CONCEPTUAL BASES OF PSYCHIATRY FOR THE PERSON

 

Historical Views on Psychiatry for the Person

 

Jean Garrab MDa and Paul Hoff MD PhDb

 

a Honorary Member, World Psychiatric Association, Paris, France

b Professor of Psychiatry, Department of General and Social Psychiatry, University of Zurich, Switzerland

 

Keywords

Ethics, history, human rights, morality, patron saints of insane persons, person-centered medicine, psychiatry

 

Correspondence Address

Prof. Paul Hoff, Department of General and Social Psychiatry, University of Zurich, Lenggstr. 31, P.O. Box 1931, CH 8032 Zurich, Switzerland. E-mail: paul.hoff@puk.zh.ch

 

Accepted for Publication: 19 January 2011

 

 


Introduction

 

The history of psychiatric medicine is punctuated with what can be considered to be breakthrough moments, times at which an individual speaks out against the shameful way in which his or her society treats the insane or mentally ill and stresses that they are first and foremost human beings.

 

 

Patron saints of insane persons

 

The first such patron was Joo Cidade (1495-1550) who, after experiencing at first hand the brutal treatments to which the insane were subjected, began to preach in their favour, resulting in the creation of the Order of St John of God. This event corresponds to the development of medical humanism at the time of the Renaissance. He was preceded by Saint Norbert (c.1080-1134) who founded the order of Premonstratensians, since it was at Prmontr, where there is still a psychiatric hospital where he received the calling to take care of abandoned sick persons. In France, the Brothers of St John of God founded many hospitals, notably near Paris, including what is now known as Esquirol Hospital.

 

 

Human Rights and Science in Psychiatry

 

This brings to mind Ph. Pinel (1745-1826) who, after observing the positive results obtained at Bictre hospice with the no-restraints policy instigated by the superintendent J.-B. Pussin (1745-1811) had the chains removed from the insane women interned in La Salptrire. This act symbolically marks the birth of modern psychiatry. Yet this act must not overshadow Pinel's life work, his Trait mdico-philosophique sur lalination mentale [1]. The start of 191 reads: "Far from being criminals in need of punishment, the alienated are patients whose pitiable state should be given all the consideration due to the suffering, and whose reason we must seek to restore using the simplest of means." Moral treatment is based on recourse to this remainder of reason retained by even the most severely alienated of patients who have therefore not lost their fundamental status as human beings. This founding act followed close on the heels of the Dclaration des Droits de lHomme et du Citoyen approved by the Convention in August 1795.

In the period between the two World Wars, psychiatric practices changed. What makes this so alarming is the fact that these changes were either made in the name of an abstract science or were completely devoid of consideration for the mental patient as a person. The degeneration theory of mental alienation formulated in the XIXth century had resulted in the widely accepted belief that some mental illnesses, notably schizophrenia, were hereditary. This was one factor leading to eugenic legislation ranging from the sterilisation of sufferers in democratic countries to "active euthanasia" in Nazi Germany. The "Aktion T4" ordered by Hitler in October 1939, was suspended following a sermon delivered by Bishop Clemens-August von Galen (1878-1946). A. Ricciardi von Platen described the story of this extermination programme [2].

Yet before the war, such a prestigious author as Robert Gaupp (1870-1953) wrote that this criminal legislation (he only mentions compulsory sterilisations following the law on the prevention of the transmission of hereditary diseases dated July 18, 1933, as the T4 programme was kept secret) assumed the superiority of German psychiatric science, particularly with regard to "racial cleansing", citing the works published by Ernst Rdin (1874-1962) and Carl Schneider (1891-1946). Eugne Minkowski (1885-1972) railed against the abandonment of an ethical reference framework in a psychiatry that claims to be scientific.

The real crime against humanity is to have considered these patients as simple objects on whom experiments could be performed freely in the name of science. It were the judgements pronounced by the Nuremberg Courts which formed the basis for legal texts on medical ethics, a field in which until that time the main reference was the humanist tradition of the Hippocratic Oath.

During the Second World War, a high number of institutionalised mental patients died of hunger. In France, the number of victims is believed to have been over 30,000. I. von Bueltzingsloewen [3] had shown that these deaths were less due to a deliberate extermination policy than to the indifference of the authorities to the fate of these patients who had been cut off from social contacts.

In the interim period between the wars, several European philosophers returned to the question of the definition of "person", almost as if they feared the forthcoming dehumanisation of the mentally ill. Max Scheler (1874-1928) defined person as "the centres from which the human being accomplishes acts through which he objectivises the world and his own body and mind [4].

Gnter Stern-Anders (1902-1992) published in Paris his essay La pathologie de la libert [5]. It was this essay that Ey quoted in his Etudes [6] and which became his own definition of mental pathology as the pathology of freedom.

With the publication of Jakob Wyrsch's Die Person des Schizophrenen, psychiatry of the person reached its first peak of development [7]. Wyrsch (1892-1980) developed the theory that schizophrenia is a disease affecting the person as a whole; in no other disease it is possible to observe a transformation comparable to that undergone by the schizophrenic patient in his relationships to the world in which, as Scheler states, he or she objectivises his or her own body and mind.

The First International (later renamed World) Congress of Psychiatry held in Paris in 1950 was considered by its organisers to be the occasion to recommence not only the scientific exchanges that had been interrupted by the war but also reflection on medical ethics. One can see here pointed interest in articulating science and humanism, the roots of what later emerged as a psychiatry for the person.

In 1957, J.J. Lopez Ibor (1906-1991) organised a symposium on schizophrenia in which Wyrsch gave two lectures, one on schizophrenia as a pathological entity and another on the person of the schizophrenic. In his second speech, he specified what should be understood by the term person:Psycho-physical constitution, intentionality and content of acts, internal vital history, personal spirit, and therefore the whole world of the individual enters into the concept of the person.

The Universal Declaration of Human Rights was adopted by the United Nations on December 1948 despite the opposition of the USSR, five people's democracies, South Africa and Saudi Arabia. Note that psychiatric associations in some of these countries were accused of abusive use of psychiatry for purposes of political repression at the VIth World Psychiatric Congress (Honolulu 1977). This led to the Declaration of Hawaii, which laid out the ethical rules for worldwide psychiatric practice.

At the beginning of the XXIst Century, we can still note that human rights are far from being universally respected and the mentally ill are not always given appropriate consideration as human beings.

Echoes of philosophy of existence up to WPA's Program on Psychiatry for the Person

First to be noted in the presentation of this program [8,9] is the definition of the person, to be thought of in a contextualised manner, in the words of the philosopher Ortega y Gasset I am I and my circumstance (circumstance is the personal world that determines the being).

Second, is the reference to a work published by Paul Ricur (1913-2005),in which he looked in particular at the relationships between personal and collective memory, insisting on the importance of the inner autobiographical story in the tradition of self examination as represented by Saint Augustine, John Locke (1632-1704) and Edmund Husserl (1859-1938). It is this inner autobiographical story that forms the narrative structure of the person.

In conclusion, psychiatry`s self-understanding for several reasons is (and probably will continue to be) more complex than that of other medical specialties. It has been a major goal of WPA`s Institutional Program on Psychiatry for the Person to prevent future psychiatry from dissolving into a number of methodically defined, but barely interconnected subunits and to strengthen person-centered approaches to psychiatric diagnosis, therapy and research [8-11]. To succeed in this demanding project, we strongly need a historical perspective: Each psychiatric concept - be it of naturalistic, descriptive, hermeneutical, anthropological or sociological in orientation - is necessarily (albeit often implicitly) linked to theoretical presuppositions. And these cannot be fully understood without acknowledging their historical and epistemological dimensions.

 

 

References

 

[1] Pinel P:. Trait mdico-philosophique sur lalination mentale. (1809). Presented by J.Garrab and DoraWeiner. Paris, Le Seuil, 2007.

[2] Ricciardi-von Platen A (1948). Die Ttung Geisteskranker in Deutschland. Frankfurt/Main, Frankfurter Hefte.

[3] Bueltzingsloewen I von (2007). : Lhcatombe des fous. Paris, Aubier-Montaigne.

[4] Scheler M: Die Stellung des Menschen im Kosmos (1928). Translated by MS Frings as: The Human Place in the Cosmos. Evanston, Illinois, Northwestern University Press, 2009.

[5] Anders (Stern) G (1934). Pathologie de la libert. Essai sur la non-identification. Paris, Recherches Philosophiques.

[6] Ey H (2006). Etudes psychiatriques. Nouvelle dition. Perpignan, Crehey.

[7] Wyrsch J (1949). Die Person des Schizophrenen. Studien zur Klinik, Psychologie und Daseinsweise. Berna, Paul Haupt.

[8] Mezzich JE (2006). Institutional consolidation and global impact: Towards a psychiatry for the person. World Psychiatry 5: 65 66.

[9] Mezzich JE (2007). Psychiatry for the Person: Articulating Medicine's Science and Humanism. World Psychiatry 6:13.

[10] Mezzich JE (2007).The dialogal basis of our profession: Psychiatry with the person. World Psychiatry 6:129-130.

[11] Hoff P: Historical Roots of the Concept of Mental Illness. In: Salloum I M, Mezzich J E (Eds) (2009). Psychiatric Diagnosis: Challenges and Prospects. Chichester, Wiley-Blackwell, pp 3 14.

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