What is good acute psychiatric care (and how would you know)?

Abstract

truths – truths perhaps accessible only to forms of self-conscious or hyperreflexive awareness unavailable to most of us. In closing, one must acknowledge some gaps in our grasp of subjectivity and its significance for psychiatry. It may be obvious to common sense that the exercise of free will, together with a person’s experience of meaning or significance, do play a role in human behavior and thereby affect the material plane of brain functioning (if I choose to close my eyes, in prayer, patterns in visual cortex are altered). But it is also true that we have difficulty incorporating the domains of conscious life and its physical substrate within a single explanatory account (the mind/body problem). In particular, we have difficulty integrating “act” with “affliction” aspects of psychological existence – that is, appreciating the subtle but decisive ways in which defensive or other goal-directed forms of thought or behavior can interact with aspects of mental life over which the person has little or no control. Even more basic is the challenge of observing and describing consciousness itself, whose ever-changing, all-encompassing flow we, as human beings and language speakers, are constantly tempted to misperceive or misdescribe. We succumb to this temptation by using words that stress the substantive over the transitory aspects of experience, or by focusing on particular objects of awareness while ignoring subtle alterations in, for example, the experience of space, time, or the overall atmosphere of reality. In fact, no approach can be fully “bottom-up” in the sense of being purely empirical or a-theoretical: when it comes to describing experience, patients as well as professionals are burdened (though also blessed) with the objectifying prejudices of their language and their worldview. The study of “lived experience” may then be impossible as a foolproof, quasi-empiricist venture. It is, however, also indispensable – and to both the ethical and the scientific enterprise of psychiatry.