Tania Gergel

Medicine and the individual: is phenomenology the answer?

The issue of how to incorporate the individuals first-hand experience of illness into broader medical understanding is a major question in medical theory and practice. In a philosophical context, phenomenology, with its emphasis on the subjects perception of phenomena as the basis for knowledge and its questioning of naturalism, seems an obvious candidate for addressing these issues. This is a review of current phenomenological approaches to medicine, looking at what has motivated this philosophical approach, the main problems it faces and suggesting how it might become a useful philosophical tool within medicine, with its own individual, but interrelated, contribution to make to current medical debates. After the general background, there is a brief summary of phenomenological ideas and their current usage in a medical context. Next is a critique of four key claims within current phenomenological medical works, concerning both the role phenomenology plays and the supposedly clear divide between phenomenology and other approaches. There are significant problems within these claims, largely because they overlook the complexity of the questions they consider. Finally, there is some more in-depth examination of phenomenology itself and the true complexity of phenomenological debate concerning subjectivity. The aim is to show that it will be both more productive and truer to phenomenology itself, if we use phenomenology as a philosophical method for explicating and gaining deeper understanding of complex and fundamental problems, which are central to medicine, rather than as providing simple, but flawed solutions.

Illness perception, time perception and phenomenology – an extended response to Borrett

Borrett joins other phenomenologists in using phenomenological ideas on temporality to explain how illness affects the individuals experience of time. Unlike others, he attempts to synthesize this use of phenomenology with a biomedical understanding of the relation between time and illness. My paper expands on Borretts ideas by reviewing current medical scholarship on time and illness perception, including Heideggers ideas on temporality. The first section considers questions and suggestions emerging from contemporary medicine. After a short review of theories of time perception, I describe and critique how Borrett and others use phenomenological temporality in a medical context. My conclusion suggests how Heideggerian temporality might help with the questions and recommendations emerging within diverse medical fields.

Fluctuating capacity and advance decision-making in Bipolar Affective Disorder — Self-binding directives and self-determination

For people with Bipolar Affective Disorder, a self-binding (advance) directive (SBD), by which they commit themselves to treatment during future episodes of mania, even if unwilling, can seem the most rational way to deal with an imperfect predicament. Knowing that mania will almost certainly cause enormous damage to themselves, their preferred solution may well be to allow trusted others to enforce treatment and constraint, traumatic though this may be. No adequate provision exists for drafting a truly effective SBD and efforts to establish such provision are hampered by very valid, but also paralysing ethical, clinical and legal concerns. Effectively, the autonomy and rights of people with bipolar are being ‘protected’ through being denied an opportunity to protect themselves. From a standpoint firmly rooted in the clinical context and experience of mania, this article argues that an SBD, based on a patient-centred evaluation of capacity to make treatment decisions (DMC-T) and grounded within the clinician–patient relationship, could represent a legitimate and ethically coherent form of self-determination. After setting out background information on fluctuating capacity, mania and advance directives, this article proposes a framework for constructing such an SBD, and considers common objections, possible solutions and suggestions for future research.

Too similar, too different: the paradoxical dualism of psychiatric stigma

Challenges to psychiatric stigma fall between a rock and a hard place. Decreasing one prejudice may inadvertently increase another. Emphasising similarities between mental illness and ‘ordinary’ experience to escape the fear-related prejudices associated with the imagined ‘otherness’ of persons with mental illness risks conclusions that mental illness indicates moral weakness and the loss of any benefits of a medical model. An emphasis on illness and difference from normal experience risks a response of fear of the alien. Thus, a ‘likeness-based’ and ‘unlikeness-based’ conception of psychiatric stigma can lead to prejudices stemming from paradoxically opposing assumptions about mental illness. This may create a troubling impasse for anti-stigma campaigns.

Psychosis and identity: Alteration or loss?

The onset of psychotic disorders often brings major changes to an individual, which, for some, are never fully reversed and remain a dominant force. Despite such changes, the individual still experiences themselves as a continuous person and must find some way to assimilate these shifts into their self-concept. From a philosophical perspective, the various models of continuing identity all depend upon some notion of fundamental stability, which seems a poor fit for the trajectory associated with psychotic disorders. This article will explore, in more depth, how the transitions that accompany psychotic disorders present a challenge to conventional and philosophical notions of selfhood. If we are not simply to judge psychotic disorders as bringing about a loss of selfhood, we will need an alternative model of identity to use in this context.

Paternalism and factitious disorder: medical treatment in illness deception

The primary aims are to consider whether a range of paternalistic medical interventions can be justified in the treatment of factitious disorder (FD) and to show that the particularities of FD and its management make it an ideal phenomenon to highlight the difficulties of balancing respect for self-determination, responsibility and duty of care in psychiatry. FD is usually classified as a mental disorder involving deliberate and hidden feigning or inducement of illness, in order to achieve patient status. Both the nature of the disorder and the approach to treatment are controversial and under-researched. It is argued that FD should be classified as a mental disorder; may well expose the patient to extreme risk; can warrant paternalistic interventions, in order to fulfil duty of care. Moreover, treatment of FD is inherently paternalistic and therefore raises interesting questions about justifications and type of paternalistic interventions in psychiatry both for FD and in general. A brief account of key questions concerning psychiatry and paternalism is followed by some case histories of FD, the clinical dilemmas posed and the question of how this disorder might warrant paternalistic interventions. In order to answer this question, two things are considered: the legitimacy and character of FD as a mental disorder; possible frameworks for and types of paternalistic interventions. To conclude, it is argued that there are no compelling reasons for rejecting the use of paternalistic interventions for FD, but that further investigation of FD and type and frameworks for psychiatric paternalism, in relation to FD and other mental disorders, are urgently needed.

Unwell in hospital but not incapable: cross- sectional study on the dissociation of decision- making capacity for treatment and research in in-patients with schizophrenia and related psychoses.

Background Consent to research with decision-making capacity for research (DMC-R) is normally a requirement for study participation. Although the symptoms of schizophrenia and related psychoses are known to affect decision-making capacity for treatment (DMC-T), we know little about their effect on DMC-R. Aims We aimed to determine if DMC-R differs from DMC-T in proportion and associated symptoms in an in-patient sample of people with schizophrenia and related psychoses. Method Cross-sectional study of psychiatric in-patients admitted for assessment and/or treatment of schizophrenia and related psychoses. We measured DMC-R and DMC-T using ‘expert judgement’ clinical assessment guided by the MacArthur Competence Assessment Tool for Clinical Research, the MacArthur Competence Assessment Tool for Treatment and the legal framework of the Mental Capacity Act (2005), in addition to symptoms of psychosis. Results There were 84 participants in the study. Half the participants had DMC-R (51%, 95% CI 40–62%) and a third had DMC-T (31%, 95% CI 21–43%) and this difference was statistically significant (P < 0.01). Thought disorder was most associated with lacking DMC-R (odds ratio 5.72, 95% CI 2.01–16.31, P = 0.001), whereas lack of insight was most associated with lacking DMC-T (odds ratio 26.34, 95% CI 3.60–192.66, P = 0.001). With the exception of improved education status and better DMC-R, there was no effect of sociodemographic variables on either DMC-R or DMC-T. Conclusions We have shown that even when severely unwell, people with schizophrenia and related psychoses in in-patient settings commonly retain DMC-R despite lacking DMC-T. Furthermore, different symptoms have different effects on decision-making abilities for different decisions. We should not view in-patient psychiatric settings as a research ‘no-go area’ and, where appropriate, should recruit in these settings. Declaration of interest None.

Diversity or disarray? A systematic review of decision-making capacity for treatment and research in schizophrenia and other non-affective psychoses.

BACKGROUND Valid consent for treatment or research participation requires that an individual has decision-making capacity (DMC), which is the ability to make a specific decision. There is evidence that the psychopathology of schizophrenia can compromise DMC. The objective of this review was to examine the presence or absence of DMC in schizophrenia and the socio-demographic/psychopathological factors associated. METHODS We searched three databases Embase, Ovid MEDLINE(R), and PsycINFO for studies reporting data on the proportion of DMC for treatment and research (DMC-T and DMC-R), and/or socio-demographic/psychopathological associations with ability to make such decisions, in people with schizophrenia and related illnesses. RESULTS A total of 40 studies were identified. While high levels of heterogeneity limited direct comparison, meta-analysis of inpatient data showed that DMC-T was present in 48% of people. Insight was strongly associated with DMC-T. Neurocognitive deficits were strongly associated with lack of DMC-R and to a lesser extent DMC-T. With the exception of years of education, there was no evidence for an association with socio-demographic factors. CONCLUSIONS Insight and neurocognitive deficits are most closely associated with DMC in schizophrenia. The lack of an association with socio-demographic factors dispels common misperceptions regarding DMC and characteristics such as age. Although our results reveal a wide spectrum of DMC-T and DMC-R in schizophrenia, this could be partly due to the complexity of the DMC construct and the heterogeneity of existing studies. To facilitate systematic review research, there is a need for improvement within research study design and increased consistency of concepts and tools.

Interdisciplinary workshop on “mental disorder and self over time”

Visiting Senior Research Fellow, Department of Philosophy, Kings College London, London, UK Senior Lecturer, Centre of Medical Law and Ethics, Dickson Poon School of Law, Kings College London, London, UK Wellcome Trust Senior Research Fellow, Mental Health, Ethics and Law research group, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK

Maudsley Reader in Phenomenological Psychiatry by Mathew R. Broome, Robert Harland, Gareth S. Owen, and Argyris Stringaris

In order to make sense of the diagnostic, ethical and practical challenges of clinical psychiatry, the psychiatrist must try, to a certain extent, to enter the experiential universe of the patient. The texts in this invaluable collection, which by and large predate the psychopharmacological revolution, offer a way into this world rarely found in contemporary psychiatry, with its emphasis on checklists and ‘‘drugs for symptoms’’. The Reader brings together excerpts from major figures in the development of both general and psychiatric phenomenology. Part I presents key philosophical thinkers and ideas which influenced the early development of phenomenological psychiatry. This is followed by extracts from Jaspers, Minkowski and Binswanger, outlining their varied approaches to phenomenology within psychiatry. Finally, Part III, ‘‘Phenomenologies of mental disorder’’, includes a range of writings in which these diverse approaches are applied to the observation of particular conditions. Many of these texts are rare, with some translated here into English for the first time. Nevertheless, in a relatively short space, they encapsulate central features of the experience of these illnesses, which could be extremely valuable, not simply for diagnosis but for the process of managing and, hopefully, negotiating with the affected individual, to find treatments, which can somehow be acceptable within their current framework. One of the most interesting aspects of the Reader is how clearly it shows the long unacknowledged plurality of ideas within the phenomenological tradition. Indeed, the editors themselves name this as ‘‘perhaps the most important discovery’’. Alongside the more familiar Jasperian approach, the most exciting sections may well be the lesser known texts which bring us, for example, the existential and structural approaches of Binswanger and Minkowski. While phenomenology is often presented in a medical context in terms which are far too simple and homogeneous, the Reader does justice to its true richness, diversity and complexity, and the manifold ways in which it can be applied. Perhaps, the strongest argument for the value of the Reader lies in the texts contained within Part III themselves, whatever their particular theoretical underpinning. For example, Binswanger’s piece ‘‘On the manic mode of being-in-the-world’’ exhibits a complex sensitivity to important, but seldom discussed, aspects of mania, such as the attendant claustrophobia, or its possible inextricability from the darker experiences of the mixed states, both of which are highly relevant to treatment and risk. Even if Schneider’s terminology of ‘‘reactive’’ and ‘‘endogenous’’ depression is outmoded, his complex process of differentiation between different manifestations of depression would be particularly pertinent to current debates surrounding what is often perceived to be the excessive pathologisation of ‘‘ordinary’’ emotions. For the question of whether psychosis can be situated on a continuum with non-pathological experience, Blankenburg’s ‘‘abnormal significant experience’’ should be of great interest. In general, in the accounts of schizophrenia, we find a depth of interest and detail in the structure of individual experiences of delusion unusual within today’s pharmacological agenda. Yet, even if clinical emphasis remains on reduction of psychosis, some extended degree of insight into the thought-world of patients, which such accounts can provide, must surely be of benefit to all involved. Clinicians may well be sceptical about bringing philosophy into psychiatry, questioning its relevance or fearing that it is being introduced purely in order to question and undermine existing clinical orthodoxies. It is true that, in a medical context, phenomenology is often presented polemically, as a radical alternative approach to what is seen as the dehumanising reductionism of conventional biomedicine. Indeed, as a branch of philosophy, it is undeniable that phenomenology was hugely influential on later postmodernist thinkers such as Foucault, who played such a key role in the evolution of antipsychiatry. However, within the phenomenological texts of the Reader, we find medical reductionism presented as a necessary aspect of psychiatry, which works together with phenomenological observation. For the authors whose works are cited within the Reader and for the editors themselves, phenomenology is not viewed as an alternative to more biomedically orientated psychiatric practices, but an approach which can augment these practices by expanding understanding of the patients’ experiences. The Reader is deserving of wide readership among all those with an interest in mental disorder: a tool to enhance, rather than undermine current psychiatric practices. In the words of Binswanger himself, although reductionist accounts of organic function remain an indispensable part of clinical psychiatry, ‘‘psychopathology would be digging its own grave were it not always striving to test is concepts of functions against the phenomenal contents to which these concepts are applied and to enrich and deepen them through the latter’’.