000029083

Psychopathology 1999;32:159–167
The Ethical Crisis in Psychiatry:
Consequences for a Comprehensive
Diagnosis and Therapeutic Practice
H. Kick
Psychiatrische Klinik der Universität Heidelberg, Germany
Abstract
Whereas antipsychiatry left the medical concept of disease and medical institutions intact at the turn of the century, this sector was fiercely called into question
in the subsequent reform efforts. The disclosure that an argumentation in terms
of pure, exact science was questionable encouraged these reform efforts and
cast doubt on the objectivism dominant at that time. However, in the clinical
domain, it also led to a profound crisis of legitimation and thus to a crisis in
psychiatry’s ethical self-conception. The absence of an integrative perspective
comprising clinical theory and practice became obvious. In the future, the basic
anthropological preconditions involved in a given clinical situation may serve as a
guideline.
Introduction
In any critical analysis of the present situation in psychiatry, in addition to
current empirical data, historical aspects always need to be taken into account.
In other words, one has to search for clinically realistic and ethically justifiable
patterns of action and interpretation in the constantly produced flow of nominalistic information. The historical approach chosen here thus draws on the history
of antipsychiatry as a paradigm; in other words, the historical approach is not
to be understood merely as an example, but rather as a way of throwing light
on current problems. Taking the methodical examination of the sources as a
starting point, this approach aims to critically review and hence understand
these sources in the context of their own period. Only then can these results be
interpreted within the framework of modern psychiatry. We are thus concerned
with analysing the historical paradigm in order to gain insight that may be
relevant for current psychiatric thought and for psychiatric ethics. Antipsychiatry
was chosen as a historical paradigm because its theories still present a basic
challenge even today; moreover, the lack of answers in this field is not only leading
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to an open crisis, but also draws attention to the existence of doubts in the way
psychiatry sees itself and in the identity of the psychiatrist.
Contemporary Tendencies of Antipsychiatry
The waves caused by the antipsychiatric movement, which reached its zenith
in terms of public and political relevance in the 1960s and 1970s, have long since
died down. This might lend support to the opinion that antipsychiatry – having
grown from a unique historical constellation – has become irrelevant with the
decline of the social and political factors and the science theory that supported
it. The concept of antipsychiatry is very imprecise [1–3]. By analogy to the many
‘antis’ in current use, such as anti-art and anti-theatre, one could of course imagine
that it simply indicates an antithesis of established psychiatry. It is certainly more
than a pompous side-show, as McHugh and Slavney [4] once referred to it, but
is it really the avant-garde of a new spiritualistic psychiatry [5]?
The image presented by the media suggests that antipsychiatric thought,
continually being formed anew in subcultures, still influences public opinion [6].
In this context, it should be noted that calmer times offer us the opportunity to
consider the challenges and questions posed by antipsychiatry more successfully.
Those disappointed by clinical psychiatry still gather in different religious, political
and philosophical groups. The scepticism felt towards established clinical medicine
has become evident in the considerable attraction that alternative forms of therapy
hold. It is worth mentioning that this scepticism can be traced back – not only
in psychiatry, but in medicine in general – to two fundamentally different attitudes:
to a more mystic, spiritualistic attitude on the one hand and to an enlightened,
socially critical one on the other. Finally, a very explosive mixture of the two
positions can also be found. In this context, the therapeutic approaches cultivated
in connection with the so-called New Age movement should also be mentioned,
approaches that constitute a form of protest not only against the model of mental
disease, but against the clinical model in general. These approaches are often
based on more or less superficially assimilated and simplified components of Far
Eastern philosophies, which allegedly regard disease merely as a basic requirement
for an individual’s spiritual development and completely deny the aspect of
deficiency implied by the reality of disease [7, 8].
Antipsychiatry is a special form of criticism levelled at psychiatry and encompasses two partly contradictory components. Firstly, the reality of mental disease
is called into question, and secondly, it is maintained that mental disease is not
adequately treated in medical institutions, but is actually caused by them.
Historical Predecessors of Antipsychiatry
Historically, antipsychiatry developed either on the basis of empirical arguments, as clearly illustrated by the example of Germany at the end of the nineteenth
century [9], or on the basis of a more theoretical approach. An antipsychiatry
fostered by Romantic theories has existed ever since new psychiatric institutions
were founded after the French Revolution, institutions that were associated with
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a highly rational formulation of the clinical concept of disease. However, the fact
that the mentally ill had acquired a definable status by being granted the same
rights as those with somatic illnesses was generally regarded as progress, a position
maintained by Griesinger [10], among others. In contrast to the previous Romantic
antipsychiatric movements, subsequent antipsychiatric movements up to the First
World War were based on rationally and empirically founded criticism levelled
at institutions [11–14]. The medical concept of disease and the way in which the
physician’s professional role and the institution’s function were regarded were
not seriously questioned [15].
Reform movements that began to have effect within psychiatric institutions in
Great Britain and North America after 1950 were essentially based on a form of
psychoanalysis with a socially critical slant. According to the concepts presented
by Jones [16], Napolitani [17], Clark [18] and Racamier [19], ideas of abolishing what
was referred to as the traditional, dyadic and asymmetrical relationship between the
physician and the patient temporarily dominated the scene; this trend was associated with ideas of putting an end to the objectifying way of viewing the patient and
hence of abandoning the apersonal model of disease [20].
The ideas of ‘critical theory’, founded in the 1930s by Max Horkheimer [20]
during his exile in Paris and further developed by the Frankfurt School, greatly
influenced psychiatric institutions in the 1950s and 1960s. The main objective of
the Frankfurt School was to make clear the interests behind scientific discovery.
This approach made inroads into psychiatric institutions, and the repercussions
were enormous since psychiatric institutions at that time were often restricted to
one-sided objectivistic patterns. Nevertheless, doubts had increasingly begun to be
raised within the institutions themselves, whether or not they were open to criticism.
The Challenge of Antipsychiatry
With the publication of Laing’s The Divided Self [22], Thomas Szasz’ The
Myth of Mental Illness [23], Goffmann’s Asylums [24] and Foucault’s Histoire de
la folie [25], all of which appeared around 1960, the tensions outlined above
regarding the traditional clinical concept of disease and psychiatric institutions
took on a new quality. The theoretical criticism referred back to the concept of
psychosis and in particular to the concept of schizophrenia; the conclusions
drawn are well known and were critical of both society and institutions. Psychopathology was regarded as an instrument of social repression of the individual
and as representing conventional values designed to stabilize the political system
of the bourgeoisie. The negation of the concept of disease led to a profound crisis
in the way physicians saw themselves, their role up to then being fundamentally
linked to diagnosis, indications and responsible and justifiable medical intervention. For those psychiatrists who had already clearly recognized the deficiencies
or non-viability of an approach based solely on an exact, objectifying science as
the source of legitimation for medical action, it was particularly difficult to find
an appropriate response to the challenges posed by antipsychiatry.
In Psychiatry and Antipsychiatry, published in 1967, Cooper [26] noted that
the central issue would be the problem of violence. However, an interesting
motif concerning interpretation appeared in Cooper’s work. He tried to give an
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The Ethical Crisis in Psychiatry
existential meaning to the psychotic crisis that went beyond a purely sociopsychogenetic interpretation: ‘Therapeusis in this context’, he explained, ‘means revival
through death and rebirth’. The mystic, spiritualistic glorification of the soul’s
pathos was followed by Basaglia’s [27] materialistic and socially critical attempt
in Italy to interpret psychoses, which were denied the characteristics of illness
and attributed an element of political protest. The concept outlining the crucial
steps for liberating the patient was presented by Basaglia in 1968 in his work
The Negated Institution [27]. According to Basaglia, psychiatry belongs to the
institution of violence through which the postcapitalist system guarantees its
stability. The organizational principle of the institution, according to Basaglia,
is a strictly maintained separation between the group of the powerful (the institution and its administrators, the doctors) and the group of the powerless (the
patients). Comparable to the socialist patient collectives in Heidelberg, which
resulted from the student protest movement of the 1960s and which declared
patients to be part of the revolutionary masses, Basaglia saw in this dichotomy
the consequence that the present institutional structures could not be reformed,
but had to be destroyed [28, 29]. However, such arguments from the repertoire of
dialectic materialism basically serve as a pretext. More important is the subjective
evidence that has been obtained from practical psychiatric experience, evidence
which takes shape in attributing sense and meaning to the psychosis by means
of the above-mentioned protest motif in an absolute and generalized manner.
This was intended as a protest against a society which was considered to be the
cause of mental illness.
The antipsychiatrists mentioned thus far showed no recognizable interest in
any real discussion about traditional clinical positions, and in fact, these positions
have never been as monolithic as antipsychiatry portrayed them. Clinical psychiatry for its part took up the controversy on a practical level by pushing ahead
with the beginnings of reform in social psychiatry, inspired by the anthropological
psychiatry of the 1950s. Notably absent at the beginning was any reflection on
the antipsychiatric criticism from a viewpoint that encompassed both clinical
theory and practice. This is also true of the careful, empirically analytical argumentation as found in the work of van Praag [30]. As such, it is a typical example
of a defensive retreat to what was presumed to be a maintainable, purely scientific
position. The provocations of antipsychiatry explicitly tended to question the
legitimacy of psychiatric institutions and the associated problem of violence as
well as the legitimacy of the professional role of the physician and the associated
problem of intervention. Existential problems of sense and meaning, which should
be taken seriously, implicitly formed the backdrop for the protest made by antipsychiatry – firstly, what is the rationale of medical action, and secondly, what sense
and meaning should be attributed to mental illness – issues which had obviously
not been adequately considered by established psychiatry.
The Crisis in the Self-Conception of Psychiatry
The implicit challenges of antipsychiatry converge at the point of how the
relationship between the physician, the patient and the disease is to be determined
within a psychiatric institution and within psychiatry as a whole. As a consequence
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of the claims made by antipsychiatry, any therapeutic intervention could be
declared an unjustified manipulation. It is important to note that in the concomitant crisis in the self-conception of psychiatry, it became increasingly evident that
an absolute, objectifying viewpoint was not adequate to fulfill satisfactorily the
requirements of the physician’s medical role. It was all too apparent that objective
knowledge of nature, particularly since being confronted with the limits of what
can be understood scientifically, increased the danger of indifference and perplexity, thus leading to the failure of the therapeutic intention (crisis of the clinical
model of disease).
If we pause to look back for a moment, the following becomes clear: when
the provocative approaches of critical theory became practically relevant as of
1950, the reforms, which now one-sidedly place emphasis on the subjective factor,
appeared to be the realization of a long overdue ‘humanization’ of the relationship
between the physician and the patient; a subjective approach which could prevent
such excesses and was to do so in the future [31, 32]. However, with the idea
of a symmetrical relationship between the physician and the patient and the
suppression of the objectifying way of regarding the patient, subjectivity came
into play; in other words, the one-sidedly objectivistic viewpoint was replaced
by an equally one-sided subjective one. Thus, a medical diagnosis based on
psychopathological signs and symptoms, and with it a disease model of psychosis,
could no longer be maintained [33]. Moreover, the danger that the subjective
one-sidedness favoured the dissolution of the structures of responsibility was
obvious, making it more difficult, if not impossible, for the physician to act
appropriately.
It seems that neither the subjective nor the objective level alone can meet
the legitimation requirements of medical recognition and action. Nonetheless,
neither aspect can be abandoned, as they are both components that determine
the relationship between the physician, the patient and the disease. Psychiatrists
are now faced with a difficult range of integrative tasks. A guideline for the
balancing act required can only be found in the basic anthropological preconditions involved in a given clinical situation. Comments of fundamental importance
were made by von Gebsattel [34] as early as 1953, but were unfortunately long
ignored by the scientific community as a whole. The physician and the patient
are confronted with one another in three different ways. The first level mentioned
by von Gebsattel is the elementary level of encounter; this is the level on which
contact is established between the therapist and the patient. At the same time,
it is the level of encounter on which an elementary empathy on the part of the
physician should converge with the patient’s subjectivity and suffering. The second
level is concerned with medical examination and diagnosis and in psychiatry
includes the operationalized methodology of clinical psychopathology. This distancing, objectifying level is indispensable for the diagnostic process, and diagnosis
in turn is indispensable for determining medical intervention. The first two levels
must, however, be justified on a third level of encounter, namely that of the
partnership between the physician and the patient.
One of the main tasks of medicine and of medical ethics is to establish,
explain and justify which level of sense and meaning is relevant at a particular
moment and to draw ethical and practical conclusions from this. As a result of
our historical analysis, it can be stated that, in the crisis of self-conception, both
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the structure of the diagnostic and therapeutic setting and, above all, the central
ideas and criteria by which the relevant level of sense and meaning could be
established were unclear.
This explicitly raises the question of our concept of human beings and with
that of a medical anthropology that defines values and guides action. Two main
questions need to be distinguished and answered: the first concerns illness and
health, and the second the ill and the healthy individual as a person. Thus, it is
necessary to make clear and to justify how health and mental illness are dealt
with in a professional setting. This can only be done in a satisfactory manner by
distinguishing between the different levels of sense and meaning in the therapeutic
situation and by establishing how they interconnect, when which level is relevant
and how personal encounters can be kept open and made possible under the
more difficult conditions created by the disease process. For clinical practice, this
means that, on the basis of their professional, ethical/moral and communicative
competence, psychiatrists have to decide which level of sense and meaning (subjective, objective or personal) is relevant at any given moment of a particular situation. In this context, not only do medical and empirical results have to be taken
into consideration, but moral and legal norms also have to be followed. Here,
we are referred back to Kant’s concept of the application of generalized empirical
and moral rules in a special situation. More recently (in 1989), Wieland [35]
addressed this problem again, which he analyzed and termed the ‘application
aporia’ of the therapeutic situation.
In order to guarantee the competence to make judgements and to take
decisions both in theory and in practice, a competence that is necessary from
both a moral and a legal viewpoint in order to ‘humanize’ clinical psychiatry,
we need to consider ethical attitudes, which are easiest to justify and clarify on
the basis of an integrative anthropological conception. If dogmatizing norms are
kept out of the anthropological dimension, the question of the values to be
realized in the concrete setting arises each time in a different way. Thus, it becomes
possible to learn to live with the ‘aporias of practical reason’ that are inevitable
in any practical science and to act in a more humane manner [36]. Conversely,
due to the existence of these very ‘aporias’, modern medicine also constantly
requires a self-critical ‘theory that can justify itself by becoming obvious in
practice’ [37].
The tension that thus arises gives concrete form to the therapeutic setting
of encounter and action and poses the question of ethical guidelines that include
standards for the correct degree of distance and intimacy. In the personal encounter between the patient and the therapist, the main concern is to bridge the gap
between subjective and objective phenomena in a joint effort [38] and at the same
time to mediate between sensory aspects and abstract science. The result of such
mediation is not the definite or theoretical solution of the above-mentioned
‘aporias’, but rather a concrete therapeutic practice inasmuch as this mediation
is always more than merely recognizing and understanding the individual and
the situation under the particular circumstances of a given disease process; in
addition, it always represents a creative complement to the given situation and
thus an answer that defines new values.
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Conclusion
Finally, we come to the question of whether there is a way to implement
these fundamental claims in practice. Is it actually possible to provide directives
for action, or do the desired solutions go beyond the possibilities offered by a
professionalized and institutionalized science of healing? It is true that only within
the framework of institutional structures can modes of existence be developed
and legal rules and regulations be laid down through which not only the tradition
of theory and practice would be possible, but through which, according to Jaspers
[39], the dangers threatening medical structures could also be averted. However,
institutional structures cannot guarantee the realization of the medical task. For
this, it is necessary to transcend the institutional structures and professional
patterns, opening up the possibility of personal synthesis. There are two requirements for this, one directed at the institution and the other at representatives of the
medical profession. Institutions cannot be adequately described by sociological
concepts; they embody central ideas or existential propositions. The central idea
of the clinical institution can only be that of forming a framework in which to
fulfill the entire medical mandate, including the integration of the three levels of
medical recognition and action cited above.
The situation becomes even more complicated in that a rational analysis
shows first of all that the clinical, therapeutic setting is embedded in a comprehensive and complex situation involving peripheral factors, i.e. the social context.
Secondly, it is crucial to recognize that ethics must be maintained in both areas.
Thirdly, however closely connected the areas are, responsibilities are arranged
differently and subtle differentations need to be made. However, this raises the
question of ethics concerning the important ‘peripheral’ factors of this particular
diagnostic and therapeutic setting. The more precisely this diagnostic and therapeutic setting is defined, the more obvious the particular circumstances of the
social periphery and the ethical challenges inherent to this context become. The
difficult issue of how profitability and humanity can be reconciled in one and
the same system has yet to be resolved. Even the criteria concerning the quality
of life are not constants, especially in a society undergoing massive restructuring
of values. A sensitive approach towards carefully weighing up the available resources also calls for stable foundations that cannot be obtained from an argumentation based solely on scientific considerations. In terms of social ethics, the
reference system from which the criteria concerning the quality of life are developed has to be considered, which in turn raises the question of the antropological concept on which our values are based. The criteria thus developed should,
however, be coordinated, kept open and at all events put in the context of their
interaction with the therapeutic situation. The crisis of values and the search for
new values in the therapeutic setting thus makes a decisive contribution to the
concepts of the ‘objective of a life culture’ [40]. We are referring here to regulatory
concepts which naturally also include the ecological dimension. The contribution
psychiatry can make is to take into consideration the complexity of the clinical
situation and the three levels of sense and meaning, as outlined above, to arrive
at a comprehensive diagnosis that is properly able to make this contribution.
In order to avoid serious dangers, which are historically undeniable, it is of
basic importance not to lose sight of the three different levels in the relationship
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between the physician, the patient and the disease in the context of this very
particular medical setting, i.e. the elementary level of encounter, the distancing,
objectifying level and finally the personal level of encounter on which the subjectivity of the physician in the sense of a unified creative activity meets with that of
the patient. These levels of encounter together are most likely to achieve a result
that is integral, sense creating and opposed to ideologies, something that antipsychiatry also endeavoured to achieve; in this context, disease is regarded as a
challenge and the solution is embodied in successful therapy. In this sense, therapy
is no more and no less than the search for a form that is both true and liveable
[41].
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