Diagnostic and Statistical Manual (...) of Mental Disorders (DSM) and the brain disease model of the biomedical approach, including the Research Domain Criteria (RDoC). I concentrate on three ways that psychiatric disorders can differ from prototypical natural kinds, such as biological species and chemical elements. First, the concept of psychiatric disorder or mental disorder is partly value-laden and cannot be defined based only on scientific facts. Second, the objects of psychiatric classifications are interactive human kinds because people with disorders respond to their classifications through looping effects. Third, sociocultural factors can shape disorders in complex ways, which is indicated by their cross-cultural variation. I argue that these challenges can be overcome with a pluralistic explanatory account that grants an explicit role to value-sensitive considerations and social scientific research. Based on this, I argue that particular disorders can in principle support inductive inferences. ------------------------------------------------------------------------------------------ My key argument is that although whether a condition is considered pathological is partly a value-laden question, this does not rule out a realist account of particular psychiatric disorders as homeostatic property cluster kinds (HPC). I assert that causal mechanisms responsible for psychiatric kinds can be understood non-metaphysically based on the contrastive-counterfactual and interventionist theories of explanation. An advantage of this account is that it can address the concern that psychiatric explanations require one to relate heterogeneous causal factors on different levels, such as genetic, neurological, psychological, and social. My novel argument is that mechanistic explanations of scientific kinds have applicability domains over which they account for specific aspects of kinds and warrant inductive inferences. That is, identifying the applicability domain of an explanation spells out the conditions under which the explanation is expected to be reliable and when it can break down. This helps to understand how different discipline approaches, including social and cultural ones, can be complementary and make an explanation of a psychiatric kind more reliable. On the other hand, the account also shows how the complex nature of psychiatric kinds can license re-classifications for different epistemic and non-epistemic purposes. Finally, in the light of the social implications of psychiatric classifications, I suggest a value-sensitive or ameliorative approach to engineering the concept of psychiatric disorder. In conclusion, my account shows that research on the social and cultural factors that shape psychiatric disorders, and weighing the non-epistemic values that influence classificatory practices, can and should inform classificatory choices as well as policy and treatment interventions. (shrink)

To consider power as not only the direct physical oppression of others, but as a production of authority through discursive knowledge and a claimed ‘expertise’ of the world, has been one of Foucault’s great legacies to critical work on mental health and illness. As arbiters of the ‘truth’ on what is and what is not mental pathology, I agree with Swerdfager that the privileged knowledge of the mental health professions and the consequential marginalization of other forms of knowledge on (...) distress can be better theorized through an investigation of the power/knowledge nexus. Practically, scholars and researchers can begin to address these... (shrink)

Psychiatric labeling has been the subject of considerable ethical debate. Much of it has centered on issues associated with the application of psychiatric labels. In comparison, far less attention has been paid to issues associated with the removal of psychiatric labels. Ethical problems of this last sort tend to revolve around identity. Many sufferers are reticent to relinquish their iatrogenic identity in the face of official label change; some actively resist it. New forms of this resistance are (...) taking place in the private chat rooms and virtual communities of the Internet, a domain where consumer autonomy reigns supreme. Medical sociology, psychiatry, and bioethics have paid little attention to these developments. Yet these new consumer-driven initiatives actually pose considerable risks to consumers. They also present complex ethical challenges for researchers. Clinically, there is even sufficient evidence to wonder whether the Internet may be the nesting ground for a new kind of identity disturbance. The purpose of the present discussion is to survey these developments and identify potential issues and problems for future research. Taken as a whole, the entire episode suggests that we may have reached a turning point in the history of psychiatry where consumer autonomy and the Internet are now powerful new forces in the manufacture of madness. (shrink)

In the first work of investigative journalism in decades to give a comprehensive view into contemporary psychiatric incarceration and forced interventions, Your Consent Is Not Required exposes how rising numbers of people from many walks of life are being subjected against their will to surveillance, indefinite detention, and powerful tranquilizing drugs, restraints, seclusion, and electroshock.

Background: Informal coercion, that is, situations where caregivers use subtle coercive measures to impose their will on patients, is common in adult psychiatric inpatient care. It has been described as ‘a necessary evil’, confronting nurses with an ethical dilemma where they need to balance between a wish to do good, and the risk of violating patients’ dignity and autonomy. Aim: To describe nurses’ experiences of being involved in informal coercion in adult psychiatric inpatient care. Research design: The study (...) has a qualitative, inductive design. Participants and research context: Semi-structured interviews with 10 Swedish psychiatric nurses were analysed with qualitative content analysis. Ethical considerations: The study was performed in accordance with the Declaration of Helsinki. In line with the Swedish Ethical Review Act, it was also subject to ethical procedures at the university. Findings: Four domains comprise informal coercion as a process over time. These domains contain 11 categories focusing on different experiences involved in the process: Striving to connect, involving others, adjusting to the caring culture, dealing with laws, justifying coercion, waiting for the patient, persuading the patient, negotiating with the patient, using professional power, scrutinizing one’s actions and learning together. Discussion: Informal coercion is associated with moral stress as nurses might find themselves torn between a wish to do good for the patient, general practices and ‘house rules’ in the caring culture. In addition, nurses need to be aware of the asymmetry of the caring relationship, in order to avoid compliance becoming a consequence of patients subordinating to nurse power, rather than a result of mutual understanding. Reflections are thus necessary through the process to promote mutual learning and to avoid violations of patients’ dignity and autonomy. Conclusion: If there is a need for coercion, that is, if the coercion is found to be an ‘unpleasant good’, rather than ‘necessary evil’ considering the consequences for the patient, it should be subject to reflecting and learning together with the patient. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Narrative SymposiumPersonal Narratives Experiences of Psychiatric HospitalizationV. Barnard, J. Carson, Eugene Doe, Robin Driben, Anonymous One, Anonymous Two, Charles Kelley, Michael Kerins, D. Millman, Anonymous Three, Viesia Novosielski, Ben Zion, and Anonymous Four• Dreaming: A Recovery Story• The Intervention of the Demon• Bent but Not Broken• Tortured Souls Do Not Rest• Homesick• A Professional Patient No More• My Spiritual Journey• Personal Account of Psychiatric Hospitalization• Psychiatric (...) Hospitalization Story• As Ice Is to Water• The Power Of Human-To-Human Contact• Dignity• HospitalizationCopyright © 2011 The Johns Hopkins University Press... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Adolf Meyer: Psychiatric AnarchistS. Nassir Ghaemi (bio)KeywordsMeyer, biopsychosocial model, Jaspers, pluralism, philosophy, psychiatryThey had weekly lunches in 1920s New York City: In one door stepped a stooped philosopher, with a mustache and a twinkle, perhaps ruminating on some recent Marxist theory; in the other door came the elegant Swiss physician, goateed and erudite. Every week, for a time, John Dewey (leader of American pragmatism) and Adolf Meyer (dean (...) of mid-twentieth century American psychiatry and long-time chair of the Johns Hopkins psychiatry department) lunched together and, somewhere in those conversations—one might imagine—the field of philosophy and psychiatry was born (Meyer 1948, 152).Yet pragmatism—as a proper school of philosophy—does not capture Meyer’s psychiatry. Rather, the core of his thinking, in my view, is to be found in a vague term that deserves analysis: eclecticism.EclecticismIt has been said that eclecticism is a vice in theory but a virtue in practice (Stone 1981), which highlights why so many are attracted to it. Deep down, practitioners just want to be free: They believe that their freedom of choice will tailor treatments best to patients and thus result in best outcomes. As a conceptual theory for psychiatry, eclecticism is a model that views any theory or method as potentially correct, but no theory or method as definitively incorrect. There is no way to avoid an “anything goes” practice with eclecticism: It is—to use a political analogy—an anarchism of mind.William James once remarked that the basis for all philosophies lies in the personalities of philosophers. So it was with Meyer’s eclecticism: congenial personally, he seemed congenitally incapable of disagreeing with any person. Any idea, even the most unusual, would receive a respectful hearing from Meyer. (Double brings out new, excellent documentary evidence of this extreme indecision in the drafts of Meyer’s unsent letters to the behaviorist John Watson.) Although quaint and commendable pedagogically, this excessive open mindedness left American psychiatry—so dependent on Meyer—prey to hard-headed biological radicals and psychoanalytic dogmatists. This is where his eclecticism failed us.Enabling Biological ExtremismMeyer played a key role in legitimizing extreme biological approaches. In addition to his interest in insulin coma (which Double mentions), Meyer enabled the popularization of colectomy and frontal [End Page 341] lobotomy. Psychiatric colectomy, developed by Henry Cotton, was based on the focal toxin theory of mental illness—the idea that mental illness was caused by toxins released by bacteria in the body, the specific locations of which where were the colon and rotted teeth. In one hundred case reports, with mostly short-term follow-up, published in his prominent text, The Defective Delinquent and Insane (Cotton 1921), Cotton laid out his case, which Meyer legitimized by writing a generous foreword. Meyer’s authority was powerful enough to render Cotton’s limited evidence base much more credible than it might otherwise have been. In the 1920s and 1930s, tens of thousands colectomies and full mouth teeth extractions were conducted in patients with mental illness. (Meyer himself sometimes recommended it).1The other biological extremist story is more famous. In a 1936 conference, with Meyer in attendance, the neurologist Walter Freeman presented, for the first time, cases of refractory schizophrenia treated with a new method: frontal lobotomy. Psychoanalyst attendees protested that Freeman was proposing nothing more than mutilation of the brain; yet Meyer intervened in favor of Free-man (“I am not antagonistic to this work, but find it very interesting” [El-Hai 2005]). Unfortunately, Freeman, like Cotton, was a dogmatist: Over time, he performed frontal lobotomy more and more extensively, not just as a treatment of last resort in the most ill schizophrenics (as in the first cases presented to Meyer), but later as a treatment of first resort for the mildest mood disorders. (By 1950 Freeman had personally conducted 2400 transorbital lobotomies, an “office procedure” that allowed him to lobotomize a patient in 15 minutes [El-Hai 2005]).2Lest my critique of Meyer in that era be seen as a Whiggish interpretation of history (the claim that we are so much smarter than those shrinks of the past; in fact I think... (shrink)

In psychiatry, the concept of “insight” commonly refers to a patient’s judgment that they have a mental illness and need clinical treatment. However, this concept has been criticized because it imposes psychiatric knowledge on the subjective experiences of mental illness and possible interventions. A significant body of literature is critical of mental health interventions; however, insight remains under-explored in this realm. This paper adds to critical analyses of insight by exploring how it is defined and deployed by mental health (...) professionals in an acute inpatient mental health unit in a Canadian general hospital and what disciplinary and epistemic effects it has on patients. To this end, I draw on Foucault’s theories of psychiatric power and Fricker’s concept of epistemic injustice to analyze results from an ethnographic study conducted in an inpatient mental health unit. The results show how patients’ resistance to medical compliance is framed by staff as a lack of insight, which reinforces the psychiatric model of mental illness. (shrink)

BackgroundPsychiatric staff members have the power to decide the options that frame encounters with patients. Intentional as well as unintentional framing can have a crucial impact on patients’ opportunities to be heard and participate in the process. We identified three dominant ethical perspectives in the normative medical ethics literature concerning how doctors and other staff members should frame interactions in relation to patients; paternalism, autonomy and reciprocity. The aim of this study was to describe and analyse statements describing real (...) work situations and ethical reflections made by staff members in relation to three central perspectives in medical ethics; paternalism, autonomy and reciprocity.MethodsAll staff members involved with patients in seven adult psychiatric and six child and adolescent psychiatric clinics were given the opportunity to freely describe ethical considerations in their work by keeping an ethical diary over the course of one week and 173 persons handed in their diaries. Qualitative theory-guided content analysis was used to provide a description of staff encounters with patients and in what way these encounters were consistent with, or contrary to, the three perspectives.ResultsThe majority of the statements could be attributed to the perspective of paternalism and several to autonomy. Only a few statements could be attributed to reciprocity, most of which concerned staff members acting contrary to the perspective. The result is presented as three perspectives containing eight values.•Paternalism; 1) promoting and restoring the health of the patient, 2) providing good care and 3) assuming responsibility.•Autonomy; 1) respecting the patient’s right to self-determination and information, 2) respecting the patient’s integrity and 3) protecting human rights.•Reciprocity; 1) involving patients in the planning and implementation of their care and 2) building trust between staff and patients.ConclusionsPaternalism clearly appeared to be the dominant perspective among the participants, but there was also awareness of patients’ right to autonomy. Despite a normative trend towards reciprocity in psychiatry throughout the Western world, identifying it proved difficult in this study. This should be borne in mind by clinics when considering the need for ethical education, training and supervision. (shrink)

Creating a space for recovery‐focused psychiatric nursing care Within contemporary mental health‐care, power relationships are regularly played out between psychiatric nurses and service users. These power relationships are often imperceptible to the practicing nurse. For instance, in times of distress, service users often turn to or/and ‘construct’ discourses, beliefs and knowledge that are at odds with those which psychiatric nurses rely on to inform them of the mental status of the service user. The psychiatric (...) nurse is in the position to impose knowledge onto service users, usually in concurrence with ‘traditional or bio‐psychiatry’, without realizing or failing to acknowledge that the service user may have an alternative explanation of his/her mental health problems/experiences. In this paper, practice examples, based on the experiences of the four authors (from within and outside of services), are used to illustrate this ‘hidden’ power relationship. The authors use Foucault's ideas about: (i) government; (ii) the knowledge/power nexus and resistance; (iii) and his analytic tool of genealogy to help unravel this paradox within psychiatric nursing practice. The authors also use the emerging discourse of recovery as an alternative (and challenge) to ‘traditional bio‐psychiatry’ and consider the implications for psychiatric nursing practice. (shrink)

Studies of the role of imprinted genes in psychological phenomena are long overdue. The target article is comprehensive, presenting a wealth of important and convergent evidence, and provides an excellent point of departure for further research. However, the authors' evidentiary grasp exceeds the explicatory capacity of the proposed model. Greater genotypic and phenotypic precision would significantly enhance its predictive power.

Discourse and rhetoric of service-user involvement are pervasive in all mental health services that see themselves as promoting a Recovery ethos. Yet, for the service-user movement internationally, ‘Recovery’ was articulated as an alternative discourse of overcoming and resisting an institutionalized and oppressive psychiatric model of care. Power is all pervasive within mental health services yet often overlooked in official discourse on user-involvement. Critical research is required to expose the unacknowledged structural and power constraints on participants. My research (...) problematizes practices of user involvement in one mental health service area in Ireland. Part I of this article examines the background context of policies and practices of user-involvement from the service-user perspective and explains developments in relation to service-user involvement in the case of Ireland. Participants in my study articulate their motivation for engagement with mental health service reform in terms of the right to participate in social justice terms, of wanting to improve services and humanise care. Power dynamics emerge as one of the primary obstacles to equitable involvement. Part II of this article presents an explanatory framework of power, using a model developed in the field of development studies; Gaventa’s (2006) ‘power cube.’ The three dimensions of the cube represent the forms, spaces and levels of power. The explanatory potential of this model to highlight how hidden and invisible power operates in mental health services is illustrated by selected comments from the same participants. The power cube is a useful tool to illuminate the dynamics occurring in service-user involvement spaces. Showing how different forms of power operate in the spaces and levels of mental health involvement can develop service-users’ awareness of the hidden and invisible aspects of power. Through this awareness, they can strategize around their potential to influence decision-making in mental health services. (shrink)

Abstract:In this paper, I offer a philosophical critique of the Power Threat Meaning Framework (PTMF). This framework was launched in the UK in January 2018 as a non-pathologizing way of understanding mental distress. It argues that those experiences diagnosed as mental illnesses are better understood as meaning-based threat responses to the negative operation of power. My critique consists of three parts. First, the PTMF argues that it is opposed to a concept of mental distress as illness. However, the (...) PTMF unfolds an account of mental distress that is very similar to other accounts of mental illness in the philosophical literature. The PTMF does not reflect upon, recognize or give an account of its own grounds for judging mental distress as distress. If it were to do so, I argue that it would produce an account of mental distress that is very similar to many other accounts of psychiatric illness or disorder. Second, I criticize the account given of meaning in the PTMF. I argue that this account is ultimately a reductive, behavioral account of adaptation that downplays important existential aspects of experience. Furthermore, the account of interpretive sense-making in the PTMF is conceptually confused. Finally, I outline a critique of the way that the concept of power, the great strength of the PTMF approach, is reduced to a concept of threat. I argue that this tends toward a linear view of causality that is reductive in its search for the meaning of mental distress. (shrink)

This book introduces and applies Foucault's most important concepts and procedures, and does so specifically for a psychology readership. Drawing on the recently published Collège de France lectures Abnormal (2003) and Psychiatric Power (2006), Foucauldian Analytics and Psychology is as useful to those concerned with Foucault's engagement with the "psy-disciplines" as it is to those interested in the practical application of Foucault's critical research methods.

This article reports on the ways in which psychiatric practice and power were constituted in a Danish asylum at the beginning of the nineteenth century. The point of departure will be a complaint by a former patient questioning the practice at the asylum in 1829. In an analysis of this narrative the study draws upon Foucauldian concepts like disciplinary power, confession, pastoral power and subjectivation. I will argue that the critique of the patient provides us with (...) an example of the way that disciplinary power works in the case of an informal indictment of the methods and practice at an asylum. A key issue is whether the critique is not itself a part of the self-legitimation of disciplinary power. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Narrative SymposiumPersonal Narratives Experiences of Psychiatric HospitalizationV. Barnard, J. Carson, Eugene Doe, Robin Driben, Anonymous One, Anonymous Two, Charles Kelley, Michael Kerins, D. Millman, Anonymous Three, Viesia Novosielski, Ben Zion, and Anonymous Four• Dreaming: A Recovery Story• The Intervention of the Demon• Bent but Not Broken• Tortured Souls Do Not Rest• Homesick• A Professional Patient No More• My Spiritual Journey• Personal Account of Psychiatric Hospitalization• Psychiatric (...) Hospitalization Story• As Ice Is to Water• The Power Of Human-To-Human Contact• Dignity• HospitalizationCopyright © 2011 The Johns Hopkins University Press... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Underplayed Ethics and the Dilemmas of Psychiatric CareChong Siow Ann and Tamra LysaghtThe practice of psychiatry is fraught with uncertainty. The exact causes and the biological substrates underlying mental disorders remain to be elucidated; even the diagnosis of these disorders is descriptive and not based on an etiological understanding and no biological diagnostic markers have been validated. The manifestation of almost all mental disorders results from a complex (...) interaction of biological and environmental factors which encompasses the patient’s unique life history, experiences and relationship with others and the community. In the face of such uncertainties — at times extending to the types of treatment (psychiatry is generally acknowledged not be an exact science) — it has been argued that adopting a pragmatic approach is necessary.1 Accordingly, this approach necessitates high ethical standards among mental health practitioners.Some mental illnesses are associated with varying degrees and types of cognitive impairments. Others have certain symptoms like auditory hallucinations and delusions that might severely compromise the patients’ autonomy, distort their sense of reality, increase the risk of harm to themselves or others and render them incapable of making informed decisions in their treatment and participation in research.Consequently, there are issues that are particular to the provision of mental healthcare. These include the need for enforced involuntary treatment with the corollary of depriving a patient of his personal liberty even [End Page 173] though it is often justified on the grounds that it is in the patient’s best interests. However, at times, it is the legal and societal obligation of mental health practitioners to protect those who might be harmed from the patient’s action that might seem to be more pressing. In this situation of double agency, lies the tension of providing confidential care for patients and acting as “an agent of the state” where that patient’s confidentiality might be breached and his liberty infringed upon. This situation is further aggravated by the stigma that clings ever so tenaciously to those who suffer from mental disorders and where it is the norm to stereotype them as dangerous and unpredictable.Consideration of a patient’s autonomy is also challenged by characteristics that are unique to the practice of psychiatry. The prescription of certain psychotropic medications can alter how people think and feel, while psychotherapy works towards changing the patient’s views and values. The philosopher, Jennifer Radden, describes this process as “re-forming the patient’s whole self or character … akin to the responsibilities of raising children”.2 The psychotherapeutic relationship is thus particularly personal and intimate because patients are asked to provide information that often reveals their innermost feelings, fears and fantasies. This information is provided on the basis of trust and assurance of confidentiality, and with expectation of being helped.Jeremy Holmes and Gwen Adshead have elaborated on the vulnerability of patients seeking psychotherapy: they might be particularly susceptible to exploitation because their past experiences of being exploited have led to their distress and help seeking — their dependency and the extreme privacy of the therapeutic relationship make any transgression difficult to be uncovered.3 There is a calamitous combination of the “unconscious wish in the patient to be used” with the complicity of an unethical therapist seeking to fulfil his own interests.4As in any other doctor-patient relationship, the relationship between the mental healthcare practitioner and the patient is one of unequal power where the former is ascendant. While that power should be exercised to heal and to relieve suffering, it also gives the practitioner tremendous power “to harm, reject, misunderstand, or exploit patients who struggle with the experience of mental illness, which itself may generate helplessness, despair, distress, and exceptional dependence on the clinician”.5 Given the potential of doing good and harm coupled with the likelihood of being so significant in the life of the patient,6 providing care for those with mental disorders and distress is necessarily ethically exacting — arguably more so than in other medical practice settings. [End Page 174]This precariousness has led to the suggestion that ethics in psychiatry should have a special status and that the more general principles of biomedical ethics are too limited in scope to... (shrink)

The data-driven approach to psychiatric science leverages large volumes of patient data to construct machine learning models with the goal of optimizing clinical decision making. Advocates claim that this methodology is well-placed to deliver transformative improvements to psychiatric science. I argue that talk of a data-driven revolution in psychiatry is premature. Transformative improvements, cashed out in terms of better patient outcomes, cannot be achieved without addressing patient understanding. That is, how patients understand their own mental illnesses. I conceptualize (...) understanding as the possession of adaptive mental constructs through which experience is mediated. I suggest that this notion of understanding serves as a bottleneck which any prospective approach to psychiatry must address to be efficacious. Subsequently I argue that, though the data-driven approach is undoubtedly powerful, it does not have a straightforward means of unblocking the bottleneck of understanding. I suggest that the data-driven approach must be supplemented with significant theoretical progress if it is to transform psychiatry. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:To Recognize the Person: Learning from Narratives of Psychiatric TreatmentLinda J. MorrisonTo know what patients endure at the hands of illness and therefore to be of clinical help requires that doctors enter the worlds of their patients, if only imaginatively, and to see and interpret these worlds from the patient’s point of view(Charon, 2006, p. 9).These narratives of psychiatric hospitalization are rich and evocative. We are fortunate (...) to have twelve descriptions appearing side-by-side, each unique in its focus, outlook, detail and narrative tone. Together their interwoven contexts describe personal and work relationships, internal and external help-seeking, encounters in community and hospital settings, and experiences of the psychiatric (psychiatrized) self as supplicant, victim, recipient, participant, product, and active agent over time (Morrison, 2005).Through their collected narratives, the authors create a distinct counterpoint to the more familiar clinical narratives of psychiatric encounters. Ordinarily the professional narrative drives interpretation of a clinical experience, whether medical or psychiatric. The caregivers populating these narratives would probably tell different stories, and the hospital notes and treatment records yet another (Hinsby & Baker, 2004; VanDerNagel et al., 2009). The disjunction between professional and patient narrative is especially true for psychiatric hospitalizations, in which the inpatient’s active narrative becomes a part of the diagnostic and treatment process (Steslow, 2010).In this symposium, the patient’s narrative is a window for interpretive insights into personal experience of the process. Each is a situated retrospective, in which added dimensions of feeling, thought and interaction provide the reader a fuller and more complex awareness of the experience of psychiatric hospitalization. The narratives provide insights about choice and agency, control and harm, safety and strength, hope and frustration, resilience and recovery, empathy and humanity; they also reveal various ethical issues related to the experience of help-seeking and treatment.It is vital to consider what each person wrote: what choices they made in representing their experience; what aspects they focused on, and what they (we imagine) left out. The authors used their own voices to create their own representations. In each narrative, “the person” provides an important standpoint. Who is this person, what is his or her experience? Where is the person in the situation; in what way does he or she appear to those who provide treatment or care? How, if at all, is the treatment pertinent to the person’s concerns? Does it feel helpful or harmful? How does the person find a way to continue, to push through, with the help of (or in spite of) those we hope are providing care? This is the first sign of agency, of choice, of “dreaming.” [End Page 35]As V. Barnard writes in Dreaming: A Recovery Story, “to make a film, one has to dream it first.” All of the authors in this symposium took the risk and the opportunity to create their own stories: what to include, what to leave out, how to tell what they wanted to say. These choices gave them the power to dream: how it was, how it might have been; how it felt, good and bad; the chance to represent their own reality—to themselves, and to unknown others (Morrison, 2006).Dreaming, Choice and Agency“My psychiatric illness is only one part of me. I am a person with hopes, dreams, love, an artist and a fellow helper of my peers.” V. BarnardV.’s narrative describes the potential for positive action, of dreaming herself as a whole into existence. Her themes of choice and agency emphasize the importance of autonomy and the capacity for autonomous action. On the farm, V. was free to choose and take risks, to take on responsibilities, to be “treated with respect as a human being trying to get better rather than a criminal suffering from something that was optional.” From disconnection, she was able to find connection, on her own terms.The support of peers adds a valuable dimension. Being recognized as a peer, a person who shares similar psychiatric experiences and respects the challenge of everyday life, brings another level to supportive relationships. Negative judgments and stigma are reduced by mutual support and acknowledgement of common goals. Mental health... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Beyond EngelClinical Pragmatism as the Foundation of Psychiatric PracticeDavid H. Brendel (bio)Keywordsbiopsychosocial model, pluralism, pragmatism, psychiatryFor many years now, there has been growing recognition of the powerful role of pragmatic reasoning in numerous disciplines, including bioethics, medicine, law, political science, and philosophy (Dickstein 1998; Rosenthal, Hausman, and Anderson 1999). But until recently, philosophical pragmatism was neglected by scholars exploring the clinical challenges and theoretical underpinnings of psychiatry. In (...) his noteworthy article The Biopsychosocial Model and Philosophic Pragmatism: Is George Engel a Pragmatist?, Bradley Lewis offers a significant contribution to the small but gradually increasing literature in this area. Lewis appropriately presents Engel as a major figure in twentieth-century American medicine and psychiatry, a critic and a visionary who dared to question the dominant paradigm of biomedical reductionism (Engel 1977)—a paradigm that led to important scientific advances, but also restricted the physician’s understanding of the patient as a complex individual with an inner world and interpersonal relationships. Lewis argues that medicine and psychiatry a generation after Engel’s seminal 1977 paper can be revitalized by reinterpreting Engel in the intellectual tradition of classical American pragmatism and neo-pragmatism. Placing Engel in the pragmatic tradition, Lewis suggests, could enhance the biopsychosocial model and have substantial benefits for both individual patients and society as a whole.There is no disputing Lewis’s argument that a pragmatic philosophy of medicine and psychiatry is a noble goal. In fact, in my book Healing Psychiatry: Bridging the Science/Humanism Divide (Brendel 2006), I present philosophical pragmatism as the most compelling theoretical approach to clinical psychiatry in the twenty-first century—the approach that is most likely to empower the clinician and the patient to collaboratively develop a treatment plan that heeds the multidimensional complexity of the patient’s life, recognizes the confusion and uncertainty that grows out of this complexity, and aims for a favorable therapeutic outcome. Drawing on work of the classical American pragmatists and contemporary pragmatic bioethicists, I identify four dimensions of philosophical pragmatism that provide a sound foundation for clinical work, which I call the “four ps”: (1) diagnostic formulations and treatment plans in psychiatry are practical insofar as they focus on results rather than a commitment to any particular theory; (2) they are pluralistic [End Page 311] insofar as they incorporate explanatory concepts that span the biopsychosocial spectrum; (3) they are participatory and collaborative, not imposed authoritatively by the clinician; and (4) they are provisional, open-ended, and malleable to newly acquired information and evolution of the patient’s condition.Lewis casts Engel as a philosophical pragmatist who battled the Goliath of biomedical reductionism that had come to dominate American medicine and psychiatry in the latter half of the twentieth century. Unfortunately, however, regardless of how elegantly Lewis reinterprets Engel, he cannot render him a full-blown pragmatist for the medicine and psychiatry of the twenty-first century. Lewis provides quotations to suggest that Engel valued a results-oriented clinical sensibility, for example “the value of a scientific model is measured not by whether it is right or wrong but by how useful it is” (Engel 1980). But Engel was not fully committed to clinical outcome as the supreme judge of theory in medicine and psychiatry. Lewis notes that Engel understood the biopsychosocial model as less “a matter of compassion and humanity” and more a matter of “rigorous application of the principles and practices of science”; he was a man of his time who could not fully escape the scientism of the day. Working within this scientistic world, he distinguished himself by reintroducing psychological, sociological, and humanistic concepts into clinical medicine, which had become obsessed with the power and robustness of the natural sciences but had neglected the suffering human subject and the social context of illness. Engel undoubtedly hoped the biopsychosocial model would lead to better clinical results but, unlike the classical American pragmatists and contemporary pragmatic bioethicists, he did not make a systematic case for privileging clinical outcome above strict adherence to scientific theory.In fact, Engel’s biopsychosocial model runs the risk of becoming a reified end in itself; those who unquestioningly espouse its basic tenets are in danger of... (shrink)

Esmin Green died in 2008, in the waiting room of Kings County Psychiatric Hospital in Brooklyn, New York, awaiting an involuntary stay. This case drew wide media attention because she died neglected and face-down on the floor, and her death was caught on video by the hospital’s own cameras. I use this case as an example of how feminist bioethics can offer a unique perspective on power imbalances within social, political, and institutional aspects of psychiatry. I also argue (...) that because psychiatry is treated structurally and legally as a “special case,” it merits especially heightened scrutiny and study, particularly within feminist bioethics. (shrink)

Michel Foucault defines the modern psychiatric hospital as an institution of power that excludes and disciplines those who are deemed immoral, perverse, or abnormal in society. Rather than a facility for healing, as Foucault has taught us, the psychiatric hospital operates more as a punitive method of the body. But what is not considered in Foucault’s historical account of the psychiatric institution are the epistemological preconditions that allowed for its original formation. Drawing on the Kyoto School (...) philosophers’ critique of modernity, this article will discuss how the biomedical model underlying modern psychiatric care is rooted in a prior epistemological duality that was developed even earlier within Western intellectual history—a duality we will call the “epistemology of nihilism.” Foucault’s political technology of the body is therefore a symptom of the epistemology of nihilism, that which leads to consequences beyond mere panoptical surveillance. This article will discuss such consequences, in particular the mechanization of human life derived from the excesses of scientific technology, in the service of introducing a new way of thinking about the limits of psychiatric treatment in today’s world. (shrink)

Lennard Davis’s Biocultural Critique of the alleged certainty of diagnosis (Davis Journal of Bioethical Inquiry 7:227−235, 2010) makes errors of fact concerning psychiatric diagnostic categories, misunderstands the role of power in the therapeutic relationship, and provides an unsubstantiated and vague alternative to the management of psychological distress via a conceptually outdated model of the relationships between physical and psychological disease and illness. This response demonstrates that diagnostic knowledge vouchsafes legitimate power to physicians, and via them relief to (...) patients who suffer from psychological distress. The history of medicine and psychiatry demonstrates that psychiatric diagnosis shares many features with physical diagnosis, while there is also reason to believe that the two types will continue to be distinct in some respects. Diagnostic categories in psychological medicine, like those in physical medicine, are provisional, probabilistic, and often uncertain. These features do not detract from the dependence on diagnosis of therapeutic efficacy in both domains. (shrink)