Introduction
Psychiatry for the Person represents
an initiative to place the whole person of the patient at the center of mental
health care [1].
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 [2] and Hellenistic in the West [3] The wisdom of these historical
precedents is reflected in the World Health Organization’s [4] 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 [5], 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 [6].
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 [7]. One of recovery’s
leading proponents [8] 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].
A multiperspectual analysis
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 [14], path-opening conceptual
analyses such as Scheler’s [15], 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 [16]. 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 [17]. 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
[18]. 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 [21]. To be noted in connection to literature is the
development of narrative medicine [22] 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 [23]
and building a psychiatry with the person [24], are emerging along with
efforts for engagement based on empathy and respect even under sensitive
circumstances [25]. 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 [26], as models for building cooperation, resolving conflicts,
and facilitating health promotion.
Colophon
Person-centered psychiatry involves
a paradigmatic effort to refocus our field from disease to patient to person by
articulating science and humanism [27]. The extension of the person-centered
approach to medicine at large adds to its depth and value. Furthermore, as
cogently proposed by Miles [28], 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.
References
[1] Mezzich JE: (2007).
Psychiatry for the Person: Articulating Medicine’s Science and Humanism. World
Psychiatry 6:65-67.
[2] Patwardhan B,
Warude D, Pushpangadan P, Bhatt N (2005) Ayurvedic and traditional Chinese
medicine: a comparative overview. Evidence-based Complementary and
Alternative Medicine 2: 465-473.
[3] Plato: Harmidis
Dialogue. Athens, Papyros, 1975.
[4] World Health
Organization: Constitution of the World Health Organization. Geneva, Author,
1946.
[5] Christodoulou
GN: (1987) Psychosomatic Medicine. New York, Plenum Press.
[6] Cloninger CR: (2004).
Feeling Good: The Science of Well Being. Oxford, Oxford University
Press.
[7] Anthony WA: (2004).
The principle of personhood: the field’s transcendent principle. Psychiatric
Rehabilitation Journal 27: 205.
[8] Amering
M, Schmolke M: (2009). Recovery in Mental Health: Reshaping scientific and
clinical responsibilities. Chichester, UK, Wiley-Blackwell.
[9] US Presidential
Commission on Mental Health: Achieving the promise: transforming mental
health care in America. Final Report. Rockville, US Department of Health and
Human Services, 2003.
[10] World Health
Organization): Mental health action plan for Europe: facing the
challenges, building solutions. Helsinki, January 12-15, 2005.
[11] United Kingdom
Department of Health: Putting People First: A shared vision and commitment to
the transformation of Adult Social Care. London, U.K. Department of Health,
2008.
[12] Mezzich JE,
Snaedal J, Van Weel C, Heath I: (2010). Conceptual Explorations in
Person-centered Medicine. International Journal of Integrated Care, 10 (Supplement).
[13] World Health
Organization (2009) Resolution WHA62.12. Primary health care, including health
system strengthening. In Sixty-Second World Health Assembly, 18-22 May 2009.
Resolutions and Decisions. Geneva, 2009 (WHA62/2009/REG1), page16.
[14] Pinel P: Traité
médico-philosophique sur l’aliénation mentale. (1809). Presented by
J.Garrabé and Dora Weiner. Paris, Le Seuil, 2007.
[15] 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.
[16] Smith MJ,
Cloninger CR: Temperament and character as schizophrenia-related endophenotypes
in non-psychotic siblings. Schizophrenia Research 104:198-205.
[17] Rutz, W. (2006).
Social psychiatry and public mental health: Present situation and future
objectives. Time for rethinking and renaissance? Acta Psychiatrica Scandinavica
113: 95-100.
[18] Fabrega H: (2009).
History of Mental Illness in India: A Cultural Psychiatry Retrospective.
Motilal Banarsidass, Delhi, India.
[19] Mezzich JE, Caracci G,
Kirmayer L, Fabrega H. 2009: Cultural Formulation Guidelines. Transcultural
Psychiatry, 46: 383-405.
[20] Kohn R and Wintrob R. (2009). Research Advances in the
Relationship Between Immigration and Psychiatric Disorders. In: Advances in
Psychiatry, Vol 3. Eds; George Christodoulou, Miguel Jorge, Juan Mezzich.
Athens, World Psychiatric Association.
[21] Thomashoff H-O
& Sukhanova E: (2008). The Person in Art. Hauppauge, New York, Nova
Publishers.
[22] Charon R: (2008).
Narrative Medicine: Honoring the Stories of Illness. Oxford, Oxford
University Press, 2008.
[23] Barham
P and Hayward P (1991). From the Mental Patient to the Person, London:
Routledge.
[24] Mezzich JE (2007).
The dialogal bases of our profession: Psychiatry with the Person. World
Psychiatry 6:129-130.
[25] Kallert T,
Mezzich JE, Monahan J (eds): Coercive Treatment in Psychiatry.
Chichester, UK, Wiley-Blackwell, in press.
[26] Amering M,
Hofer H, Rath I (2002). The "First Vienna Trialogue" – experiences
with a new form of communication between users, relatives and mental health
professionals. In: Lefley, HP, Johnson DL (eds): Family interventions in
mental illness: International perspectives. Westport, CT, London, Praeger.
[27] Mezzich JE,
Snaedal J, van Weel C, Heath I: From disease to patient to person: Towards a
Person-centered Medicine. Mount Sinai Journal of Medicine, in press.
[28] Miles A (2009). On a Medicine of
the Whole Person: away from scientistic reductionism and towards the embrace of
the complex in clinical practice. Journal of Evaluation in Clinical Practice
15: 941-949.
