Paul Schimmel

Swimming against the Tide? A Review of the Therapeutic Community

Objective:The therapeutic community is an established psychiatric treatment method which may be in decline. This paper reviews the nature of inpatient therapeutic community treatment, and re-evaluates its role. Method:The principles and practice of such treatment are summarised, with a focus on the functions of staff. Results:The inpatient therapeutic community is conceptualised as combining socio-therapeutic treatment, psychotherapeutic treatment, and the advantages of the inpatient setting. This unique treatment environment allows for therapeutic regression while mitigating against anti-therapeutic behavioural regression. Research evidence supports the efficacy of therapeutic community treatment for patients with borderline personality disorder. Conclusion:Further research is needed to assess its efficacy for other diagnostic groups. This intensive treatment approach may be most appropriate for patients who have proved treatment resistant by other means. Possible reasons for the marginal-ization of therapeutic community treatment are considered. Access to quality inpatient therapeutic community treatment is essential in the provision of a comprehensive psychiatric service.

Mind Over Matter? I: Philosophical Aspects of the Mind–Brain Problem

Objective: To conceptualize the essence of the mind–body or mind–brain problem as one of metaphysics rather than science, and to propose a formulation of the problem in the context of current scientific knowledge and its limitations. Method and results: The background and conceptual parameters of the mind–body problem are delineated, and the limitations of brain research in formulating a solution identified. The problem is reformulated and stated in terms of two propositions. These constitute a ‘double aspect theory’. Conclusions: The problem appears to arise as a consequence of the conceptual limitations of the human mind, and hence remains essentially a metaphysical one. A ‘double aspect theory’ recognizes the essential unity of mind and brain, while remaining consistent with the dualism inherent in human experience.

The psychotherapeutic management of a patient presenting with brief psychotic episodes

Objective: The aim of this article is to illustrate: (i) the advantages of a psycho-dynamically informed management of patients with a borderline personality organisation who require inpatient treatment; and (ii) the principles of a ‘therapeutic community’ approach in practice. Method: The 18-month residential therapeutic community treatment of a patient presenting with a history of brief psychotic episodes is described. An attempt is made to analyse the relationships between treatment variables and the patients clinical progress over the treatment period. Results: By the end of treatment significant improvement in the patients clinical state had occurred. Evidence is presented to support the conclusion that the treatment was an important factor in this outcome. Conclusions: Clinical management based upon a psychodynamic understanding of the borderline patients presentation is likely to best fit the individual patients needs. Such a treatment approach, as embodied in a well-functioning therapeutic community, may help create the possibility of a ‘new beginning’ for the patient.

Mind Over Matter? II: Implications for Psychiatry

Objective: To explore concepts of causality within the mind and aetiology of psychiatric disorders in the light of the proposed formulation of the mind–brain problem. Method: Taking the two propositions of this formulation as ‘first principles’ a logical analysis is attempted. Results and conclusions: Neural activity cannot in principle be regarded as causing mental activity, or vice versa. Causal processes are most coherently conceptualised in terms of the ‘mind–brain’ system. Determination of causal and aetiological effects will always necessitate consideration of contextual evidence. Because of the ‘explanatory gap’ between explanation in neurophysiological terms and ‘mentalistic’ terms, whenever formulation in mentalistic terms is possible this will carry greater explanatory power; that is, it will carry meaning in the way a neural formulation cannot.

The elephant on the couch: side-effects of psychotherapy

In response to one element of Berk and Parker ’ s paper [1], I would point out that, logically, the sexual exploitation or abuse of a patient cannot be considered a ‘ side-effect ’ , or even an ‘ adverse outcome ’ , of psychotherapeutic treatment, for the obvious reason that the sexual exploitation of patients is not treatment. This applies whether the treatment is psychotherapeutic, psychiatric or medical. By the authors ’ logic the sexual abuse of a patient by a physician could be deemed an ‘ adverse outcome ’ of the pharmacological treatment. In their Discussion the authors allude to the problematic nature of the logic of their argument, suggesting it is ‘ akin to an individual criticizing religion on the basis of disliking their local minister ’ . Despite this they have chosen to ignore their own caution.

Medicine and the manic defence

Objective: The aim of this paper is to explore the relevance of the concept of the manic defence to understanding the treatment behaviours of doctors, and psychiatrists in particular. Method: The manic defence and manic reparation are defined. Treatment approaches by doctors in physical and psychiatric medicine are examined within the perspective offered by these concepts. Results: Evidence for the operation of a manic defence can often be discerned in treatment approaches to psychological and psychosomatic disorders. Widespread reliance on the prescribing of antidepressant medication for depression provides an example. Conclusions: In the face of psychological and psychosomatic presentations, doctors may resort to reductionist aetiological formulations which promote active but reductionist treatments. Such approaches represent the enactment of a manic defence against depressive anxieties that might otherwise be experienced by patient and/or practitioner.

Book Review: Psychotherapy of Psychosis

Chris Mace and Frank Margison (eds) Melbourne: Blackwell Science Asia, 1997 ISBN 0 88048 579 5 pp.283

Psychotherapy of psychosis

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Book Review: Hidden Faults: Recognizing and Resolving Therapeutic Disjunctions:

Chris Mace and Frank Margison (eds) Melbourne: Blackwell Science Asia, 1997 ISBN 0 88048 579 5 pp.283

Response to book review: The fall of an icon: psychoanalysis and academic psychiatry (2)

90.00