Wednesday, May 20, 2009

Moral Treatment and the Personality Disorders

A few comments on one article of particular interest to me, "Moral Treatment and the
Personality Disorders" by Louis Charland in The Philosophy of Psychiatry: A Companion, Jennifer Radden [3d], [Oxford Universit Press, 2004] [pp64-77].
I became interested in Charland because of what he has written about Philippe Pinel, whose work I have been researching for a few years. His thoughts about Personality Disorders are of more general interest. His argument is that Cluster B personality disorders [Anti-social, and Borderline] are not medical kinds but what he calls interactive kinds and should not be within the purview of medicine. His argument is that the treatment of Axis I disorders as well as Cluster A and Cluster C disorders do not require "the sort of moral willingness and effort required by
Cluster B disorders." While "the dependent individual," he notes, "may annoy others … [he/she] does not necessarily intend to annoy them for the sake of it." Charland suggests that people with Cluster B disorders do intend the annoying [harmful] effects they have on others and therefore require a moral treatment, not a medical one, that will help them to intend otherwise. I find his distinction between moral and medical treatments unsatisfactory, to say the least. My own experience with people with Antisocial and Borderline diagnoses is that they like people with any disease, pursue treatment [if we must use that term] to diminish their own personal suffering and not to be be better people [more thoughtful of others feelings]]. The threat of jail is modestly good "treatment" for some people with an Antisocial diagnosis and when Borderlines benefit from treatments [like DBT], it is because help them feel better. It seems to me that the whole
discussion of "kinds" is as misguided when it is pursued by critics of psychiatry like Charland, as it is when it is done by the authors of the DSM.
Charland reveals himself to be a dualist, identifying a realm of
actions that one intends and one that one does not intend. While this
is not the cartesian dualism of substances, it serves the same
function--to distinguish that which we are responsible for--mind,
intention, from that which we are not responsible for--body, cluster A
syndromes. Psychotherapy as inspired by Freud [and Pinel, I would
argue] in contrast is based on a monist principle. Psychoanalytic
discourse does not make a distinction between the intended and the not
intended, or perhaps I should say that the concept of unconscious
motivation is a a concept that joins the intentional and unintentional
in a way that allows one to talk about the intentional in a non
judgmental way. It makes moral therapy as Charland uses it obsolete. I
think that Charland is thinking in pre-Freudian terms and from reading
his work on Pinel, he is also thinking in eighteenth-century dualist
[though obviously not about substances] terms as well.

Friday, May 15, 2009

Waterboarding as Psychotherapy

While we are properly horrified to learn about the use of deliberate near-drowning (waterboarding) as an interrogation technique, it is worth noting that for a period of nearly two hundred years the same procedure was regarded as a form of psychotherapy. The influential seventeenth century physician Jan Baptiste Van Helmont (1580-1644), originated this treatment after observing that a madman, who was revived following an accidental near-drowning, was relieved of his mental symptoms. The most influential eighteenth century physican Hermann Boerhaave. (1668-1738) mentions the use of submersion in the treatment of insanity but recommends it for only the most desperate cases. Boerhaave's student Jerome Gaub also discusses the treatment and attributes its efficacy to anxiety. "The most deeply seated mental defects and the most incurable forms of madness" he writes, "may sometimes be rooted out by anxiety." Perhaps, he speculates, this is "because the tormented and frightened mind is revived by the terrible punishment of her greatly depressed senses…." He cites "men with minds held captive by the violence of love or grief," who recovered their soundness of mind when revived after accidental near-drowning. He insists that the cause of this recovery is the "frightful torment that near loss of life from suffocation inflicts on the mind." Gaub acknowledges that "submersion therapy" is "a terrible remedy" but adds that it is "one hardly to be exceed in efficacy." Gaub took the trouble to attempt a medical explanation of "submersion therapy." He argued that "submersion therapy" worked by provoking anxiety, which he understood as a powerful emotion caused by bodily changes. The most frequent cause of anxiety, he felt, is interference with respiration, which hinders the passage of blood through the lungs and thus places life in jeopardy. These bodily events affect the "common sensorium" [where mind and body meet] so as to excite ideas in the mind that cannot be contemplated without horror and cannot be dispelled. The value of such shock therapy was widely recognized in the eighteenth century. “In mania,” a Montpellier doctor wrote in Diderot and D'Alembert's encyclop├ędie, “therapy is directed to the body, in which it aims to produce a shock and a deep disturbance .” Such ideas even influenced Philippe Pinel, who cites Van Helmont. Although Pinel did not use "submersion therapy," he did include the role of powerful emotions like fear in dispelling fixed ideas as a component of his moral therapy.

Wednesday, May 13, 2009

Military Mental Health

The complexities of providing mental health services to soldiers was suggested by the recent case of the soldier who shot and killed five of his fellow soldiers at a military mental health center in Iraq. Although he managed to find a gun to use, it seems that his commanding officer was alert to his problems. He had the soldier turn in his gun and referred him for counseling. But that apparently isn't the way the soldier experienced it. In an interview, the soldier''s father said that his his son had recently angered a commanding officer, who had "threatened"  him. When the officer ordered the soldier to undergo counseling and relinquish his weapon--a major rebuke in the military-- he became nervous that the Army was "setting him" up to be discharged. Having recently built a new home, he was deeply anxious that he could loose not only his steady paycheck but also his military pension, his father said.“If a guy actually goes to the clinic and asks for help, they think of him as a wimp and he’s got something wrong with him and try to get rid of him,” Mr. Russell said. “Well, he didn’t go and ask voluntarily for help. They scheduled him in, and they set him up. They drove him out. They wanted to put as much pressure on him as they could to drum him out.”

He added: “I think they broke him.”

A General in charge of the soldier's unit, however, said that, “The tools were all being used. They thought that he needed a higher level of care than the unit could provide, so they sent him to the clinic. I mean, you see, all the kind of things that we’re taught to do were in place.”

Monday, May 11, 2009

Psychiatry without Psychotherapy

An article in the August 2008 issue of the Archives of General Psychiatry noted not only a significant decrease in the number of psychiatrists practicing psychotherapy, but a lack of interest in learning psychotherapy among psychiatric residents in the United States. A letter in the April 2009 issue of the same journal notes that a survey among Canadian residents showed that 84% "anticipated practicing psychotherapy and viewed it as an important component to their work and identities." For those who are inclined to see the rise of biological psychiatry as portending the inevitable decline of psychotherapy, this survey strongly suggests that economic and cultural factors are at work as well.