Leston Havens

Historical perspectives on diagnosis in psychiatry

Abstract Three sources of the instability of psychiatric diagnostic systems are suggested: the effects of new knowledge in psychiatry, the sectarianism of the field, and differing basic approaches to diagnosis. A view of the historical place of DSM-III is presented.

The development of existential psychiatry.

The contributions of Jaspers, Minkowski, and Binswanger to the development of existential psychiatry, using their own case material and stressing the gradual refinement of the existential clinical method, are described. Jaspers extended the objective-descriptive schools interest in accounts of the patient as viewed from outside to include the patients own view of his experience from within (phenomenology). Minkowski enlarged these accounts from within by literally moving in with the patients and then not withdrawing either physically or through intellectual formulations. The result was a series of emotional explosions or confrontations between the doctor and patient out of which came change in both. Binswanger carried forward still further this technique of being and staying with the patients, especially through analysis of the intellectual obstructions to contact (the need for a “phenomenological reduction”) and of the empathic experience itself. Thus the existential method came to stress an area of observation (inner experience), the phenomenological reduction, being and staying with the patient, confrontation, and empathy. Existential empathy is an empathy with the sick or dissociated parts of the personality which becomes possible only when the conventional idea of sickness is given up. The paper contrasts the existential method with the methods of objective- descriptive psychiatry, psychoanalysis, and interpersonal psychiatry.

The Best Kept Secret: How to Form an Effective Alliance

The strength of the therapeutic alliance is robustly related to treatment outcomes.1–3 The alliance itself has identifiable components and can be easily taught. Its construction also includes features that are part of the treatment. It should not be relegated to placebo status or to nonspecific effects. Its effects are very specific indeed. Nor does an effective alliance have to wait upon the gradual emergence, as in classical analysis, of a positive or unobjectionable transference. Alliance formation is the first order of clinical business whenever the purpose is not largely investigative. The present paper details systematic operations for alliance formation, within workable time constraints. Plainly, specific means of alliance formation need to be taught and practiced whatever the particular treatment method. The first goal is for the clinician to find the patient, and the patient to find the clinician, as both are required for a real alliance. The second is dealing with differences between patient and clinician.

A New Approach to the Study of Psychogenic Disturbances

Abstract Psychiatry suffers from many misunderstandings and from some of its own excursions into various schools of thought. It needs to become as realistic and meaningful as possible in terms of the doctors grasp of the inner experience of the patient. Also, a resourceful, resilient, multifaceted approach is sought after by many. Toward these goals a realistic encounter with the primary material of human nature in its many vagaries has been designed through a specially developed use of dramatic works. As background for this, an integrated approach was used to assess the contribution of each school of thought to the development of psychiatry and its present-day potential.

Two views of a delusion.

Mr. P. is a 30-year-old married white man who has been referred for psychopharmacological treatment of paranoid ideation involving his wife’s family. His symptoms have developed over the past 3 years. Five years ago, after ending a 4-year relationship, Mr. P. became romantically involved with both his future wife, Molly, and a woman who worked in his office. Within a year he ended the relationship with the second woman, and because of the subsequent tension at work he found another job. Although he was never sexually involved with the second woman, he nonetheless felt guilty about having dated two women at the same time. Mr. P initially denied the other relationship to Molly but eventually told her about the liaison. She forgave him at the time, but he has never been able to free himself completely of guilty feelings. One year later, Mr. P. changed jobs again and began work-