Philosophers, Carers, and Psychodramatic Games Corinne Gal (bio), Alexandre Chapy (bio), Marielle Fau (bio), and Muriel Guaveia (bio) Dear Jonathan D. Moreno, Thank you for the honor of taking the time to comment on the work we do. It is very meaningful for us to be able to talk with you. We, too, see a big difference between philosophers and carers (in the broadest sense) who deal with the suffering of patients and try to find methods to help them. But, if theory is at the service of the clinic, it becomes a formidable asset to refine our therapeutic methods and better understand what is happening to our patients. Indeed, patients suffering from psychosis, severe neurosis … are difficult to accompany and “recalcitrant to therapy by word alone” to use your terms. It is on this point that Ludwig Binswanger distanced himself from psychoanalysis. Binswanger ran a sanatorium in Switzerland (the Bellevue Clinic) and took in patients suffering from this type of psychological pathology. Aware that “the divan” and the analysis of the transference (unconscious) made little progress, he sought other ways of understanding his patients. The work of Edmund Husserl, the founder of the phenomenological movement, and then the work of Martin Heidegger1 fascinated him because they attempted to answer fundamental questions about being. The patients we work with ask themselves and us the same question: What is being? How can we feel existence within ourselves? Binswanger then created daseinsanalysis as an analysis of existence in which he was able to develop, among other dimensions, what he called “artists’ gestures,” including the possibility of (physical) contact with the patients. The body regained existential importance in the therapy. There are also strong similarities between psychiatric phenomenology and the work of Jacob Levy Moreno (2014, p. 214). We would like to quote your work: “ Nonetheless, there were links between them. Heidegger and J.L. shared preoccupation with personal authenticity and meaning [End Page 230] just enough to be considered part of the trends that led to postwar existentialism and fueled the new humanistic psychology, NTL, and encounter groups.” Jacob Levy Moreno’s working methods are much more powerful, allowing us to work as closely as possible with bodily feelings, since the body involved in the action is so present in psychodrama. Because, to this question of being posed by our patients, is linked the body as a felt, sensing body: the body that I am (which differs from the object body). Schizophrenic patients often express, and this is a terrible suffering, that they no longer feel anything, that they no longer feel they exist, that they no longer feel emotions or feelings. They do not know how to be in the world and with others. For us it is a fundamental symptom, as much as hallucinations. We link it to the loss of natural evidence (Blankenburg, 1991), the loss of contact with reality (Minkowski, 1929). Most of the time, in psyc
Corinne Gal(个人简介)，Alexandre Chapy(个人简介)，Marielle Fau(个人简介)和Muriel Guaveia(个人简介)亲爱的Jonathan D. Moreno，感谢您抽出时间评论我们所做的工作。能和你谈话对我们来说很有意义。我们也看到了哲学家和护理人员(广义上)之间的巨大差异，后者处理病人的痛苦，并试图找到帮助他们的方法。但是，如果理论是为临床服务的，它就会成为完善我们的治疗方法和更好地了解我们病人身上发生的事情的强大资产。的确，患有精神病和严重神经症的病人很难陪伴，用你的话来说，他们“不愿单靠言语治疗”。正是在这一点上，路德维希·宾斯旺格与精神分析拉开了距离。宾斯旺格在瑞士开了一家疗养院(贝尔维尤诊所)，收留患有这种心理疾病的病人。意识到“沙发”和移情(无意识)分析几乎没有进展，他寻求其他方法来理解他的病人。现象学运动的创始人埃德蒙·胡塞尔和马丁·海德格尔的作品都使他着迷，因为他们试图回答关于存在的基本问题。我们治疗的病人会问他们自己和我们同样的问题:什么是存在?我们怎样才能感受到自身的存在?宾斯旺格随后创造了daseinsanalysis，作为一种对存在的分析，在这种分析中，他能够在其他维度中发展他所谓的“艺术家的姿态”，包括与病人(身体)接触的可能性。身体在治疗中重新获得了存在的重要性。精神病学现象学与Jacob Levy Moreno (2014, p. 214)的作品也有很强的相似之处。我们想引用你的作品:“尽管如此，他们之间还是有联系的。海德格尔和J.L.对个人真实性和意义的共同关注，足以被认为是导致战后存在主义的趋势的一部分，并推动了新的人文主义心理学、NTL和相遇团体。”雅各布·利维·莫雷诺(Jacob Levy Moreno)的工作方法更加强大，允许我们尽可能地与身体感觉密切合作，因为参与动作的身体在心理剧中是如此的存在。因为，我们的病人提出的这个问题，是把身体作为一个感觉的，感知的身体联系起来的:我的身体(它不同于客体身体)。精神分裂症患者经常表达，这是一种可怕的痛苦，他们不再有任何感觉，他们不再觉得自己存在，他们不再有情绪或感觉。他们不知道如何生活在这个世界上，如何与他人相处。对我们来说，这是一种基本症状，就像幻觉一样。我们将其与自然证据的丧失(Blankenburg, 1991)、与现实的接触的丧失(Minkowski, 1929)联系起来。大多数时候，在心理剧中，我们“外化”患者在玩家扮演的不同角色中的感受，这使我们能够在每个人的互动中遇到困难的核心。安妮·安塞琳·施岑伯格(Anne Ancelin schzenberger)对我们进行了心理剧的训练，我们有一套技巧来支持心理剧的表达，这是一种“工具箱”。根据情境，病人的时刻，我们自己的状态，我们打开我们的工具箱，尝试选择和使用最适合游戏需求的技术，以及我们对主角或团队难度的理解。我们不做任何系统的事情，我们是工匠。我们选择呈现一个非常简单的游戏，没有使用任何技术，除了最初的独白，一个稳定的病人患有无症状的精神分裂症。这是为了证明相遇的可能性，构成了存在，是心理剧的一个基本维度。我们感谢你为我们提供的例子，它们将成为灵感的源泉，并将充实我们的工具箱。致约翰·诺尔特:我们非常感谢您的评论，这使我们感到荣幸。这篇文章的目的是展示在……
{"title":"Philosophers, Carers, and Psychodramatic Games","authors":"Corinne Gal, Alexandre Chapy, Marielle Fau, Muriel Guaveia","doi":"10.1353/ppp.2023.a908274","DOIUrl":"https://doi.org/10.1353/ppp.2023.a908274","url":null,"abstract":"Philosophers, Carers, and Psychodramatic Games Corinne Gal (bio), Alexandre Chapy (bio), Marielle Fau (bio), and Muriel Guaveia (bio) Dear Jonathan D. Moreno, Thank you for the honor of taking the time to comment on the work we do. It is very meaningful for us to be able to talk with you. We, too, see a big difference between philosophers and carers (in the broadest sense) who deal with the suffering of patients and try to find methods to help them. But, if theory is at the service of the clinic, it becomes a formidable asset to refine our therapeutic methods and better understand what is happening to our patients. Indeed, patients suffering from psychosis, severe neurosis … are difficult to accompany and “recalcitrant to therapy by word alone” to use your terms. It is on this point that Ludwig Binswanger distanced himself from psychoanalysis. Binswanger ran a sanatorium in Switzerland (the Bellevue Clinic) and took in patients suffering from this type of psychological pathology. Aware that “the divan” and the analysis of the transference (unconscious) made little progress, he sought other ways of understanding his patients. The work of Edmund Husserl, the founder of the phenomenological movement, and then the work of Martin Heidegger1 fascinated him because they attempted to answer fundamental questions about being. The patients we work with ask themselves and us the same question: What is being? How can we feel existence within ourselves? Binswanger then created daseinsanalysis as an analysis of existence in which he was able to develop, among other dimensions, what he called “artists’ gestures,” including the possibility of (physical) contact with the patients. The body regained existential importance in the therapy. There are also strong similarities between psychiatric phenomenology and the work of Jacob Levy Moreno (2014, p. 214). We would like to quote your work: “ Nonetheless, there were links between them. Heidegger and J.L. shared preoccupation with personal authenticity and meaning [End Page 230] just enough to be considered part of the trends that led to postwar existentialism and fueled the new humanistic psychology, NTL, and encounter groups.” Jacob Levy Moreno’s working methods are much more powerful, allowing us to work as closely as possible with bodily feelings, since the body involved in the action is so present in psychodrama. Because, to this question of being posed by our patients, is linked the body as a felt, sensing body: the body that I am (which differs from the object body). Schizophrenic patients often express, and this is a terrible suffering, that they no longer feel anything, that they no longer feel they exist, that they no longer feel emotions or feelings. They do not know how to be in the world and with others. For us it is a fundamental symptom, as much as hallucinations. We link it to the loss of natural evidence (Blankenburg, 1991), the loss of contact with reality (Minkowski, 1929). Most of the time, in psyc","PeriodicalId":45397,"journal":{"name":"Philosophy Psychiatry & Psychology","volume":"41 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135588281","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1353/ppp.2023.a908268
Marga Reimer
Understanding First: Exploring Its Scope and Testing Its Limits Marga Reimer, PhD (bio) I thoroughly enjoyed reading and reflecting on this provocative, engagingly written, and persuasively argued paper. My commentary focuses on the authors’ “understanding first” principle. I begin by exploring that principle’s scope by appeal to aesthetic analogues to the moral cases of Pete and Jacob; I then explore its limits by appeal to cases involving agents struggling with maladaptive traits that are more self-destructive than antisocial. According to the authors, when attempting to eliminate or reduce a maladaptive trait, it is important that the agent begin with a non-moralizing understanding of that trait’s “root cause.” In this way, the agent avoids some of the epistemically distorting and otherwise counterproductive effects associated with an approach that begins with a moralizing assessment of the problematic trait. They can then proceed with a reason-based “dispensation” of that trait. The cases of Pete and Jacob make these points vivid and lend them considerable credence. Moreover, the authors’ “understanding first principle” arguably exemplifies a more general, and no less plausible, principle concerning the remediation of virtually any problem. Who would deny that an objective, non-normative, understanding of a problem’s “root cause” might be useful in addressing that problem? Who would deny that normativizing a problem before understanding its origin might prevent a deeper understanding of that problem and therewith its maximally effective “treatment”? One way to showcase the intuitiveness of the authors’ “understanding first” principle would be to explore the applicability of an analogous principle to problems beyond those involving “moral matters.” Problems involving aesthetics might prove particularly illuminating in this regard insofar as aesthetics, like morality, is inherently normative and yet it lies beyond the scope of morality proper. If an “understanding first” principle can be shown to be applicable to certain types of aesthetic problems, then the authors’ already strong case for the applicability of such a principle to certain types of moral problems would be further strengthened. In the cases of Pete and Jacob, the problems are unambiguously moral: the patently antisocial behaviors of these two individuals are paradigmatically “bad” and their premature assessment as [End Page 205] such can be epistemically distorting and otherwise counterproductive. Consider now analogous cases involving aesthetic problems. Pete and Lucie are getting ready for the holidays and are expecting family from out of town. But there are a couple of problems. Pete notices an “ugly” stain on the living room carpet and Lucie notices a subtle but decidedly “nasty” odor permeating the entire house. Neither Pete nor Lucie know where the stain came from, nor where the odor is coming from. But both the stain and the odor are “pretty gross” and so they need to “get
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Pub Date : 2023-09-01DOI: 10.1353/ppp.2023.a908269
James Phillips
The Limits of Self-Constitution James Phillips, MD (bio) I am in general agreement with the authors that a psychoanalytic or psychodynamic approach is a good response to simple pruning procedures. That said, however, I do have questions about how they develop their argument. I was surprised at the very notion of pruning, and quite surprised that it is as popular as the authors suggest. The idea that Pete should deal with his inappropriate outbursts by erasing or pruning that aspect of his personality seems so ridiculous that it beggars belief. It leaves one wondering whether Pete, or anyone agreeing with this argument, is credulous enough to think you can just prune away an undesirable part of yourself. The authors write: Importantly, this expulsion is often thought to be a good thing not simply because the undesirable elements are morally wanting but because in some important sense, they are not really a part of the agent proper. This point many seem extravagantly wishful, but is intuitively plausible. Really, “intuitively plausible” that personality traits are not part of the agent? I can understand that the agent may not grasp his or her involvement in the undesirable trait, but to argue that the trait is in reality not part of agent is a very odd claim on the part of the authors. When the authors write that “It would be difficult to exaggerate the prominence of the pruning view of agential self-constitution in philosophy,” they are strongly connecting the notions of pruning and self-constitution. I am aware that self-constitution is a major theme for philosophers like Korsgaard. The authors strongly embrace this principle in drawing out their arguments. In a footnote to their article the authors claim that various notions of a “true self” imply a pruned self. For Winnicott, an originator of the “true self,” this note of pruning does not hold. Winnicott contrasts the true self, a sense of self based on spontaneous authentic experience and a feeling of being alive, with a false self, a defensive veneer without the vivacity of the true self. The notion of pruning simply does not belong in this discussion. What the authors and their supporting philosophers leave out are two limitations to self-constitution. For the first, let me invoke another philosopher, Martin Heidegger, and his notion of “thrownness”—Geworfenheit. We are “thrown” into the world in the particular circumstances of our birth. We do not self-constitute our beginnings; we are plunged into them. The question then becomes what we make of these beginnings. [End Page 209] If they are undesirable, we can brood over them, or we can attempt to overcome them. And as we all know, if the beginnings are bad enough, we may not be able to overcome them. The second limitation to self-constitution resides in the “self.” Does the individual constitute him or her self, or is it more a matter of the self developing out of dialogic relationship of self and other? Here I invoke another philosopher, P
自我构成的极限詹姆斯·菲利普斯，医学博士(生物)我基本上同意作者的观点，即精神分析或精神动力学方法是对简单修剪程序的一个很好的回应。尽管如此，我还是对他们的论点有疑问。我对修剪的概念感到惊讶，也很惊讶它像作者所说的那样受欢迎。皮特应该通过抹去或修剪他个性的这一方面来处理他不恰当的爆发的想法似乎是如此荒谬，以至于令人难以置信。这让人怀疑，皮特或任何同意这一观点的人是否足够轻信，认为你可以把自己不受欢迎的部分修剪掉。作者写道:重要的是，这种驱逐通常被认为是一件好事，不仅仅是因为不受欢迎的元素在道德上是缺乏的，而是因为在某种重要的意义上，它们并不是真正的主体的一部分。这一点似乎是一厢情愿，但从直觉上讲是合理的。人格特征不是行为人的一部分，这种“直觉上似乎合理”的说法是真的吗?我能理解行为人可能没有意识到他或她参与了不受欢迎的特质，但认为这种特质实际上不是行为人的一部分，这是作者非常奇怪的主张。当作者写道“很难夸大主体自我构成的修剪观点在哲学中的重要性”时，他们将修剪和自我构成的概念紧密地联系在一起。我知道自我构成是像科斯加德这样的哲学家的一个主要主题。作者在阐述他们的论点时强烈地采用了这一原则。在文章的脚注中，作者声称，“真我”的各种概念都暗示着一个被修剪过的自我。对于“真我”的创始人温尼科特来说，这种“修剪”的说法并不成立。温尼科特将真实的自我与虚假的自我进行了对比，真实的自我是一种基于自发的真实体验和活着的感觉的自我意识，虚假的自我是一种缺乏真实自我活力的防御性外表。修剪的概念根本不属于这个讨论。作者和支持他们的哲学家忽略了自我构成的两个限制。首先，让我引用另一位哲学家马丁·海德格尔(Martin Heidegger)和他的“抛掷”概念——geworfenheit。我们是在出生的特殊情况下被“扔”到这个世界上的。我们不能自我构成我们的开端;我们陷入其中。那么问题就变成了我们如何看待这些开端。如果它们是不受欢迎的，我们可以沉思它们，或者我们可以尝试克服它们。我们都知道，如果一开始就很糟糕，我们可能无法克服它们。自我构成的第二个限制在于“自我”。是个体构成了他或她的自我，还是从自我与他人的对话关系中发展出来的自我?在这里，我要引用另一位哲学家保罗·里科，他从多个角度探讨了这个问题。在指示层面上，“我”或自我是一个移位者，根据其上下文具有不同的含义。在语用学的层面上，个体从事于对另一个人的言外之语，简单地说，这意味着我们生活在对话中。与这一讨论更相关的是，Ricoeur注意到自我认识并不是直截了当地的:“自我并没有立即认识自己，而是通过各种各样的文化标志迂回地间接认识自己，这些文化标志使我们说行动是象征性地中介的”(Ricoeur, 2016, p. 240)。最后，Ricoeur主张替代性优先于反身性。“将差异性置于反身性之上进一步推进，一些人会强调个人身份依赖于对……的认同。”英雄、象征人物、模范和教师”(第248页)。为了澄清这一说法，Ricoeur将通过反思的自我构成与自我-他者关系进行了对比，在这种关系中，自我需要他者来构成自己——当然，他是在为后者辩护。虽然我在质疑作者关于……的概念。
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Pub Date : 2023-09-01DOI: 10.1353/ppp.2023.a908272
Jonathan D. Moreno
Notes on Psychodramatic Treatment of a Person with Schizophrenia Jonathan D. Moreno, PhD (bio) I have enjoyed reflecting on Mr. Chapy’s account of work in psychodrama with a patient with schizophrenia. Although at one time many years ago I was interested in phenomenological psychiatry, and especially the writings of Ludwig Binswanger and Medard Boss, I am not an authority on dasein-analysis, so I have nothing to add to the discussion. I should say, however, that my father had little interest in this approach, which was far too abstract for his taste. He proceeded from the standpoint of the theater, of action and enactment. He believed that the drama itself provided the insight. For the purposes of this response, I take it as a given that the patient in question has been accurately diagnosed, although in the description of the scene with his father he does not exhibit the usual symptoms, such as auditory hallucinations. People with schizophrenia often find it difficult to manage the voices they are hearing without substantial preparation for a psychodrama. According to psychodramatic method, one way to prepare them is to externalize the voices, allowing a different therapist to take the role of each one as the protagonist instructs them how to play that role. Chair may be set up so that each “voice,” personified by an auxiliary ego, can sit in each chair in an array. This preparation may require a number of sessions. If the scene is to be enacted with a significant other, like the father in this instance, the patient may not be able to warm up to a direct encounter, especially with all the different voices competing for his internal attention. So he may be directed to observe each voice in the encounter with his father, preferably played by a therapist of his choosing and trained for the role, usually by giving the father-player certain lines so that they can learn something about the father and the way he addresses his son. Or consider the patient whose illness manifests itself as delusions, often of a megalomaniac character. They may be a messiah, for example, or the rightful heir of a royal line whose identity is being suppressed by governmental forces. The patient might be invited to choose key therapists to play the roles of key members of their circle, [End Page 225] enacting critical scenes like the sermon on the mount or speeches to their oppressed followers. In this way the patient’s “act hunger” may be to some degree satiated and have a calming effect on their anxiety and irritation with the frustrating world around them that refuses to accept their “authentic” identity and belief system. In these ways, psychodrama therapy can take advantage of one of the remarkable advantages of this method for such patients, who are generally recalcitrant to talk therapy alone and for whom medication is at best modestly effective. Still, these disorders are among the most challenging for psychotherapists. Although the process of treating them may open
{"title":"Notes on Psychodramatic Treatment of a Person with Schizophrenia","authors":"Jonathan D. Moreno","doi":"10.1353/ppp.2023.a908272","DOIUrl":"https://doi.org/10.1353/ppp.2023.a908272","url":null,"abstract":"Notes on Psychodramatic Treatment of a Person with Schizophrenia Jonathan D. Moreno, PhD (bio) I have enjoyed reflecting on Mr. Chapy’s account of work in psychodrama with a patient with schizophrenia. Although at one time many years ago I was interested in phenomenological psychiatry, and especially the writings of Ludwig Binswanger and Medard Boss, I am not an authority on dasein-analysis, so I have nothing to add to the discussion. I should say, however, that my father had little interest in this approach, which was far too abstract for his taste. He proceeded from the standpoint of the theater, of action and enactment. He believed that the drama itself provided the insight. For the purposes of this response, I take it as a given that the patient in question has been accurately diagnosed, although in the description of the scene with his father he does not exhibit the usual symptoms, such as auditory hallucinations. People with schizophrenia often find it difficult to manage the voices they are hearing without substantial preparation for a psychodrama. According to psychodramatic method, one way to prepare them is to externalize the voices, allowing a different therapist to take the role of each one as the protagonist instructs them how to play that role. Chair may be set up so that each “voice,” personified by an auxiliary ego, can sit in each chair in an array. This preparation may require a number of sessions. If the scene is to be enacted with a significant other, like the father in this instance, the patient may not be able to warm up to a direct encounter, especially with all the different voices competing for his internal attention. So he may be directed to observe each voice in the encounter with his father, preferably played by a therapist of his choosing and trained for the role, usually by giving the father-player certain lines so that they can learn something about the father and the way he addresses his son. Or consider the patient whose illness manifests itself as delusions, often of a megalomaniac character. They may be a messiah, for example, or the rightful heir of a royal line whose identity is being suppressed by governmental forces. The patient might be invited to choose key therapists to play the roles of key members of their circle, [End Page 225] enacting critical scenes like the sermon on the mount or speeches to their oppressed followers. In this way the patient’s “act hunger” may be to some degree satiated and have a calming effect on their anxiety and irritation with the frustrating world around them that refuses to accept their “authentic” identity and belief system. In these ways, psychodrama therapy can take advantage of one of the remarkable advantages of this method for such patients, who are generally recalcitrant to talk therapy alone and for whom medication is at best modestly effective. Still, these disorders are among the most challenging for psychotherapists. Although the process of treating them may open ","PeriodicalId":45397,"journal":{"name":"Philosophy Psychiatry & Psychology","volume":"30 1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135588282","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1353/ppp.2023.a908279
Chloe Saunders
Abstract: Psychiatric diagnoses are increasingly seen as viable categories around which self and social identities might be drawn. This introduces a new pressure on the “boundary problem” for psychiatry: when members of the public request diagnoses to affirm their self-identities how should we draw the line between mental disorder and normality? If psychiatrists have the authority to recognize and diagnose mental disorder, how can roles as diagnosers and gate-keepers be balanced in a post-stigma era of mental health care? Focusing on the disorder identified would-be patient who would not attract the diagnosis they seek were they not to seek it, this essay explores what it means to have an identity bound to a psychiatric diagnosis and considers a framework for psychiatrists to negotiate clinical encounters that involve the seeking of identity affirming diagnoses.
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Abstract: The authors argue that Morenian-inspired existential psychodrama turns out to be a formidable lever for opening up existence as it allows schizophrenic patients to incorporate the experience of an “absolutely other” on which the foundation of any autonomous self is built. More precisely, by relying on their clinical experiences, the authors show how psycho-dramatic play goes along with an intense movement of original projection which carries psychotic patients externally in relation to themselves. Offset from their pathological world, these patients feel more inclined to “wear someone else’s shoes,” for the duration of the game, and they do so in a manner that is both sensorial and pathic. This surprising and creative “journey,” which allows them to return to the world better attuned to others and to themselves, is merely an enactment of a “true” intersubjective encounter: the very essence of existential psychodrama. By applying phenomenology to this psychodramatic method, notably by relying on the hypothesis of psychosis being a disorder of what Bin Kimura calls the “ aida ,” the authors hope to contribute to the advancement of psychosis’ psychotherapy.
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Pub Date : 2023-09-01DOI: 10.1353/ppp.2023.a908270
Iskra Fileva, Linda A.W. Brakel
Could Understanding Harm? Iskra Fileva, PhD (bio) and Linda A.W. Brakel, MD (bio) We would like to thank the editors for organizing this symposium and our commentators—Marga Reimer and James Phillips—for the thought-provoking feedback. Although we had thought about the ideas we discuss from many different angles, our commentators raised several interesting issues we had not considered. We are grateful for the opportunity to continue the conversation. Reply to Reimer As Professor Reimer notes, we advocate an approach to self-constitution that we dub “understanding first.” On this approach, non-moral and non-normative understanding of the origin of maladaptive traits must precede moral evaluation and attempts to free oneself—or as we say “prune”—undesirable traits. Professor Reimer presents several interesting cases meant both to extend and test the limits of our proposal. We appreciate this approach and respond to each case in turn. Genes and Alcoholism Suppose Alejandro, an adult raised by adoptive parents, struggles with alcohol addiction. He learns that his biological parents died of alcoholic liver disease and comes to believe that his alcohol problem is caused by a genetic propensity toward alcohol abuse. One can ask: “Does an understanding first approach have the potential to undermine the sense of agency that is necessary for the effective treatment of maladaptive traits?” Answer: It can be explained to Alejandro that genetic proclivities are just that—proclivities—that can be overridden. In fact, behavior can alter our very genes—although not at the sequence level— changes known as “epigenetic.” And the liver disease of the biological parents can serve as a cautionary tale. If even in light of these considerations, Alejandro’s tendency to see genetic propensities as deterministic persists, it is worth asking why. There is no evidence that “genes are destiny,” so the disposition to see them that way must have a psychological explanation. What is the explanation? A self-destructive desire? Fear of freedom? This exploration can itself be empowering. [End Page 211] Adaptive Forgetting Suppose Beata, who has an eating disorder, was molested by her own father when she was a child. Subsequently, her father shot himself and now she has no recollection of the molestation. However, Beata’s eating disorder is largely a result of those experiences. It is quite possible that if Beata were to recall being molested, that would do more harm than good. In this connection, one can ask together with Reimer: “Does an understanding first approach have the potential to undermine an adaptive ‘forgetting’ of root causes of maladaptive traits?” Answer: Here, understanding the history, instead of forgetting it, might allow Beata to gain insight into and empathize with possible motives that may have led to becoming obese. For example, she might have the phantasy that if she had been obese and unattractive, she could have prevented the molestation—hence, become that
理解会造成伤害吗?Iskra Fileva，博士(生物)和Linda A.W. Brakel，医学博士(生物)我们要感谢编辑组织这次研讨会和我们的评论员——marga Reimer和James phillips——为发人深省的反馈。虽然我们从许多不同的角度思考了我们讨论的观点，但我们的评论员提出了几个我们没有考虑到的有趣问题。我们很感激有机会继续对话。正如雷默教授所指出的，我们提倡一种自我建构的方法，我们称之为“理解为先”。在这种方法中，对不适应特征的起源的非道德和非规范的理解必须先于道德评价和试图释放自己——或者正如我们所说的“修剪”——不受欢迎的特征。Reimer教授提出了几个有趣的案例，旨在扩展和测试我们建议的局限性。我们赞赏这种做法，并对每个案件轮流作出回应。假设由养父母抚养长大的成年人亚历杭德罗与酒精成瘾作斗争。他得知他的亲生父母死于酒精性肝病，并开始相信他的酗酒问题是由酗酒的遗传倾向引起的。有人可能会问:“理解第一的方法是否有可能破坏有效治疗适应不良特征所必需的能动性?”回答:可以向亚历杭德罗解释，遗传倾向只是可以被推翻的倾向。事实上，行为可以改变我们的基因——尽管不是在序列水平上——这种改变被称为“表观遗传”。而亲生父母的肝脏疾病可以作为一个警示。即使考虑到这些因素，亚历杭德罗将遗传倾向视为决定性的倾向仍然存在，我们也有必要问一下为什么。没有证据表明“基因决定命运”，所以这样看待它们的倾向一定有心理学上的解释。解释是什么?自我毁灭的欲望?害怕自由?这种探索本身就是一种力量。适应性遗忘假设贝娅塔患有饮食失调症，在她还是个孩子的时候被她自己的父亲猥亵过。后来，她的父亲开枪自杀了，现在她对性骚扰没有任何记忆。然而，贝娅塔的饮食失调很大程度上是这些经历的结果。很有可能，如果贝娅塔回忆起自己被猥亵过，那将弊大于利。在这方面，我们可以和雷默一起问:“理解第一的方法是否有可能破坏对不适应特征根源的适应性‘遗忘’?”回答:在这里，理解历史，而不是忘记它，可能会让Beata深入了解和同情可能导致肥胖的动机。例如，她可能会幻想，如果她肥胖且没有吸引力，她就可以阻止性骚扰——因此，她现在变成那样是为了防止性骚扰再次发生，更希望能逆转它。(在无意识的进行中，时间被认为存在于“未经检验的现在”中)(brake 2009, p. 63;2015，第131页;2022，第4页;2023，第404页。)这样做的一个好处是，在获得这种类型的认可后，Beata可能会发现改变自己的行为更容易，否则她不会这样做;防止自己被骚扰从来都不是她的责任，她现在也没有理由让自己对已故的父亲失去吸引力，也没有理由为了阻止现在的男人而保持肥胖。克莱尔是一名钢琴演奏家和酒鬼。重要的是，克莱尔并不认为自己对酒精的渴望是破坏性的，相反，这是她自己身份的组成部分。她说:“没有酒精，我就不是我自己。”雷默问道，我们的方法是否“适用于行为人将适应不良特征视为其身份组成部分的情况?”回答:虽然没有一种方法可以保证成功，但我们的观点是，我们的方法比被称为修剪视图的主要替代方法有更好的机会。既然根据规定，克莱尔不倾向于把自己的酗酒视为一个问题，那么…
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Pub Date : 2023-09-01DOI: 10.1353/ppp.2023.a908276
Peter Zachar
Diagnostic Criteria, Psychological Tests, and Ratings Scales: Extending the History Peter Zachar, PhD (bio) Le moigne narrates a history of the development of psychiatric ratings scales as hybrids between psychological tests and diagnostic categories. In his telling, psychological tests seek to quantify population-based traits on which every person has a position and which tend to be conceptualized as being stable. Personality traits are often conceptualized as dispositions. Diagnostic categories represent not trait-like properties of populations but episodic states consisting of clusters of symptoms experienced by individuals with disorders. Ratings, scales, he notes, are hybrids between the two. They are used to quantify psychiatric symptom clusters so that change over time can be measured. Le Moigne argues that these distinctions were initially suggested during the development of measures that could assess outcomes in psychopharmacological treatment studies. With respect to depression, Le Moigne writes that in the 1970s and 1980s something akin to depressive personality was reconceptualized as a temperament. A key move, somewhat reflective of Kraepelin’s notion of a depressive temperament, was to view a dysthymic temperament as both a predisposing factor and an attenuated form of depression. Thus, an episodic state commandeered the predisposing–dispositional role that was assigned to stable personality traits. This conceptual shift allowed test-like ratings scales to be seen as useful for quantifying not just stable traits, but salient features of episodic states that are potentially subject to change in response to interventions. To put it another way, in the development of a psychological test, one goal is to have high test-retest reliability (i.e., stability of measurement). With rating scales used to measure change, one wants the scores to not be as stable; ideally the scores on the later assessments will be lower. According to Le Moigne, when dysthymia was subsequently placed on axis I of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III (as a syndrome) and segregated from personality disorders which were placed on axis II, personality traits were evicted from the conceptualization of depressive disorders. One perennial feature of psychiatry and psychology is that even if an older idea is superseded [End Page 253] in the view of some thinkers, it can still attract adherents. Indeed, interest in understanding a relationship between personality and attenuated states did not fully disappear. For example, based on research in genetics, the schizophrenia spectrum concept included not only schizophrenia, but also milder conditions such that were conceptualized as personality disorders; that is, schizotypal personality disorder and paranoid personality disorder (Kety, Rosenthal, Wender, & Schulsinger, 1971). During the development of the DSM-IV, some people wanted to add depressive personality disorder to the manual (Phillips,
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Pub Date : 2023-09-01DOI: 10.1353/ppp.2023.a908267
Iskra Fileva, Linda A.W. Brakel
Abstract: In this paper, we criticize what we dub the “pruning view” of self-constitution, championed widely by philosophers, mainly though not exclusively in the Kantian tradition, and instead defend an alternative view inspired by psychoanalysis. We argue that normative assessment comes much too early on the pruning view, so early that it interferes with achieving deeper self-understanding that can produce lasting change. On the proposal we advocate, self-constitution must begin with a non-moralizing attempt to truly understand why one has undesirable and unwanted propensities. We call this the “understanding first” principle. Only after deeper self-understanding has been achieved are attempts to liberate oneself from unwanted elements likely to succeed.
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Pub Date : 2023-09-01DOI: 10.1353/ppp.2023.a908277
Greta Kaluzeviciute-Moreton
“What Is Actually Being Measured?”: Causality and Underlying Scientific Thinking Process in the Assessment of Depression Greta Kaluzeviciute-Moreton, PhD (bio) Depression is a complex mental health phenomenon due to its multifaceted nature. For one, depression is thought to have a significant genetic component, with studies suggesting that heritability is a significant factor in the development of the disorder (Sullivan, Neale, Kendler, 2000). In clinical psychology, environmental factors such as childhood trauma, chronic stress, social isolation and negative life events (e.g., the loss of a loved one) have been documented as significant risk factors for the development of depression or as trigger events for depressive episodes (Fu & Parahoo, 2009; Kendler, Kuhn, & Prescott, 2004; Neitzke, 2016). Despite this, causal theories of mental health conditions are often tricky and/or scarcely reflected in both diagnostic and rating scales. For instance, the Diagnostic and Statistical Manual of Mental Disorders classifies mental health disorders primarily based on observable symptoms and behaviors, rather than on the underlying psychological and neurobiological processes that may contribute to these symptoms (Kendler, 2006). Similarly, rating scales for depression are typically designed to assess the severity of symptoms, rather than their underlying causes, that is, most rating scales are used as screening tools to identify individuals who may require further evaluation and treatment. Some rating scales may include items related to causal factors, such as the Beck Depression Inventory-II (BDI-II) includes an item that asks about “loss of interest in sex,” which could be related to either biological or psychological factors. Several rating scales include items assessing risk factors for depression, such as family history of depression or personal history of trauma. This may be indicative of both genetic and environmental risk factors, such as the Patient Health [End Page 255] Questionnaire-9, includes an item that asks about family history of depression. However, while risk and causal factors are related, they are distinct in the assessment of depression. Risk factors refer to factors that increase the likelihood of developing depression, while causal factors refer to factors that directly contribute to the development of the condition. The presence of a risk factor does not necessarily mean that an individual will develop depression (Peterson & Seligman, 1984). However, the two are frequently blurred and equated in psychotherapy research (Westen & Bradley, 2005). As such, the historical issues of rating and diagnostic scales, aptly depicted by the Le Moigne (2023) as full of “composite, if not contradictory, heritage, weaving together the classificatory and discontinuous tradition of psychiatry, on the one hand, and the psychometric and continuous tradition of psychology, on the other” (p. XX<EQ>), suffer from an epistemological oversight when it comes
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