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The Psychiatrist as Helping Professional

Assuming that psychiatric disorders imply restrictions of freedom and autonomy (see Chapter V, 3.4.3), how do psychiatrists approach their patients from this basic notion? The main question is, who or what is considered responsible for the origin of a psychiatric disorder? In other words, if it is not patients’ fault and responsibility that they have come to this, then whose is it? There are, as is well-known, many kinds of hermeneutical explanations. In each of these responsibility for psychiatric disorders is laid elsewhere.

In intrapsychical theories of explanation, the most important of which is the psychoanalytic, explanations are sought in people’s early experiences, particularly in early childhood. People are not or hardly held responsible for their early experiences. During treatment their parents are considered responsible for what they did with the child. So the person himself is exculpated and the parents are in a sense incriminated. Certain factors in the child could be relevant. Alice Miller mentions giftedness in children as a possible source of neuroses although the child is not at all held responsible of course.

Client-centered psychotherapy (Rogers) is based on the axiom that if the therapist can accomplish a number of basic conditions in his relationship with patients the latter will develop themselves further and expand their autonomy. These basic conditions involve general human values such as warmth, genuineness, unconditional positive regard, and acceptance. This axiom implies that people who can so recover have in the past not been given adequate opportunities by their fellow humans to develop themselves. Otherwise these special conditions of psychotherapy would not be necessary. So the explanation, if not the blame, and with that, the responsibility for the patients’ disorders is placed on the environment.

Family interaction theories differ. The Laingian view leaves no doubt about the blame: the origin of psychoses is to be found in the destructive terror of the family. Other theories also put responsibility with the family. The “schizophrenic mother” is a more concrete condemnation. In some theories of family interaction the idea of the existence of a patient is considered wrong. The family system is to be viewed as the patient while the patient who applied for treatment has only been “labeled” as such. Yet other theories emphasize not so much families’ responsibility for the origin of the disorder as their capacity to deal with or solve it.

Sometimes society as a whole is blamed, especially by Marxist psychiatrists . Perhaps Szasz, although certainly not a Marxist, also belongs in this group, as to an important degree he holds the paternalistic tendencies of states as partly responsible for the existence of psychiatric disorders.

I could name more examples but these suffice to make the point. Every theory of explanation exculpates the patient one way or another except for one, namely, that the disorder is the person’s own fault. As far as I know no one in psychiatry holds this theory any longer. This way of thinking in history is probably most clearly represented by Heinroth. He ascribed mental illness to sin and guilt, and willing submission to evil. Other representatives of this position in distant history are to be found in religion rather than medicine. Perhaps Szasz, too, to a certain extent, belongs in this peculiar group because he asserts that people abscond from responsibility by displaying psychiatric disorders. (See 4 below.)

Exculpating theories of explanation also affect the subjects to whom the theories are applied. Exculpation can be seen as an authentic explanation of events, but also, just as well, as a maneuver aimed at releasing a particular patient of his stifling guilt feelings, freeing up space for development and change. Szasz points out that exculpation is at the same time infantilization. This element becomes even more clear when viewing therapeutic statements in different theories of explanation.

In general psychiatry poses a paradox for patients, by which is meant a seeming irreconcilability. “You are not responsible for the fact that you are ill (as is obvious, among other things, by your behavior), but you are responsible for your actions.” This is especially obvious in forced measures applied to psychiatric patients for restlessness, hyperactivity, or aggressiveness. Psychotherapy features the paradox, “The disorder makes you unfree and thus incompetent; to recover you are offered a relationship in which you are considered free, responsible, and competent, so that you can become free again.”

In principle there are only two possibilities. The first is an offer of care, an offer in which helping professionals acknowledge and accept patients’ powerlessness and inability to be different, choose their side, and offer guidance. This offer changes patients’ situations so they themselves can change. But if they do not change that is all right too. The point is not changing them but accepting them as they are. The other possibility is an offer of treatment with the inherent purpose and desirability of change. But in psychiatry that is not only a change in the current situation. It is also a change in people’s functioning, the patients themselves must change. For psychoanalysis this treatment offer implies a paradox which Szasz expresses thus: psychoanalysis is a historistical theory, and at the same time, an antihistoristical therapy. More generally, the paradox can be formulated as this: the patient has become ill due to no fault of his own, but healing himself is within his capacity, albeit with the assistance of the person who offers this paradox. In psychotherapy, again the offer of the paradox is paradoxical: although no advice, medication, and so forth are offered as the patient must himself lead the way to recovery, yet in the offer of psychotherapy itself a prescription is given, and the way to recovery pointed out.

Finally, in practice, one is confronted daily with two sides of the view that people with psychiatric disorders cannot be held responsible for them. One side is that patients are not necessarily burdened by guilt about their failures. The other side is that they may be passive about their recovery and leave whatever is to happen to them up to the helping professional. Sometimes, for instance, in the case of disorders that respond well to medication, the passive attitude is not so disadvantageous. Often, however, patients shortchange themselves by being passive, and in so doing reduce their chances of recovery. Helping professionals are challenged with the task of attempting to clarify to them that their own actions and efforts are important for their own future prospects. This means that a disease concept which absolves them of all responsibility for their being ill can actually only make them sicker. The realization that one is not totally powerless but primarily responsible for what one makes of one’s own life is a highly important realization in psychiatry. This is so not only in the sense of accepting the disorder, comparable to accepting a somatic disorder, but particularly in the sense of the opportunity for changing the disorder itself that this realization can bring about. Furlong concludes, “Empirically, a sense of inner determination, freedom, and choice appears to be a mark of mental health.” This means that when psychiatrists succeed in clarifying to patients that they are not powerless but rather remain themselves responsible for what they make of their lives, not only has the probably most important condition for recovery been created, but at the same time the process of recovery is in fact already occurring. This means nothing more or less than that patients are not held responsible for the conditions in which they find themselves yet by taking responsibility for their recovery upon themselves they are already recovering.

The main problem in practice in psychiatric treatment is where to draw the line between accepting patients’ helplessness and powerlessness, and confronting them with their responsibility for their own lives. When someone is about to drown it is not helpful telling him about the different ways he might learn to swim. Helping professionals are first of all to pull the person back onto dry land. In such circumstances pointing out responsibility is heartless as obviously the person is not able to come out of the water on his own. Yet helping professionals who repeatedly pull such a person out of the water and then let him fall back in are not only lacking, they are also making the person prone to drowning dependent on them, in addition to all of his other problems. This line is partly drawn by the helping professionals’ intuition, experience, personal qualities, courage, and special skills, so that patients’ treatment is hardly transferable or objective.

A special difficulty is that as a rule patients cannot know how their psychiatrists will approach them and to which explanatory theory they subscribe. It means that “informed consent” which includes psychiatrists’ explanations of their views is extremely important. On the other hand, the theory of explanation could lose its power when told. That is the case in a modification of psychoanalytic theory proposed by Taylor. He suggests using the tactics that most efficiently evoke behavioral changes regardless of the contextual correctness. So a contention would not have to be true, as long as it stimulates change. Possibly a part of directive therapy, namely, the paradoxical approach, would also lose its efficacy if patients were told exactly (so: not paradoxically) what the treatment entails. This raises the question to what extent such treatments are morally justifiable. For the sake of brevity this will not be discussed here.
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