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 Fax+41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Accessible online at: http://BioMedNet.com/karger Prof. Dr. H. Kick Schwetzinger-Strasse 28 D–68165 Mannheim (Germany) Tel. +49 0621 444 548, Fax +49 0621 444 941 Downloaded by: University of Missouri-Columbia 128.206.9.138 - 10/26/2017 12:24:38 PM Ó1999 S. Karger AG, Basel 0254–4962/99/0323–0159$17.50/0 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 Psychopathology 1999;32:159–167 Kick Downloaded by: University of Missouri-Columbia 128.206.9.138 - 10/26/2017 12:24:38 PM 160 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 Psychopathology 1999;32:159–167 161 Downloaded by: University of Missouri-Columbia 128.206.9.138 - 10/26/2017 12:24:38 PM 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 Psychopathology 1999;32:159–167 Kick Downloaded by: University of Missouri-Columbia 128.206.9.138 - 10/26/2017 12:24:38 PM 162 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 Psychopathology 1999;32:159–167 163 Downloaded by: University of Missouri-Columbia 128.206.9.138 - 10/26/2017 12:24:38 PM The Ethical Crisis in Psychiatry 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. Psychopathology 1999;32:159–167 Kick Downloaded by: University of Missouri-Columbia 128.206.9.138 - 10/26/2017 12:24:38 PM 164 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 Psychopathology 1999;32:159–167 165 Downloaded by: University of Missouri-Columbia 128.206.9.138 - 10/26/2017 12:24:38 PM The Ethical Crisis in Psychiatry 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]. References 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 166 Kisker KP: Gedanken zur Antipsychiatrie. Psychiatrische Praxis 1974;1:10–17. Kisker KP: Antipsychiatrie (AP); in Kisker KP, Meyer JE, Muller M, Strömgrem E (eds): Psychiatrie der Gegenwart, Berlin, Springer, 1979, vol 2. McHugh PR, Slavney PR: The perspectives of psychiatry. Baltimore, Johns Hopkins University Press, 1983. Glatzel J: Über Antipsychiatrie. Ther Gegenwart 1981;120:109–126. Condrau G: Film und Psychiatrie; in Condrau G (ed): Die Psychologie des 20. Jahrhunderts, Transzendenz, Imagination und Kreativität. Zurich, Kindler, 1979, vol 15. Grün JF: Die Fische und der Wassermann. Hoffnung zwischen Kirche und New Age. Munich, Claudius, 1988. Rosin U, Hammers AJ: Parapsychologie, Okkultismus, Teufelsglauben, Besessenheit, Exorzismus und Wunder; in Condrau G (ed): Die Psychologie des 20. Jahrhunderts. Transzendenz, Imagination und Kreativität. Zurich, Kindler, 1979, vol 15. Cording-Tömmel C: Antipsychiatrie; in Müller C (ed): Lexikon der Psychiatrie. Berlin, Heidelberg, Springer, 1986. Griesinger W: Ueber Behandlung der Geisteskranken und ueber Irrenanstalten; in Griesinger W (ed): Gesammelte Abhandlungen. Berlin, Hirschwald, vol 1, 1872. Beyer B: Antipsychiatrische skizze. Psychiatr Neurol Wochenschr 1909;11:275–278. Beyer B: Die Bestrebungen zur Reform des Irrenwesens. Material zu einem Reichs-Irrengesetz. Für Laien und Ärzte. Halle, Marhold, 1912. von Kunowski: Der Fall Lubecki. Psychiatr Neurol Wochenschr 1908;10:313–320. Lomer G: Ein antipsychiatrisches Zentralorgan. Psychiatr Neurol Wochenschr 1909;11:273–275. Kick H: Antipsychiatrie um 1900. Zur Tradition des Konfliktes zwischen Psychiatrie und Presseberichterstattung. Nervenarzt 1982;53:299–300. Jones M: Towards a classification of the therapeutic community concept. Br J Med Psychol 1959;32: 200. Napolitani F: Die Führung einer psychiatrischen Krankenabteilung mit Hilfe von Patienten anstelle gelernter Pflegekräfte. Referate-Sammlung, 16. Gütersloher Fortbildungswoche, Münster, 1963. Clark DH: Administrative therapy. London, Tavistock, 1964. Racamier PC: Le psychanalyste sans divan. Paris, Payot, 1970. Menninger K: The Vital Balance: The Life Process in Mental Health and Illness. New York, Viking Press, 1963. Horkheimer M: Traditionelle und kritische Theorie. Z Sozialforschung 1937;VI/2:245–294. Laing RD: The Divided Self. London, Tavistock, 1960. Szasz TS: The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York, Harper and Row, 1961. Goffmann E: Asylums: Essay on the Social Situation of Mental Patients and other Inmates. New York, Aldine, 1961. Foucault M: Histoire de la folie à l’âge classique. Paris, Plon, 1961. Cooper D: Psychiatry and Antipsychiatry. London, Tavistock, 1967. Psychopathology 1999;32:159–167 Kick Downloaded by: University of Missouri-Columbia 128.206.9.138 - 10/26/2017 12:24:38 PM 1 2 29 30 31 32 33 34 35 36 37 38 39 40 41 Basaglia F: L’institutio negata. Turin, Einandi, 1968. von Baeyer W, Claessens D, Feger H, Neidhardt F: Das ‘Sozialistische Patientenkolletiv’ in Heidelberg (SPK); in von Baeyer-Katte W (ed): Analysen zum Terrorismus, Gruppenprozesse. Opladen, Westdeutscher Verlag, 1982. Sozialistisches Patientenkollektiv Heidelberg: Aus der Krankheit eine Waffe machen. Munich, 1972. van Praag HM: The scientific foundation of antipsychiatry. Acta Psychiatr Scand 1978;58:113–141. Ey H: L’anti-antipsychiatrie ou les progrès de la science psychiatrique. Evol Psychiatr 1972;37:49–67. Janzarik W: Die Krise der Psychopathologie. Nervenarzt 1976;47:73–80. Saß H: Die Krise der psychiatrischen Diagnostik. Fortschr Neurol Psychiatr 1987;55:355–360. von Gebsattel VE: Die Sinnstruktur der ärztlichen Handlung. Studium generale, Universität Heidelberg 1953;6:461–471. Wieland W: Aporien der praktischen Vernunft. Frankfurt, Vittorio Klostermann, 1989. Gadamer HG: Über die Verborgenheit der Gesundheit. Frankfurt/Main, Suhrkamp, 1993. Schipperges H: Im Gleichgewicht von medizinischer Theorie und ärztlicher Praxis. Festvortrag, 45. Fortbildungstagung für Ärzte, Regensburg 1970. Dewey J: Art as Experience. New York, Capricorn Books, 1980. Jaspers K: Allgemeine Psychopathologie. Berlin, Springer, 1965. Schipperges H: Lebensqualität und Medizin in der Welt von morgen. Passau, Rothe, 1996. Handke P: Langsame Heimkehr. Frankfurt/Main, Suhrkamp, 1979. The Ethical Crisis in Psychiatry Psychopathology 1999;32:159–167 167 Downloaded by: University of Missouri-Columbia 128.206.9.138 - 10/26/2017 12:24:38 PM 27 28
1/--страниц