CONCEPTUAL BASES OF PSYCHIATRY FOR THE PERSON
Introduction to the Conceptual Bases of Psychiatry for the Person
Juan E. Mezzich MD MA MSc PhDa, George N. Christodoulou MD PhD FRCPsych FICPMb, (Bill) K.W.M. Fulford DPhil FRCP FRCPsychc
a Deputy Editor-in-Chief, International Journal of Person Centered Medicine, Professor of Psychiatry, Mount Sinai School of Medicine, New York University, USA, President, International Network for Person-centered Medicine
b Emeritus Professor of Psychiatry, Athens University and Honorary President, Hellenic Psychiatric Association, Athens, Greece
c Emeritus Professor of Philosophy and Mental Health, University of Warwick, Editor, Philosophy, Psychiatry and Psychology and Special Adviser for Values-Based Practice, Department of Health, London, UK
Conceptual basis, multiperspectual analysis, person-centered psychiatry
Prof. Juan E. Mezzich, Professor of Psychiatry, Mount Sinai School of Medicine, New York University, Fifth Avenue and 100th Street, Box 1093, New York NY 10029, USA. E-mail firstname.lastname@example.org
Accepted for Publication: 19 January 2011
Psychiatry for the Person represents an initiative to place the whole person of the patient at the center of mental health care . Its aims are highlighted by the promotion of a psychiatry of the person (of the totality of the person’s health, including its ill and positive aspects), for the person (assisting the fulfillment of each person’s life project), by the person (with clinicians extending themselves as full human beings, scientifically grounded, and with high ethical aspirations), and with the person (in respectful and empowering collaboration with the person presenting for care). The person is conceived of in a contextualized manner, in line with the words of Ortega y Gasset, I am I and my circumstance.
The ancient roots for this initiative can be found in the etymology of the term health in Sanskrit (hal, meaning wholeness) as well as in the broad concepts of health and the personalized health practices in ancient civilizations around the world, including Chinese and Ayurvedic in the East  and Hellenistic in the West  The wisdom of these historical precedents is reflected in the World Health Organization’s  definition of health as a state of complete physical, emotional and social wellbeing, and not merely the absence of disease.
The development of modern medicine (and psychiatry) along with impressive advances on the scientific bases of disease and diagnostic and therapeutic technologies, has been accompanied by absorbed attention to disease, hyperbolic dependence on technology, fragmentation of care, and a pervasive commodity-orientation. An approach that would combine science as an essential tool (involving a broad biopsychosocial theoretical framework for understanding ill and positive health, person-centered attention to clinical processes and outcomes, and integration of care around the person of the patient), and ethical and humanistic concerns attending to the dignity, autonomy, values and responsibility of every person involved is becoming a growingly recognized necessity.
The psychosomatics movement , with its emphasis on the unity of the whole person, has contributed considerably to the holistic and personalized perspective and so has the emphasis on positive mental health . The holistic approach has been extended to also include the environment as a very important contributor to health. The growing recovery movement in mental health is consonant with person-centered care . One of recovery’s leading proponents  has identified personhood as the field’s transcendent principle.
Important public health statements are promoting the reorganization of mental health services around the needs of individuals and carers [9-11]. Concern for the centrality of the person is also being adopted by influential international health organizations through recent statements [12,13].
The increasing importance of person-centered psychiatry calls for a careful analysis of the conceptual bases of this paradigmatic approach. To this effect, small groups of leading scholars were invited to contribute consensual short papers from each of ten perspectives (historical, philosophy of science, values and ethics, biological, psychological, social, cultural, spiritual, literature and the arts, and user and family) relevant to the theoretical framework of psychiatry for the person.
The first paper, on historical views, traces back the roots of medical humanism to the patron saints of insane persons such as Joao Cidade (1495-1550). It then reviews the unfolding of the sensitive interactions between science and human rights in psychiatry, including the shining integrative work of Philippe Pinel , path-opening conceptual analyses such as Scheler’s , and, in stark contrast, the dark pages of psychiatry in Nazi Germany. The authors elucidate in the proceedings of the First World Congress of Psychiatry in 1950 a pointed interest on articulating science and humanism and the seeds for the current initiative on psychiatry for the person. They further find among the crucial historical grounds for this initiative Ortega y Gasset’s contextualized concept of the person and Ricoeur’s contributions on the person’s narrative structure.
The second paper, upon presenting philosophy of science perspectives on psychiatry for the person, discusses the possibility of balancing psychiatry’s natural scientific underpinnings with an increasing focus on the importance and role of the person. The authors perceive such a proposal as mirroring Karl Jaspers’ response to the then prevailing view that mental illnesses are brain diseases by emphasizing the role of understanding and explanation in psychiatry. The debate on the correct method in psychiatry was joined later by philosophers working along Wittgenstein’s analytic line distinguishing between the proper places of natural sciences and human sciences. Illustratively, the authors perceive person-centered diagnostic models as reflecting the need to give a fuller picture of the human patient, a person whose experiences need both understanding and explanation.
The third paper, on values and ethics perspectives on psychiatry for the person, addresses the challenge of combining the generalized findings of objective science with responsiveness to the diverse values of each individual patient. Two main kinds of ethical resources for person-centered psychiatry are noted. One involves substantive ethics, where pointed attention is given to utilitarianism, deontology, and principlism. The other involves analytic ethics, for which the authors focus on philosophical value theory. To illustrate both kinds of ethics, they discuss compulsory treatment. Argued further is that the new philosophy of psychiatry as a whole represents a rich conceptual resource for a psychiatry that is both firmly science-based and genuinely person-centered.
The fourth paper, on biological perspectives, posits that too often psychiatry has been guided by either “mindless” or “brainless” approaches that try to divide the whole person into separate entities of mind or body. Instead Psychiatry for the Person emphasizes the need for integrative approaches that recognize the psychobiological nature of both positive health and ill health. Some try to reduce the whole person to deterministic molecular processes, but genetic and other biological research is showing that most mental disorders as well as personality traits important for well-being are complex multifactorial processes in which multiple genetic and environmental factors interact . Consequently, diagnosis and treatment of the person should depend on an integrative person-centered approach that recognizes the fact that biological and psychological processes are intertwined inextricably.
The fifth article, on psychological perspectives, brings to bear the importance of a broad holistic theoretical approach to understand ill health and positive health, attention to inner subjectivity, inter-subjectivity as well as objectivity, and consideration of psychopathology within the context of the individual’s life and social environment, all crucial for a psychiatry for the person. In line with the above, the article discusses psychopathology in terms of phenomenological, structural, metaphoric/symbolic, and family/environmental dimensions. The authors call for enough room to be given to the listed factors, along with the patient’s values, in the development of crucial clinical procedures, such as diagnosis, so that they can truly fulfill the goals of personalized clinical treatment and health promotion.
The sixth paper, on social perspectives, deals with the relevance of person-centered psychiatry for public health and for dealing with major social diversity issues. First, it argues that population-based approaches are needed to minimize pathogenic factors such as helplessness and loss of existential cohesion as well as to support salutogenesis, identity, integrity, autonomy, resilience, and dignity . Then it submits that international migrants and refugees pose challenges that to be properly faced require holistic approaches and call for comprehensive and integrative diagnostic, treatment, prevention, and health promotion models. Finally it comments on the situation of developing countries, where most of humanity lives and which traditionally have endorsed broad concepts of health and personalized attention to ill people, and that along with plural deprivations seem to show relatively strong family and social cohesion.
The seventh article discusses the cultural perspectives of person-centered psychiatry. The history of ethnomedicine and cultural psychiatry reinforces the claim that the diverse needs of persons experiencing distress are central concerns of psychiatric practice. Connecting psychiatry to its ethnomedical roots helps clinicians as well as investigators return their attention to all dimensions of disease, pain and suffering, and to a renewed emphasis on human values. The authors warn that the content of conditions of psychiatric interest which are embraced in other contemporary ethnomedical traditions can not only be bypassed, but their authenticity and cultural significance undermined by a simplistic application of biological reductionism . There is, at the same time, ample justification for construing and assessing conditions of psychiatric interest in ways that affirm the cultural diversity of the person [19,20].
The eight articles explore the spiritual perspectives of psychiatry for the person, with a focus on the integrative aspects of our field. First examined is the need for a broad theoretical framework, one in which the conventional bio-psycho-social elements are enriched with a spiritual dimension. Such a dimension is also germane to an adequate consideration of the principal activities of person-centered clinical care. In fact, attention to spirituality is required for a broad diagnostic assessment both to tease out the intricacies of certain symptoms as well as for a full delineation of positive health. Spirituality is also to be considered for the activation of a full range of therapeutic resources and for assisting a person to lift his or her level of health. The growing multi-ethnicity of communities across the world make it necessary to shift models from a disease orientation towards a more integrative view, which reflects the entirety of life circumstances bringing psychiatry closer to patients’ needs.
The ninenth article discusses the relevance of literature and the arts to person-centered psychiatry. Both involve the engagement of the biological, psychological and social aspects and resources of the person for the creation of the present, based on the past and with a sense of the future. As pointed out by the authors, a person’s creative potential depends on his or her ability to reconstruct, to dissolve existing structures and to rebuild them in a new way. The role of art in facilitating personal empowerment and fostering a healing process has been explored from a variety of disciplinary approaches in a recent collective volume, The Person in Art, under the auspices of the World Psychiatric Association Program on Psychiatry for the Person . To be noted in connection to literature is the development of narrative medicine  as a powerful approach to find meaning in illness and to enhance healing.
Last but not least, the patient/user and family perspective on psychiatry for the person, along with promising collaborative prospects, are presented in the tenth article. The problems experienced by some patients in being disrespected physically and emotionally and their views not receiving adequate attention by clinicians have led to a strong critical movement. At the same time, proposals for recognizing the whole person presenting for care  and building a psychiatry with the person , are emerging along with efforts for engagement based on empathy and respect even under sensitive circumstances . Families and carers of people experiencing mental disorders are also pressing to be recognized as full persons, bringing another dimension to psychiatry for the person. All these efforts emphasize the importance of partnerships as fundamental to good clinical practice. This perspective is being extended creatively by the development of trialogs among users, families and professionals , as models for building cooperation, resolving conflicts, and facilitating health promotion.
Person-centered psychiatry involves a paradigmatic effort to refocus our field from disease to patient to person by articulating science and humanism . The extension of the person-centered approach to medicine at large adds to its depth and value. Furthermore, as cogently proposed by Miles , there is an urgent need to overcome reductionism by embracing the complex in clinical practice, as well as to display compassion, consolation, empathy, insight, discernment and intuition in parallel and full integration with scientifically informed strategies to ameliorate, attenuate and cure. We hope that the set of papers presented in this monographic endeavor will illuminate productively the complexity to be grasped and delineate promising paths towards a psychiatry and medicine for the whole person.
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