Comments on "cyclical swings" by Professor Hannah Decker: The underappreciated "solid center" of psychiatry

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The history of psychiatry is characterized by some deep ideological and conceptual divisions, as adumbrated in Professor Hannah Decker's essay. However, the schism between "biological" and "psychosocial" models of mental illness and its treatment represents extreme positions among some psychiatrists-not the model propounded by academic psychiatry or its affiliated professional organizations. Indeed, the "biopsycho-social model" (BPSM) developed by Dr. George L. Engel has been, and remains, the foundational model for academic psychiatry, notwithstanding malign market forces that have undermined the BPSM's use in clinical practice. The BPSM is integrally related to "centralizing" and integrative trends in American psychiatry that may be traced to Franz Alexander, Karl Jaspers, and Engel himself, among others. This "Alexandrian-Jaspersian-Engelian" tradition is explored in relation to Professor Decker's "cyclical swing" model of psychiatry's history. (PsycINFO Database Record

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... Dies steht im Gegensatz zum Wunsch vieler Patienten, mit ihren individuellen Geschichten Gehör zu fin den [59]. Gerade Jaspers mit seinem sowohl geisteswissenschaft lich verstehenden als auch naturwissenschaftlich erklärenden An satz kann hier integrierend wirken und als Teil einer gedanklichen Mitte oder eines Fundaments der Psychiatrie (solid center) ange sehen werden [60]. ...
... Hier beginnt eine Tradition des genetischen Verstehens, die wichtig ist für eine Psychiatrie, die die Anforderungen der Menschen in einer postmodernen globalisierten Welt ernst nimmt. Karl Jaspers steht in dieser Tradition und formuliert zentrale gedankliche Grundlagen psychiatrischen Handelns [52,60]. ...
Zusammenfassung Boccaccios „Das Dekameron“ ist ein Werk, das im ausgehenden Mittelalter entstand, aber bereits neuzeitliche Ideen zum Menschen als Individuum enthält. Vor dem Hintergrund der Kontroverse um den Einfluss der Neuzeit auf Psyche und Psychiatrie und auf das Konstrukt der Identität untersuchen wir „Das Dekameron“ hermeneutisch mit einem Fokus auf Beschreibungen einer Gesellschaft im Wandel, der Liebe (als Ausdruck des Individuums), von seelischem Leiden und der Rolle therapeutischen Handelns. Dabei zeigt sich, dass es bei Boccaccio ein Interesse an intrapsychischen Vorgängen als Ausdruck der frühen Neuzeit gibt. Dies wird in Bezug auf Karl Jaspers‘ Ansatz des genetischen Verstehens diskutiert.
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The authors discuss the biopsychosocial (systems) model of medicine formulated by George L. Engel. The interaction among systems is explained in terms of selection, negation, and the reduction of the complexity of events. In psychosocial systems, vast possibilities of experience and behavior are selected and negated through structures of meaning. The authors illustrate how meaning organizes the experience and activity of a man suffering a myocardial infarction, a case originally discussed by Engel. The role of meaning in psychosocial systems leads to a discussion of the scientific method for investigating it that is provided by Karl Jaspers' psychology of understanding.
In the UK, as in most western countries, neurology and psychiatry evolved into separate disciplines in the late 19th and early 20th centuries. In the late 20th and early 21st centuries, there are signs of some convergence of the two disciplines, stimulated in part by a common interest in neuroscientific studies of the brain, but also a greater awareness of the psychological and social dimensions of neurological disorders and the re-emergence of the concept and discipline of neuropsychiatry. Neither the Royal College of Psychiatrists nor the Association of British Neurologists has a specialist interest group on history, but might there be support from both disciplines for a joint history group? So-called neurological and psychiatric diseases have been recorded for up to four millennia and the history of these disorders is profoundly intertwined. Against this background, a symposium was held at the Institute of Psychiatry in London on 9 July 2014 on “The Historical Evolution and Future of Neurology and Psychiatry”. The event was partly sponsored by King's College London with the encouragement of the principal, Sir Richard Trainor, himself a historian, who welcomed 157 delegates and 13 speakers, including neurologists, psychiatrists, clinical and basic neuroscientists and historians. Sir Richard emphasised the commitment of King's College to neurology and psychiatry with its new joint Institute of Clinical Neurosciences, as well as to the Historical Sciences. He viewed this symposium as a high point of his last year as principal. Babylonian neurology and psychiatry Dr Edward Reynolds, a King's College neurologist, reviewed his collaborative studies over the past 25 years with James Kinnier Wilson, a Cambridge-based Babylonian scholar and son of the distinguished neurologist, Samuel Alexander Kinnier Wilson (1878-1937). He summarised detailed Babylonian cuneiform descriptions of epilepsy, stroke, facial palsy, psychoses, obsessive compulsive disorder, phobias, psychopathic behaviour, depression and anxiety. These accounts, which date from the first …
It noted that psychiatrists are taught to listen to people in particular ways: they listen for signals most of us cannot hear, and they look for patterns most of us cannot see. This book describes psychiatrists' 2 primary tasks of diagnosis and psychopharmacology, on the one hand, and psychodynamic psychotherapy, on the other—teach them to listen and look in different ways. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Freud considered Franz Alexander, the first graduate of the Berlin Psychoanalytic Institute and an assistant in the Berlin Polyclinic, to be "one of our strongest hopes for the future." Alexander went on to become the first director of the Chicago Institute for Psychoanalysis in 1932 and modeled some of the Chicago Institute's mission on his Berlin experiences. He was also a researcher in psychosomatic medicine, a prolific writer about psychoanalysis and prominent in psychoanalytic organizations. As he proposed modifications in psychoanalytic technique, he became a controversial figure, especially in the elaboration of his ideas about brief therapy and the corrective emotional experience. This paper puts Alexander's achievements in historical context, draws connections between the Berlin and Chicago Institutes and suggests that, despite his quarrels with traditional psychoanalysis, Alexander's legacy may be in his attitude towards psychoanalysis, characterized by a commitment to scientific study, a willingness to experiment, and a conviction about the role of psychoanalysis within the larger culture.
The biopsychosocial model, the current method in psychiatric assessments, is reviewed and critiqued. The history and original intents leading to the conception of the biopsychosocial model are briefly discussed. Five inherent problems with the use of the biopsychosocial model in psychiatric assessments and training programs are presented. Two alternative approaches are discussed and promoted for clinical, educational, and research practices in medicine.
The biopsychosocial model is the conceptual status quo of contemporary psychiatry. Although it has played an important role in combatting psychiatric dogmatism, it has devolved into mere eclecticism. Other non-reductionistic approaches to medicine and psychiatry such as William Osler's medical humanism or Karl Jaspers' method-based psychiatry should be reconsidered.
( This reprinted article originally appeared in Science, 1977, Vol 196[4286], 129–236. The following abstract of the original article appeared in PA, Vol 59:1423. ) Although it seems that acceptance of the medical model by psychiatry would finally end confusion about its goals, methods, and outcomes, the present article argues that current crises in both psychiatry and medicine as a whole stem from their adherence to a model of disease that is no longer adequate for the work and responsibilities of either field. It is noted that psychiatrists have responded to their crisis by endorsing 2 apparently contradictory positions, one that would exclude psychiatry from the field of medicine and one that would strictly adhere to the medical model and limit the work of psychiatry to behavioral disorders of an organic nature. Characteristics of the dominant biomedical model of disease are identified, and historical origins and limitations of this reductionistic view are examined. A biopsychosocial model is proposed that would encompass all factors related to both illness and patienthood. Implications for teaching and health care delivery are considered.
In the 19th century the triumphs of neuropathology and the clinico-anatomical method led to the evolution of neurology as a separate 'organically' based discipline associated with the concept of functional localisation. At the same time the growth of psychodynamic psychiatry contributed to the progressive separation of the two disciplines, with neuropsychiatry sitting uneasily in the middle. Psychiatrists are now showing increasing interest in the structure and function of the nervous system, but are having difficulty in integrating their findings into 'functional' diseases. This may be because disorder of function in the nervous system is much more complex than previously envisaged. The function of the nervous system is profoundly affected by psychological and social factors. The view that neurology is wholly 'organic' and synonymous with structural disease of the nervous system is fallacious. Neurological patients have complex dynamic disorders of function in the nervous system whether or not structural disease is present.
The great triumphs of 19th century scientific medicine in the fields of morbid anatomy, microbiology and biochemistry resulted also in a narrowly organic orientation which fostered increasing specialization and a neglect of the psychological aspects of medicine. Freud, Pavlov and Cannon paved the way for the introduction of the psychosomatic approach to medical practice and research. Their methods and theories offered potential tools for the measurement of emotions and access to repressed, unconscious, psychological content. The psychosomatic movement which started in Germany and Austria was further elaborated through the psychosomatic research of American psychiatrists and particularly psychoanalysts, with psychologists increasingly entering the field. Gradually, interest in the psychodynamics and psychoanalytic treatment of patients with psychosomatic disorders yielded to a growing exploration of the place of environmental stress, consultation psychiatry and pharmacotherapy in psychosomatic disorders. As laboratory studies have burgeoned, occasional rifts have occurred between those in basic psychosomatic research and those in applied psychosomatic medicine. The numerous conceptual models of mind-body relationships in general and psychosomatic diseases in particular are summarized and discussed. While uncertainty abounds and initial hopes of finding an exclusive psychogenic explanation for puzzling diseases and methods of treating them easily by psychotherapy have not materialized, the psychosomatic approach has nonetheless had a profound impact on medicine.
Pluralism is the hallmark of 21st century psychoanalytic discourse. Nevertheless, an unpleasant byproduct of pluralism is a tendency in some quarters to retreat into orthodoxy, stemming from a perceived need to shore up theoretical boundaries in the service of differentiating one theory from another. The delineation of borders places us at a risk of losing sight of the fact that genuine psychoanalytic thinking is fundamentally non-reductionistic. Moreover, the core psychoanalytic notion of overdetermination, which Freud never abandoned throughout his career, has recently been neglected as authors argue in their communications that one point of view is better than another. Both analysts and their patients secretly are drawn to simple formulations that eschew complexity. The need to remain open to the "infinite space" of meaning, motive, and causation should be a hallmark of clinical psychoanalytic practice. The author considers the implications for technique, and provides case material to illustrate some of the challenges inherent in approaching psychoanalytic work as a complex phenomenon.
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