of the 4th International Conference on Philosophy and Psychiatry
Madness, Science and Society
Florence, Renaissance 2000
August 26-29, 2000
The Italian Society for Psychopathology
The Philosophy Group of The Royal College of Psychiatrists

Symposium "Psycopathology: back to the future"

- Developmental Psychopathology of the Emotional System: Impact on Psychiatry

F. Resch, P. Parzer, R. Brunner, E. Koch

Dept. of Child- and Adolescent Psychiatry, University of Heidelberg

Developmental psychopathology as a continuously growing field of knowledge provides a new perspective on pathogenetic processes in psychiatry. It provides a conceptual framework for psychopathology, equally based on developmental and clinical psychology and the neurosciences including related disciplines.
Developmental psychopathology focuses on impacts of normal child development on the emergence of clinical symptomatology in conditions of maladaption and disturbance. In addition, emphasis is put on atypical developmental processes in the light of risk and psychopathology.
Developmental psychopathology takes into account, how typical developmental tasks are being mastered by individuals, using adaptive strategies within the context of an emotionalized social surrounding. Equally, the role of traumatic events as triggers of internal disequilibrium deserves specific interest. Regulatory functions of the emotional system will be demonstrated: the impact of emotional states on memory, perception and self-development will be emphasized.
Two emergency systems of autoregulation and adaptation in the face of stressors are being presented: the "emotional arousal system" leading to fight-flight decisions and action tendencies, and the "dissociation pathways" resulting in detachment from unbearable experiences. Activation of emotional autoregulation may result in sensitization to stressors and/or disturbances of the awareness of historical continuity of the self.
The Heidelberg study on 161 consecutive adolescent psychiatric patients aimed at elucidating the impact of dissociation and trauma on personality development and psychopathology. Patients with symptoms of automutilation and structural self-deficits presented with significantly elevated scores of dissociation and biographical trauma.

- The Psychpathological Premises for the Psychotherapy of Delusion

C. Mundt

Psychiatric Hospital of the University of Heidelberg, Germany

Recent experimental psychopathological work on the pathogenesis of delusion includes the paradigm of Capgras-Syndrome, probabilistic reasoning, and the construction of the interpersonal space investigated by means of the Kelly-grid-technique. However, conclusions for psychotherapeutic intervention remain sparse.
More practical recommendations for psychotherapy can be derived from phenomenological and clinical psychpathological hypotheses of the pathogenesis of delusion. Of those approaches which will be elucidated and psychotherapeutically evaluated three can be mentioned here:
- Delusion as concretism. This theory implies that the deluded statement is a concretistic message about the deluded patient's mental state. The statement is pre-predicative, i.e. it signifies a subjective experience of exclamatory character which cannot be discussed, like 'I feel happy' or 'I feel embarrassed'. Deciphering the latent message of the delusion and working with it will be demonstrated with a case-vignette.
- The structural-dynamic interpretation of delusion focusses on the emotional overcharge of psychic contents before the delusion manifests f. e. in transference-psychoses, the structural prerogatives, and the therapeutic means to contribute to disactualization and restruchturing.
- The Gestalt-Circle is the theory of unity of perceiving and moving. If one element is weakened as in elderly paranoid who show an increase in hearing deterioration adjustment of perception and ist interpretation is diminished to the advantage of projective mechanisms.
In addition to these specific pathogenetic hypotheses some general cognitive stimuli will for the therapeutic milieu will be discussed like forwarding curiosity and active unlearning delusion.

- The influence of society on the concepts of madness 1900-2000

E. Gabriel

Psychiatric Hospital of Vienna, Vienna, Austria

The paper deals with the conceptual management of psychopathological disorders and tries to compare the pertinent concepts taught in the beginning and the end of the 20th century using the teaching of the school of Vienna as an example. It should be a commentary of a clinician to the basic assumption that these concepts vary not only by the increase of knowledge but by the circular influences between manners to look on, empirical data and the construction of new models. That development happens in a atmosphere which might be more polarizing or more integrative both in general as in particular as well.

- Schizophrenia and the loss of freedom

O.P. Wiggins, M.A. Schwartz*

Department of Philosophy, University of Louisville, USA; *Department of Philosophy, Tufts University, Boston, Massachusetts, USA

People suffering from schizophrenia lack the capacity to conform to social norms and to enact social roles although they struggle profoundly to come to grips with society's expectations. We call this facet of schizophrenia its "agonomia." We trace this facet to the weakening of the constitution of the world that pervades schizophrenic mental life. The severe weakening of world-constitution undermines the "common sense" of the person with schizophrenia. This loss of common sense entails a loss of the ability to gear into a pre-structured lifeworld that is shared with others.

Seminar "Compulsory treatment and the right to self-determination"

- Competence to refuse treatment in anorexia nervosa

J.O.A. Tan*, A. Stewart, R.A. Hope

*Department of Child and Adolescent Psychiatry, Berkshire Adolescent Unit, Wokingham Hospital, Barkham Road, Wokingham, Berkshire RG41 2RE; Department of Child and Adolescent Psychiatry, Highfield Unit, Warneford Hospital, Oxford; The Oxford Institute for Ethics and Communication in Health Care Practice, University of Oxford.

The deprivation of an individual of his liberty is a very serious act, but one which is done internationally on a regular basis by mental health professionals using legalised means, the compulsory holding powers. However, due to the seriousness of the removal of a person's freedom, we need to be thoughtful of the basis for this act by psychiatrists, and ask the question: why is mental illness given this unique consideration?
The mental disorder of anorexia nervosa is a particularly problematic one for psychiatrists, as these patients tend to resist treatment to the point of endangering their lives, but appear to do so in full comprehension of the consequences. This paper will discuss the ethical and legal issues concerning competence to consent to treatment in this patient group, with reference to empirical data from a pilot study exploring factors relating to competence. In this study ten patients with anorexia nervosa were interviewed using detailed semi-structured methods, in order to ascertain their attitudes and beliefs concerning their illness and treatment, compulsory or otherwise. Their capacity to consent to, or refuse, treatment was measured using a validated instrument developed by Grisso and Appelbaum in New York, and standardised self-report instruments measuring levels of anxiety, depression and eating disorder pathology were also administered.
Findings of this pilot study suggested that the patients generally scored well on the formalised test of capacity, fulfilling legal criteria for capacity. However, we found that many of these patients had difficulty making balanced decisions about treatment, because of wider issues such as future orientation, attitudes and values, acceptance of societal scripts and roles, and a sense of personal identity as separate from the illness.
We suggest that these support the notion of a more comprehensive model of competence than the current legal criteria for capacity.

- Advance directives in psychiatric care: a communicative approach

G.A.M. Widdershoven, R.L.P. Berghmans

Dep. Of Health Care Ethics and Philosophy, Maastricht University, The Netherlands

Advance treatment planning for mental illness by way of written advance directives is one of the issues of debate in contemporary psychiatry in a number of western civilised societies. As is well known, there are certain mental illnesses that have periodic features. The most prominent are the manic-depressive psychoses, but we can also think of young chronic schizophrenics.
Through the use of psychiatric advance directives, it would be possible for mentally ill persons who are competent and with their disease in remission, to give prior consent to treatment at a later time when they are incompetent, have become non-compliant, and are refusing treatment.
In this paper we discuss a number of ethical issues that are raised by psychiatric advance directives. These issues concern: the moral value of advanced directives, the problem of personal identity, the way to deal with refusals and the possibility of abuse. We will argue that the dominant, principlistic approach which focuses upon patient autonomy as a base for advanced directives has a limited value in settling these issues. Therefore, we will present an alternative communicative ethical approach. In stead of making patient autonomy the moral basis for advance directives, we will contend that advance directives can better be regarded as based upon a communicative work of patient and physician, making sense of joint experiences with critical events.

- Accomplishing compliance outside the hospital without using the law

S. Sjöström

Senior Research Fellow, Social Sciences Education and Research Centre, Luleå University of Technology, Luleå, Sweden

The aim of this paper is to describe how "home supporters" working in the homes of persons with mental disorder accomplish compliance on behalf of their clients.
In the setting under study, the staff does not have the option to apply the Swedish Compulsory Psychiatric Care Act (LPT). Thus, they need to find other ways in order to make their clients comply to various goals. Dilemmas may occur in persuading patients to accept medication, to tend to their personal hygiene, to control their finacial situation and to lead an everyday life which will help them stay in a relatively stable mental condition.
To the staff, there are several features of the organisational context of home support that can be used as resources in accomplishing compliance on behalf of clients. The analysis illustrates the complexity of defining the concept of coercion. A central theme is the importance of the asymmetrical relationship between staff and patients, e.g. how clients are depending on the staff to manage many situations in their everyday life.
The paper attempts to analyse how features in the organisational context play a part in accomplishing everyday communication between staff and clients. Data are collected through ethnographic observations in homes where people with mental disorder live.

- Ought we to sentence people to psychiatric treatment?

T. Tännsjö

Gothenburg University, Sweden

In principle, there seem to be three main ways, in which society can react, when people commit crimes under influence of mental illness.
1. The Excuse Model. We excuse them. If they are dangerous, they are detained in the interest of the safety of the rest of the citizens.
2. The Mixed Model. We hold them responsible for their criminal offence, we convict them, but we do not sentence them to jail. Instead we sentence them to psychiatric treatment.
3. The Full Responsibility Model. We sentence them to jail, but offer them (voluntary) psychiatric treatment.
The advantages of the Full Responsibility Model are obvious. We get a clear delineation of roles. We allow the psychiatrist to be just a doctor, not a warden. We liberate psychiatry of the objective of deciding whether people who were mentally ill when they committed criminal offences "could have acted otherwise" - a hopeless task. We allow that psychiatrists live up to their professional ethical code (the Hawaii Declaration). We treat psychically ill persons as "normal", we allow them to repent their crimes, which renders easier their recovery.
However, three objections to the Full Responsibility Model come to mind. First of all, is it not unfair to sentence people who could not help doing what they did to goal? And, secondly, the question of fairness set to one side, is it not inhumane to sentence mentally ill persons to goal? Is it not inhumane to the mentally ill persons themselves, and does it not mean that they will be a burden to other prisoners? Finally, when the people sentenced to prison have served their time, they must eventually be released. But what if, because of their mental disorder, they are still dangerous to others?
In my paper, which is based on my recent book, Coercive Care: The Ethics of Choice in Health and Medicine (London and New York: Routledge, 1999), I show that, if our system of criminal punishment takes a civilised form, neither of these objections carries any weight.

Seminar "Risk factors and outcomes evaluation"

- Cannabis use correlates with schizotypal personality traits in 232 healthy students.

P. Dumas, C. Gutknecht, M. Saoud, S. Bouafia, J. Dalery, T. d'Amato

EA 1943 Université Lyon I (J. Dalery), CH le Vinatier, 95 boulevard Pinel, 69500 Bron, France

Many reports have evidenced links between cannabis use and schizophrenia and most psychiatrists admit today cannabis use among schizophrenia risk factors. In addition, it has been shown that schizotypal personality disorder [SPD], or even some SPD traits, may be a clinical expression of vulnerability to schizophrenia. The evidence that cannabis use and SPD traits both constitute risk factors for the later development of schizophrenia asks the question of their relationships. The aim of the present study was to examine the association between cannabis use and SPD traits in young healthy French individuals. For this purpose, we have recruited 232 students, aged from 18 to 25 years old, who have completed the Schizotypal Personality Questionnaire [SPQ] and four of the Psychosis Proneness Scales developed by Chapman and colleagues [Magical Ideation Scale: MIS; Perceptual Aberration Scale: PAS; Revised Physical Anhedonia Scale: PhA; and Revised Social Anhedonia Scale: SA]. Subjects were parted into three groups according to cannabis use: Never-Users [NU]; Past or Occasional-Users [POU] and Regular Users [RU].
By the mean of a two-way mixed effects model, we observed higher scores for RU or POU compared to NU at SPQ and MIS scales after adjustment for potential confounding factors [anxiety, depression, use of other recreational drugs and tobacco smoking]. These results indicate that cannabis use is associated with categorial SPD [evaluated by SPQ total score] and more precisely with the clinical positive dimension of this disorder [evaluated by MIS and some SPQ sub-scales]. Such a relationship could be interpreted either as a single co-occurrence or as a real inter-dependence of these two phenomena. In order to clarify this question, further longitudinal studies on schizophrenia risk factors should include both an evaluation of cannabis use and the study of SPD traits.

- Family risk factors of mental disorders and medical-genetic aid

E.V. Gutkevitch

Mental Health Research Institute Tomsk Scientific Center, Siberian Branch, RAMSci, Russia

For the definitioning of family risk factors and for rendering medical-genetic aid were studied the families of three groups of children. The first group - it's patients of children's mental department of Tomsk psychiatric hospital (126 people). The second group consists on 286 pupils of boarding and secondary schools. The third group is definited in passing of genetical-epidemiological research into schizophrenia in Tomsk region. The age of inspected is 2-17 years. The main part (64%) of patients of children's mental department consists on patients with mental retardation. Among them were differented chromosoming diseases (46,XY, 46 inv 9(p11q12), Turner's syndrome with man's caryotype), monogenical - phenylketonuria, leukodystrophy. Speciality of the family status was in the half of families where parents affected from alcoholism. For these families was taken retrospective medical-genetic counseling (the offspring prognosis). In 40% of researched pupils of school and children of boarding school were found mental disorders - of psychological development, hyperkinetic disorders and other behavioural and emotional disorders with onset specific to childhood or adolescence. The risk factors of there appearing were young age (before 20 years) of parents at their birth, birth of them as the first ones in the family, less number of brother-sisters, incomplete family (more frequently father was absent) and presence of mental disorders in the nearest. More often there were disorders resulting from use of alcohol. "Risk groups" have been formed from brothers-sisters of examined schoolchildren for whom prognosis of appearance of psychopathological signs and conducting of prophylactic measures with the aim of prevention of deviations in health, behavior and learning are possible (the health prognosis). Taking researches of prevalence of schizophrenia in families and population (Tomsk Register of Schizophrenia) showed, that in families of 2850 patients may be 1,5 thousand of children. They are children - "syperphrenycs" and they apply to "risk group". For these children "the health prognosis" is possible with early diagnostics of possible primary symptoms of disease and with taking psychosocial rehabilitation.

- Philosophical aspects of evaluating psychiatric and psychotherapeutic treatment

P.-A. Tengland, Ph.D.

Department of Health and Society, Linköping university

What mental health is is not an easy question to answer. Is it freedom from mental illness, the ability to think rationally, being self-fulfilled, having a balance between the ego, id and superego, the ability to cope, to feel well, or is it the ability to love and work? The list can be made much longer.
Given this difficult question it is not an easy task to construct instruments purporting to measure mental health. Still, there are hundreds of such instruments, general screening instruments and psychiatric/psychotherapeutic treatment outcome instruments. In many of these instruments the important conceptual questions are not addressed. This can create problems of incoherence and lack of validity, and I will illustrate this by discussing some commonly used instruments.
In the remainder of the paper I want to discuss how to solve these problems. I have argued elsewhere that in order to answer the first question we first have to decide what general health is. I intend first to present some different kinds of general theories of health, showing what choosing such a theory means for defining mental health and constructing mental health instruments. I then show how working with one such theory, the holistic theory of health, influences the construction of health instruments. The holistic theory states that health is the (general) ability to reach vital goals. Thus, an instrument, in order to measure health, has to concentrate on this general ability.
In discussing mental health we have, however, to focus on the mental part of the general ability. Even though the goals of the individual in general have to be taken into account, it might be possible to specify what mental health at a more basic level, "minimal mental health", is without taking these goals into account. This means that it might be possible to construct instruments that, at least partly, focus on specific mental abilities. Finally, I will show how subjective ill-being (suffering) is taken account of in this kind of instrument.

- Predictors of treatment response in panic disorder

S. Gariboldi, C. Cimmino, C. Balista, M.E. Menini, G. Paulillo, M. Amore, C. Maggini

Institute of Psychiatry, University of Parma

Objective. Results of a one-year-follow up study aimed to find out personality and clinical predictors of response to pharmacological therapy in patients with Panic Disorder are reported.
Method. A sample of 31 patients (9 males, 29% and 22 females, 71% ; mean age: male 35,6+/-13,3; female31,2+/-8,6) with a DSM-IV diagnosis of Panic Disorder with (n= 23; 74,2%) or without (n= 8; 25,8%) agoraphobia were assessed from the baseline to the end point visit with the following instruments: HAM-A, HAM-D, SCL-90, PAAAS, WAYS OF COPING, DSQ-40, TCI. At the end patients were divided into Responders (R: n=23; 74,2%) and Non-Responders (NR: n=8; 25,8%) on the basis of score reduction of anticipatory anxiety <5 and absence of panic attacks for at least 4 weeks, were compared regarding symptoms, age of onset, coping, defence style, personality, temperament and character features.
Results. There was a significant difference in mean age of onset between R and NR (R:29,9+/-11,8 vs NR:19,3+/-4,1; p=0,02).R differ significantly from NR in the intensity of unespected attacks (R:1,29+/-2,9 vs NR:4,5+/-4,4; p=0,043) and in the percentage of anticipatory anxiety (R:38,7+/-8,8 vs NR:27,3+/-10,3; p=0,032). As for SCL-90 Scale R scored significantly lower in the dimension of paranoid ideation (R: 4,95+/-4,2 vs NR: 8,87+/-5,69; p=0,046) while concerning coping and defence styles they adopted less avoidant-flight behaviours (R:11+/-4,8 vs NR: 20,1+/-12,9; p=0,014) and less immature defence than NR (R: 3,78+/-0,87 vs NR: 4,89+/-0.80; p=0.005). Regarding temperamental dimensions R differ from NR in significantly lower scores in Harm Avoidance (R: 23,4+/-3,9 vs NR: 27,5+/-6,4; p=0,04) and higher scores in Persistence (R: 4,6+/-1,4 vs NR: 3,1+/-1,9; p=0,02). Character differs between R and NR: almost all dimensions of Self directedness were significantly higher in R than in NR (Self directedness tot, R: 26,5+/-6,4 vs NR: 19,8+/-4,8; p=0,01. Purposefulness vs lack of goal direction, R: 4.5+/-1.5 vs NR: 3.0+/-1.6; p=0.02. Self-acceptance vs self-striving, R: 4.0+/-1.5 vs NR: 2.0+/-1.6, p=0.04. Congruent second nature vs incongruent habitis, R: 7.9+/-2.0 vs NR: 5.2+/-0.8; p=0.01).
Conclusions. These results suggest that an earlier onset of Panic Disorder, severity of unespected panic attacks and anticipatory anxiety are negative predictors of outcome. Furthermore high scores of paranoid ideation, an avoidant style of coping and higher immature defences are indicative of poor response to treatment. Regarding Temperamental and Charater aspects high scores in Harm Avoidance,low scores in Persistence and in all dimentions of Self Directedness suggest a poor outcome.

Symposium "Technology and Psychiatry"

- The technological mode of being manifested in psychiatric classification

J.Z. Sadler, M.D.

Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX, USA

Heidegger and his students have elaborated the "question of technology" as posing a specifically ontological kind of danger to society. This ontological danger concerns the tendency of technology to shape or unduly influence our ways of thinking, leading to what Heidegger calls "enframing" or the holding of nature in "standing reserve." Technology, from this perspective, tends to assimilate all human action by subjugating all human interests to economic production, material control, and pragmatic problem-solving. Building on Heidegger's, Albert Borgmann's, and other technology theorists ideas, I describe a "technological mode of being" which is characterized, among other ways, as involving a particular and restrictive set of values as ones to live by, and indeed, to assume. These values associated with the technological mode of being include the following (for example): productivity, simplicity, efficacy, efficiency, convenience, economy, disposability. Such values are designed-into technological artifacts, giving us products which make our lives more convenient, productive, efficient, etc. These values can be contrasted with the values characteristic of what one might call the "poietic mode of being"; e.g., values like creativity, tradition, emotional connectedness or intimacy, personal discipline, and the values of nature. The often contradictory nature of technological and poietic values will be noted. The "god" which can "save us" from domination by the technological mode is restitution of the poietic mode and placing technology into its proper role as servant to ultimate human values.
I relate the technological mode of being and its associated values to structural and meaningful aspects of the American diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). That is, I indicate how technological values like productivity and efficiency are designed-into the DSM-IV techno-artifact. I then discuss both the positive and negative significance of such "technologizing" of nosology for psychiatric practice, including how the technological mode of being in psychiatry is dehumanizing. Drawing from the existential psychiatry and care ethics traditions, I conclude by sketching two strategies for preserving the poietic mode of being in psychiatric practice, as well as how to keep the technological mode of being in its morally proper place.

- The Dominance of Technical Reason in Contemporary Psychiatry

J. Phillips, M.D.

Department of Psychiatry, Yale School of Medicine, USA

Perhaps the most striking feature of contemporary psychiatry is the growing dominance of technical reason in virtually all aspects of the field. This dominance is evident in psychiatric theory, diagnosis, treatment and funding. Several factors have contributed to the technical dominance. One is the recent advances in neuroscience and psychopharmacology. Psychiatry has wanted to identify itself as a medical subspecialty, and advances in neuroscience and psychopharmacology have facilitated the medicalization of the field. Since the rest of medicine has fully embraced technical reason, psychiatry, as it becomes more medical, becomes more technical. Another factor is the predominance of the DSM diagnostic system. The DMS-IV both reflects the technical approach and fosters it. Finally, especially in the U.S. but increasingly in other developed countries, the effort to contain costs has fostered and even demanded a technical approach to psychiatric treatment.
In this presentation I will attempt to analyze this condition of contemporary psychiatry. In doing so I will contrast technical reason with its contrary, practical reason, and argue that psychiatry's abandonment of the latter has been a significant loss for the field.
The distinction between technical and practical reason follows the original differentiation articulated by Aristotle between techne (technique) and phronesis (practical knowledge), and his early analysis and its legacy will be described in the presentation. By technical reason is meant the position that for any problem area there is a systematic body of generalized knowledge, with specific rules of application that can define the handling of particular cases and thus minimize or eliminate the need for real judgement on the part of the individual practitioner. From this point of view knowledge is essentially instrumental, organized into means/ends structures; any problem can be analysed in a way that allows for a means/ends formulation and a formulaic solution. In contrast, the position of practical reason is that practical action (or clinical practice) is bound to the particular situation and the unique challenges it poses. The particular situation is an area in which unvarying universal principles are not available that will dictate what is to be done. The general principle is there for guidance, but in each circumstance it will be applied-and indeed understood-somewhat differently. Practical knowledge cannot be simply taught, or learned from a manual; it is learned through experience, for which there is no substitute.
The penetration of technical reason into every aspect of contemporary psychiatry-theory, diagnosis, practice, and funding-and the concomitant abandonment of practical reason, have not merely resulted in a distinctive approach to psychiatric treatment. They have culminated in a transformed notion of human existence, a notion I will draw out in a final section of the presentation. Under the dominance of technical reason, the psychiatric patient becomes a manipulable object, and the practitioner a technician of such manipulation.

- Praxis-based versus Technology-based psychotherapy: An initial exploration of differences

L.S. Berger, Ph.D.

Psychotherapy has been swept along and shaped by the same intellectual, professional, cultural, socioeconomic and political forces that have brought us to a technology-based psychiatry. Yet, although even from its beginnings therapy has mostly succumbed to these various pressures to be conventionally scientific, also since those beginnings there have been signs of a "poietic" counter-force. This humanistic opposition movement, however, while persisting and finding diverse expression within various psychotherapeutic modalities as the field evolved, has been a minority force that has had but scant and fleeting success. A technology-based psychotherapy continues to win the day.
Of course, the major reason for this state of affairs is the great power of the forces that press for technology-based psychotherapies. But another, another, less obvious contributing factor has also been at work: the absence of a truly viable alternative to an enframing, reductionist, scientistic conception of psychotherapy.
This lack may now be remediable. Current work is revisiting and building on the Aristotelian notion of praxis, and that expanded conception may offer the beginnings of such an alternative. Although this contemporary work has significantly illuminated our general understanding of praxis it has done little to tell us specifically what a praxis-based approach would mean and entail in a clinical context. This presentation seeks to make a start toward alleviating this lack.
Since a praxis-based approach by its very nature defies capture by means of formal, universal definitions, the delineation of a praxis-based psychotherapy is approached instead through comparisons and contrasts with technology-based therapies. Part of this early attempt to explicate praxis-based therapy, then, is to clarify what that kind of therapy would not be.
Thus, in important respects a praxis-based psychotherapy would differ radically in approach and character from clincial frameworks and practices. Those differences would raise obvious and highly problematic questions for the field, such as: What would replace conventional research? theorizing? formal diagnostics? empirical validation? treatment planning? Furthermore, since in a praxial approach the notion of wisdom, phronesis, always is central, what would "clinical wisdom" mean, specifically? How could it be acquired, justified, validated? These and similar questions will be considered, though obviously not resolved.
Since praxis is so heavily rooted in individual (rather than consensual) conceptions of what constitutes practical wisdom, I will conclude by offering my own incipient and tentative vision of a praxially-based psychotherapy as an exemplar.

Seminar "Narrative and meaning"

- New Hermeneutic: Clinical Considerations

D. Padro Moreno

Hospital Civil de Basurto (Servicio de Psiquiatría)

This paper focuses in the way hermeneutic 's principles can be translated to clinical praxis. In that sense, it analyze the constructivism social theory of Hoffman, recently appeared in Northamerican psychoanalysis, that presents great similitudes with hermeneutics.
The author points out the basic's propositions of hermeneutic's work, remarking that some of these, were advanced by Spanish anthropology psychiatry. A clinical case is presented and commented on hermeneutic basis, proposing this type of knowledge, as an integrative paradigm, that integrates the physis and the word, both of them dissociated since medicine's origin.

- Il dramma della psichiatria: una scienza in cerca del suo metodo

J. Del Meglio

S.S. Psichiatria e Psicoterapia, Università "La Sapienza", Roma

Il rapporto dell'uomo con la natura, con le avversità di una realtà prepotente che lo circondava, è stato fin dalle origini volto a trasformarla. L'uomo ha modificato l'ambiente naturale per adattarlo ai propri bisogni ed alle proprie esigenze. Non si è accontentato del riparo offerto dalla natura agli agenti atmosferici, ma ha pensato di costruirsi una sua casa. Non si è limitato a guardare le stelle, ma ha pensato di andare a staccarle dal cielo. Non si è contentato di credere alle malattie come a manifestazioni di forze soprannaturali incomprensibili, ma ha pensato di poterle conoscere e curare.
Il suo intervento modificatore presupponeva un'attività di conoscenza , un metodo.
In medicina organica la scoperta e l'applicazione del metodo scientifico alla realtà biologica del corpo si è rivelata assai proficua. Lo sguardo storico sulla medicina dell'800 ci dimostra come lo sviluppo delle conoscenze mediche abbia avuto un andamento esponenziale a partire dal momento in cui ci si è avvalsi di un corretto metodo di studio dell'organismo umano nella sua dimensione più propriamente fisica, percepibile cioè ai cinque sensi. Lo stesso non si può dire per la psichiatria, ramo più giovane della medicina, come sostiene Ackerknecht, disciplina talmente importante da meritare di stare accanto alla medicina interna e alla chirurgia. Se è vero che Pinel alla fine del '700 sottrae la malattia mentale alle nebbie della demonologia rendendola così oggetto di studio e ricerca, è altrettanto vero che l'applicazione del modello sperimentale-empirico galileiano alla realtà psichica si è dimostrata inadeguata alla sua conoscenza. Occorre forse un nuovo metodo di ricerca della dimensione umana che vada oltre l'approccio positivista basato esclusivamente sulla percezione dei cinque sensi . E' forse necessario avere il coraggio, che l'uomo non sempre ha trovato, di andare oltre le proprie intuizioni, percezioni di un attimo che attraversano la mente, per non rendersi ancora una volta primitivo in balia della natura avversa.

- A typology of the envious man?

G. Di Piazza, M. Nitti, F. Brogi, F. Cernuto, M. Cerretini, M. Del Sole, L. Luccarelli, V. Migliorini., P. Castrogiovanni

Cattedra di Psichiatria, Università degli Studi di Siena

How experience of envie reveals itself at our eyes and how is it possible to delineate an hypotetical typology of the envious man? Since <<typification structures and organizes the field of our experience>> (Schwartz M.A. and Wiggins O.P.), it permits to represent the distinctive features of this feeling as incommunicable, renegaded, rejected as paradoxically evident and not easily hiding. Although the envious man attempts to disguise his feeling, the envie overflows and manifests itself in a "slanting look", in to throw the "evil eye" that now we knock against, now keep us at a distance: the mimic of the envious man is prim, his insincere smile not participated by his eyes is bited between his tooths. His eyes are blushing of hate against the envied person.
The grim and askew look of the envious man denotes his transversal condition, his way of slanting being against the Alter ego and his reiterative attempt of "thwart a spoke in Alter Ego's wheel", of interpose an obstacle along the way of the envied so that he stumbles: if whereas in the typus melancholicus, guardian of the arranged order, his moral hyperconscientiousness and hyperidentification at roll's identity show up, on the contrary in the envious man we assist at an insuccessfull attempt of cross his own roll's identity and upset the status quo. Indeed for the envious man the others, the destiny are his debitors: he feels persecuted by bad fate. The envious man reputes himself more assailed than aggressor and this paranoic modality of facing reality let him project outside himself the responsibility of his own malaise, keeping away the insight of his own feelings, so socially abhorred. Instead of the do-for-others of the typus melancholicus, here we assist at a be-against-others, instead of solicitude and hyperaltruism we see the indifference and the egoism, instead of the symbiotic tie we seize the close of any kind of relationschip. So, what could we say typus invidiosus has not? More than possession, material objects or qualities, his unsatisfied and unappeasable state originates from his fruitless sterility, from his incapacity at syntony with his own fellow-man, from his being a "shut monad".

Schwartz M.A. and Wiggins O.P.: The first step for clinical diagnosis in psychiatry, J. Nerv. Ment. Dis., 1987

- About thoughts' mutual constraint during the cultural trip

J. Naudin

A trip in Japan the author did with a scientific purpose leads him to consider the scientific trip in itself as phenomenon. As a form of scientific trip, the psychiatrist's cultural trip aims to reduce trans-cultural differences to specific symptoms. However, it has its own psychopathology: some travelers become wizened on stereotypes (Gaijin's neurosis), some others bracket their cultural anchorage within the daily life. This kind of reduction changes in depth the observer's point of view. It allows the atmospheric meeting of European and Japanese thoughts by instituting mutual constraint relationships. The traveler questions his/her own culture and find back in his/her Japanese daily-life experience a daily worked-out form of the Westerner phenomenological thought - namely that of Heidegger, Straus, and Merleau-Ponty -. The instituting room of the language within the Freudian unconscious and that of its below are then to be questioned.

Symposium "Psychopathology as the science of the suffering subject"

- Suffering and Meassuring - the Problem of Objectivity in Psychopathology

M. Heinze

GPWP, Landesklinik Teupitz

Concentrating on the aspect of "Pathos" in the term psychopathology and translating it back to "suffering" opens up a field of connections between objective mental symptoms and the more concrete subjective forms of experience. Suffering much more than the meassured pathology is a question for the practical science of therapy. There are growing doubts about the possibility at all to objectify suffering and about the epistemeological status the term "suffering" should gain. Only the subjective ways of individual suffering with mental symptoms are legitimatizing therapeutic actions and as well motivate the patients participation ("Leidensdruck"). On the other hand, psychiatry as a clinical science faces a growing need to develop standardized instruments of objectivation of symptoms and daignoses, especially since the psychiatric community is growing and cannot anymore relate to local traditions and their historical experience. With this, the status of the theory of suffering becomes crucial for the devellopment of moden theoretical psychopathology.
The paper wants to open up this dialectical field by first going through some theoretical reframings of suffering in the older literature originating of the tradition of "Anthropologische Psychiatrie" in Germany. In contrast, newer and more objective forms of meassuring psychopathology, espesially DSM and ICD will be discussed. The thesis is that by fowolling the unquestionable necessary need to more and more objectify mental symptoms the relations with individual forms of suffering gets lost. In an outlook theoretical strategies to overcome this dilemma will be discussed.

- The transformation of identity in the course of schizophrenic illness

K. Leferink

GPWP, Landesklinik Teupitz

What is the relationship between schizophrenia and identity and how does identity change in the course of the illness? - The initial manifestation of schizophrenia, the subsequent treatment in a psychiatric hospital and the breakdown of the social existence demand from the patient initially to formulate a radical redefinition of his/her construction of identity. Aspects of this 'new identity' may be recognized in the contents of higher schizophrenic symptoms (delusions, halluzinations, ego-psychopathology). They represent in some way images of self-other-relationships.
The paper argues that the transformation of identity may be understood as a semiotic process which changes the interpretative structure of self-representation. The patient 'operates' with signs and fragments of discourse taken from various fields of discourse in society (politics, religion, philosophy etc.) as if he wants to generate an new formula for his/her whole life.
The outcomes of this process have in some ways properties which may be called 'ideological'. A central part of this 'private ideology' is the refusal to accept the ascription of an illness. 'Lack of insight' can neither be sufficiently explained by distortions of perception, attention or thinking nor by the stigma of the diagnostic label. It is an effort to establish a (solipsistic) model of identity which integrates the experiences of illness as well as the representation of the personal and social situation of the patient.
The paper offers an empirical approach to identity based mainly on narratives of life history.

- The concept of suffering in the definition of mental disorders

A. Heinz

Zentralinstitut Mannheim

Competing theories try to define mental disorders either as a deviation from functional or behavioral norm, as a loss or reduction of self-determination or free will, or as suffering. We argue that functional deviations cannot by themselves define mental maladies, as they may be irrelevant for everyday life and pose potentially circular question of the ideal norm. A concept of suffering in the absence of a causal outside agent may be a necessary construct to define mental disorders. Problems of the naive and historically contingent empirical foundation of such a concept of suffering are discussed.

- The experience of "another time" in melancholical suffering

Chr. Kupke

GPWP Berlin

Text: There are two models in the scientific understanding of the temporality of melancholy: the first model is the dualism of subjective and objective time, the second the concept of the threefold dimensional time (present, past and future). In my lecture I want to discuss these two models in questioning their efficiency to understand the specific disturbance or disorder the depressive subject is suffering in experiencing time. I want to show that when we prefer the first model for explaining this suffering we have to relate at last to our understanding of natural and social processes of time for "objective time" is the cipher for the specific interrelation of three time conceptions: that of physical, of biological and sociocultural time. So, for example, when we realize or when the patient realizes that he "falls behind" the speed of time (Straus, Gebsattel) we have to ask what time it is he falls behind. But when we prefer the second model for explaining the temporal suffering of the depressive subject we have to relate to our understanding of "biographical time" for this is the space of time in which the subjects time experience is dominated by the past. So when we realize this domination as a "deformation" or even as a "breakdown" of dimensional time (Kraus, Glatzel, Theunissen) we have to ask how we can scientifically describe this deformation as a specific constellation of present, past and future. In my lecture I want to show this specific, "depressive" constellation and, at last, try to explain how this constellation also causes the break between subjective and objective time as ground of the experience of "another time" in melancholical suffering.

Symposium "Psychiatry and phenomenology: Italy 1960-2000"

- The structure of the communitarian place in a phenomenological view

G. Calvi*, L. Calvi**

*Responsabile della Comunità terapeutica Az. Ospedaliera Fatebenefratelli di Milano
** Università degli Studi di Milano

The care, the treatment and the rehabilitation for psychiatric patients, when managed in therapeutic community instead of hospital, they draw the attention not to a clinical place but to a place that can be lived in.
The phenomenological approach can describe the main structure of the place of the community in temporal, spatial and corporal terms.
This approach helps to make the community place significant to the eyes of medical doctors and other sanitary operators.

- The role of psychopatology in the daily routine of a Psychiatric Service

L. Cappellari

U. O. di Psichiatria di Camposampiero (Pd) AULSS n.15

The Author dwels upon the importance of the henomenological psychopatology as a method necessary to esplore the personal esperiences of the patient.
This method allows a correct therapy within the psychiatric practice.

- Community psychiatry and its tacit foundation

M. Rossi Monti

In what way did phenomenological psychopathology contribute to the development of community psychiatry in Italy? It certainly didn't do it explicitly. Phenomenological psychopathology's role has always seemed to be quite marginal but, nevertheless, it helped create a setting that actually made the change from a mental hospital-centered to a community-centered model possible. In fact, it's no chance that the father of Italian psychiatric reform (i.e., law 180 passed in 1978), Franco Basaglia, himself had a background in psychopathology. Phenomenological psychopathology, however, didn't appear at the forefront of the anti-institutional ('antipsychiatric') reform movement; rather, it stayed in the background. It was precisely this low-key role that allowed for the opening up of a virtual space between the symptom and the person, based on the analysis of internal experiences. If the socio-genetic/socio-environmental side made up the "manifest content" of community psychiatry in Italy, the psychopathological side was the "latent content" - its profound soul. Refusing to consider mental illness as an inescapable senseless destiny, phenomenological psychopathology advanced that mental illness was, on the contrary, full of sense and, indeed, articulated along a wide range of developing pathways. This was the way that phenomenological psychopathology, begot by Jaspers within the mental hospital system itself, tacitly created the foundations of overthrowing of the mental hospital system in Italy.

Symposium "Combining empirical and philosophical methods"

- A neo-aristotelian ethics of care in medical health

A. Noguera

Department of Philosophy, University of Warwick, United Kingdom

Important as the ethics of care are in literature, their theoretical structure is insufficiently worked out to engage successfully with some of the key problems in mental health ethics. Philosophy offers various possibilities for extending "care theory", but I favour neo-Aristotelian virtue ethics because recently renewed interest in both classical ethics and in the virtues provide a rich resource for study. I believe that the Aristotelian emphasis on "flourishing" provides a direct link with the ethics of care in a form specifically related to the ethically problematic status of involuntary psychiatric treatment and that Aristotle connects flourishing to proper function in a way which reflects the values by which psychopathological concepts are partly defined, while remaining fully consistent with neuroscientific understandings of the brain.

- Perceived quality of co-operation - A study of two different modes of organizing work in psychiatric teams

A. Hempel

Department of education and psychology, Linkoping university, Sweden.

This paper concerns the perception of co-operation and work process within psychiatric teams. The main interest concerns the team members' attitudes to and perception of work conditions and co-operation within the teams.
The purpose of this study is threefold and pertains to the following issues: First, to investigate how psychiatric team members perceive co-operation and work in relation to the mode of team organization. Second, to show if there are any systematic differences in the team members' views on their own teams regarding irrational qualities. The third purpose is to develop a theoretical model indicating a relationship between antecedent and media-ting variables and the perception of co-operation and work satisfaction among team members. The actual instruments are based on theories concerning perception psychology, group dynamics theory influenced by Bion, and occupational psychology. Four psychiatric teams of two different kinds, rehabilitation teams and general outpatient teams participated. The main result is related to the suggested theoretical model. This model seems to be useful and valid. Work conditions, such as autonomy, group composition, situational factors, and mode of work, seem to influence the quality of co-operation (i.e. conflict resolution, collaboration, consultation and irrational processes). Another important outcome is that members of teams with more group oriented work strategies were more satisfied with co-operation than those working more individually.
Key words: Co-operation, collaboration, teamwork, psychiatric teams, work satisfaction, work mode, outpatient teams.

Symposium "Antipsychiatry today: the user's voice"

- Antiphilosophy and its implications for antipsychiatry

Y. Örs

Dept. of Deontology, Ankara Un. Medical Faculty, Ankara, Turkey

By "antiphilosophy", I mean an overall methodological attitude to philosophical activity, in particular towards traditional, for the most part rationalist philosophy. Both conceptually and from a psychological standpoint, the latter is a highly individual-, self- and/or man-centered activity. Considered in connection with such concepts as 'metaphysics', 'speculative philosophy', 'philosophical knowledge claim' and similar others, we must be in a position to psychologically "diagnose" most of philosophical activity as a complex body of rationalizations. Further, philosophy can also be of psychological/psychosocical interest in the light of such concepts as 'wishful thinking', 'utopia' and 'ideology'.
In terms of an overall academic methodology, and thus from a predominantly rational standpoint, too, traditional, past-oriented philosophy is deficient. It must be clear that for a thorough understanding of the psychological/social factors involved in the practice of philosophy, the interested psychologist/psychiatrist should expectedly have a basic methodological notion of what philosophical activity is about, together with the main assertions of the opposing schools in this activity.
Scientific philosophy evidently represents that sort of philosophical understanding and approach which is most closely, and positively, related to the philosophy of science as one of the activity's main branches. And this branch, with a scientific philosophy conception of science in mind, is necessary for a methodological inquiry into psychiatry as a branch and integral part of clinical medicine.
My ultimate purpose in the present context is to discuss the methodological status of psychiatry, considering philosophical inquiry as one of its sufficient conditions. To this end, I will analyse the notion of antipsychiatry from a methodological point of view. Antiphilosophy becomes crucial here also, because it can show us the dangers of a "philosophization" of psychiatry in the "hands" of those thinkers who are the followers of traditional philosophy in one of its various forms.

- Latent forms of antipsychiatry

Y. Savenko, L. Vinogradova

Independent Psychiatric Association of Russia, Moscow

We use the concept of antipsychiatry for defining only the nihilistic half of its manifest - its rejection of objectivity of the clinical method, of necessity of biological therapy, of biological nature of psychoses, of psychopathological reality, as well as of the notion of belonging psychiatry and psychiatrists to medicine, but not to police. Although in the 60-80ies psychiatry first of all played the role as social-political couter-reaction to utmost politicized and sociologized image of psychiatry, it was a period of activization of this theme in all its aspects. Antipsychiatry is a particular expression of change of the general scientific paradigm and in its radical form is the expression of antiscientism. Besides direct agressive forms of antipsychiatry there is a huge variety of its latent indirect forms acting in different spheres in non-evident way, so as psychiatrists often condemn their own brain child. Antipsychiatry always acts in the inseparable connection with practice of psychiatric service and the latter - with a definite theory. Shortcomings of psychological, sociological and cultural reductionism and relativism inevitably feed antipsychiaric tendencies. Exclusion from ICD-10 of homosexualism has not been followed by exclusion of other perversions and other forms of psychic pathology. Instead of formation of respectful attitude to mental illnesses and psychic deviation the interests of representatives of individual groups, actually at the expense of others are being "lobbied". As a result, the base of everything that should be opposed, only strengthens. It also refers to re-naming of many psychopathies and even the notion of psychopathy itself. The phenomenological method and the critical ontology of Nikolay Hartman in the most reliable way serve the process of de-mythologization and finding an adequate shape of clinical reality.

- The application of Foucault to the psychopathic offender

D. Hargreaves

Department of Philosophy, University of Warwick, UK

The status of psychopathic disorder has long been a difficult issue for psychiatry. In contrast to the conventional historical analysis of psychopathy, which emphasises a seamless but spurious continuity - thereby supporting a scientifically realist view of the disorder - the work of Foucault anticipates the medicalisation of psychopathy as a means of administrative expediency - a solution to the individual 'not amenable to discipline'. Initially a problem to be transferred from prison to hospital, ostensibly for purposes of 'treatment' the failure of this solution has now brought forth the prospect of a new type of containing institution aiming to deliver sequestration and risk reduction.
And yet the Foucault account seems to leave something out at the level of the individual case which fails to account for the distinction made between the psychopath and the 'ordinary recidivist offender'. If the psychopath is not capable of responding, then this calls for a shift in our attitude towards him, and a modification of responsibility attribution. There has been an enormous reluctance on the part of the judicial authorities to accept this. This reluctance to abandon what Strawson termed the 'reactive attitude' reveals a tension between our interactions as individuals and the objectivising tendencies of disciplinary society.
This poster will report on work in progress to investigate the above tension in practice by recourse to actual legal cases. The empirical study will focus on the application of the English Law doctrine of Diminished Responsibility in cases of homicide involving defendants diagnosed with Psychopathic Disorder. My hypothesis is that in addition to any scientific evidence, the decision to accord Diminished Responsibility will depend crucially on the circumstances of the offence and its effect on 'reactive attitudes'. In short, that the decision to recruit medical evidence will follow only after some tacit recognition that alternative measures are needed.

- Involving service users in the appointment of consultant psychiatrists

J.P. Watson, I. Morris, A. Jefford

South London and Maudsley Mental Health NHS Trust, Guy's Hospital London SE1 9RT UK

This brief report is of the involvement of current service users in the process of appointment of a new consultant psychiatrist whose main responsibility was to be medical responsibility for a milieu therapy unit dealing with 15 inpatients and about 50 daypatients as part of the local acute mental health service.
As part of the consultant job description, short-listed applicants were to be required to make a presentation to unit patients and staff, the results of which would contribute to the appointment process culminating in the advisory appointments committee whose composition and procedures are governed by statute.
The ward nursing manager consulted staff colleagues about the topics to be part of the presentation and invited service users to suggest questions which they might ask as part of a 30-45 minute session with each applicant individually. Staff and users attending the presentations were to make individual ratings of candidates, the whole to be collated by the ward manager. Presenters were to address the question: how on the unit might psychotherapy be integrated with general psychiatry. Users decided to ask questions as, 'how would you help people such as myself stop acting out and repeatedly harming ourselves?'
The results were that presenters found the experience a severe test, but impressed staff and user audience with the way they took the occasion seriously and with their answers to questions. Audience ratings were clear expressions of the impressions given at the presentations and made a major contribution to the deliberations of the consultant appointments committee. Service users commented that they felt committed to working with their new consultant, since they had taken part in the choice.
The method is recommended.

- The Concept of Mental Disorder: the 1960s critiques and their post-modern development

D. Bolton

Institute of Psychiatry, London, U.K.

In the 1960s mainstream psychiatry was subject to penetrating critiques by Foucault, Szasz, Laing, and others. These critiques brought into question the concept of mental disorder that had arisen during the modern age and specifically since the beginnings of the science of psychiatry in the early decades of the present century. They were historical, philosophical, social and political in nature. The paper will discuss these critiques in the light of developments in the theory of disorder and in mental health services in the last few decades and currently, including community care, user involvement, changes in mental health legislation, and the rise of cognitive therapy. Themes in such developments are characteristically post-modern, insofar as they involve questioning of absolute values and power relations, and relativistic approaches to the understanding of order and disorder. The paper will speculate on possible future directions for mental health services.

Video presentation and Workshop

Towards integration of Euro-American and traditional African therapies: a transcultural exploration of the treatment of psychosis in a post-modern world.

H. Campbell, MRCPsych, E. Burke*, MSc Couns Psych

South East Health Board, Ireland; *Private Practice

Workshop participants will be invited to explore in small groups the role of ritual, spirituality and religious systems in their current therapeutic practice and how this might change as we enter the post modern era, drawing on insights derived from traditional African healing practice. Participants will be given an outline of the historic and pre-historic development of therapeutic systems in a transcultural and evolutionary context. An example of a traditional Tanzanian healing intervention with a sufferer from paranoid schizophrenia will be shown using videotape. Similarities and difference between traditional African therapeutic systems and modern Euro-American systems which have roots in Cartesian philosophy will be outlined.

Plenary session

- Anxiety - animal reactions and the embodiment of meaning

G. Glas

Department of Psychiatry, University Medical Centre Utrecht, The Netherlands, Department of Philosophy, University of Leiden, The Netherlands

In this presentation the question will be raised whether pathological forms of human anxiety are simply remnants of some archaic animal reaction or must be seen as totally distinct from animal physiology, for instance as bearer of existential meaning. I will explore a third position, which suggests that in the human world animal reactions can be enriched with - or opened-up to - social, moral and even existential meanings.
This position asks for a structural analysis of the various aspects of anxiety and their coherence. I will attempt to offer such a conceptual analysis. I will refer to and comment on recent work of neurologists and neuroscientists like LeDoux, Edelman, Damasio, Ramachandran. Putting the mind back in the brain, like they suggest, is indeed one important step. Opening-up the brain in such a way that brain functioning obeys to psychological regularities and is responsive to social norms and moral values, is another.

Seminar "Psychiatry and the past beyond the history of psychiatry. I"

- Origins of Psychotherapy

D. Padro Moreno

Hospital Civil de Basurto (Servicio de Psiquiatria)

Beginning with the shaman as the first practitioner of techniques which we call today psychotherapy, the author studies this figure as a wise man, in the context of ancient classical Greece, the time when mythical conceptions embarked on their journey towards the world of logos. In this transition, the enchantment (epode) of shamanic practise gave rise on the one hand to philosophical logos and hence the word as a curative instrument and, on the other hand, to medicine. This division, presents a clear parallelism with the current dichotomy between the physis and the logos involved in the psychotherapeutic techniques used today. A new paradigm, of New Hermeneutics is proposed which combines the physis and the word at their point of origin.

- On the "romantic" and the "rationalistic" in psychiatry

J. Ihanus

Department of Psychology, University of Helsinki, Finland

Two broad traditions of psychiatry are presented in this paper. The "romantic" tradition has stressed, beginning from the late 18th and early 19th centuries, the connections of madness to emotions, fantasies, hidden, unconscious "night" sides of the human soul, and to moral factors. Its later ramifications and modifications, for example through psychoanalytic and phenomenological-humanistic views, have brought forth empathic-intuitive understanding and "revealing" depth-interpretation of unique experiences and intrapsychic conflicts. Introspective and idiographical case histories, listening with the "third ear" in psychotherapeutic settings, and subjective symbolic manifestations of personal problems in living have dominated the ethos of this approach.
The "rationalistic" tradition in psychiatry derives from the late 18th-century enlightenment, and from 19th-century evolutionistic social theory and the rationalistic-positivistic "science cult." The shift in psychiatry from a focus on emotions and moral factors to clinical reason, medical somatogenetic explanations and the "objective" nomothetic approach was launched by the late 19th-century neuro-psychiatric and psychopathological research, by attempts at diagnostic classifications, and by statistical methods of collecting large data for the managerial and administrative purposes of public and semi-public psychiatric institutions, and for socio-political purposes.."Curability" rates and etiological laws were finally expected to be proved with the help of statistical data and epidemiological generalizations based on them. Symptoms and syndromes were seen by psychiatric expertise as observable elements of a total disease to be treated preferably by institutionalized custodial "care."
Between these two traditions there have been tensions and breaks but also intercations and mixtures. For example, in psychoanalysis, clinical rationality has been in dialogue with "romantic" irrationality. In Freudian thought the "dictatorship of reason" was one version of liberal rationalities which have elaborated progressivity, self-control, individuality, education to "realities" and opposition to artificial restrictions and inhibitions.

- Incoherence and significance: reading the logic or madness of the Renaissance physician and philosopher Girolamo Cardano

K. Jensen

Head of Incunabula and Western European Books to 1850, Early Printed Collections, British Library, London

The sixteenth-century physician and natural philosopher Girolamo Cardano (1501-1579) presents a number of characteristics which to modern readers of his texts may indicate that he suffered from mental illness. This is partly due to some of his beliefs, which to us seem to be delusions, partly due to his use of language, but also because of his sometimes disconcertingly unusual logic. Despite all his contradictions and all his astonishing arguments, Cardano was not ignored by his contemporaries and undoubtedly made a contribution to the changing approach to natural philosophy in the sixteenth century.
A modern reader risks either dismissing Cardano's texts as hopelessly aberrant or making them philosophically acceptable by imposing a consistency and coherence which the works do not possess, a process of normalisation. Cardano's academic contemporaries also read him as an author who was seriously divergent from the norm and either dismissed him or also attempted normalisation. In order to examine sixteenth-century attempts to get to terms with his works, it is important for a historian to acknowledge that Cardano's texts are simultaneously incoherent and significant. We can thereby approach an insight into the philosophical issues which were at the heart of Cardano's concerns, however unsystematically thought or expressed. We must read reactions to Cardano's texts with an awareness that sixteenth-century discourses of madness or mental divergence employed everyday language located in a common-sense, pre-professional approach to the subject. This will provide an insight into one of the ways in which mental divergence was viewed, specifically within the context of academic debate. This took place in a hierarchical society where forms of reasoning and forms of expression were regulated by explicit and rigid rules, based on an assumption of a metaphysically established equivalence between the structure of the human mind and the structure of the world. These social, linguistic, and philosophical rules enabled a transparent discourse within a closed society, but they also created obstacles to innovation which could therefore be socially and intellectually marginalized as an expression of mental abnormality.

- Melancholic States: Two Sixteenth Century Epistemologies

J. Radden

Born in the same year of 1515, Johann Weyer and Teresa of Avila are each regarded - although for very different reasons - as towering intellects and important historical figures. And both wrote extensively about melancholia, Weyer as a physician who treated melancholic patients, Teresa as an abbess in charge of communities of nuns who sufferered melancholia. A comparison of the writing of these two thinkers not only reveals the humanity, subtlety and philosophical sophistication of each, but differences of conceptual frame, purpose, moral psychology and presuppositions about human nature, so great as to require the label of differing, and contrasting, epistemologies. Thus: Weyer begins with a conception of the person which is individualistic and is guided by the goal of curing that individual; Teresa, in contrast, with her more relational conceptions and her differing pragmatic goals, responds to melancholia, from the start, as a social problem. The purpose of my paper is to show the way these fundamental differences of approach affect and shape the accounts of melancholia these authors offer.

Seminar "Philosophical foundations of psychotherapies I"

- Psychotherapy, ethics and Immanuel Kant

J.S. Callender M.D. F.R.C.Psych

Royal Cornhill Hospital, Aberdeen, U.K.

Psychotherapy is an activity which takes many forms and which rests on many theoretical bases. This paper argues that psychotherapy contains paradoxes in relation to free will and rationality and that these can be resolved by the application of Kantian theory.
Psychotherapy is, by some accounts, concerned with expanding autonomy and self-realization. At the same time psychological theory increasingly brings emotion, thinking and behaviour into a scientific, deterministic model. As the explanatory power of science expands it encroaches increasingly on the realm of autonomy. The end result may be that everything is explained and the causal role of free will is negated. Psychotherapy may therefore be offering enhanced autonomy with one hand and taking it away with the other.
With regard to rationality, some forms of therapy aim to help clients by applying rational thinking to their problems. This is done explicitly in cognitive therapy in which a central therapeutic tactic is to replace irrational, dysfunctional assessments of reality with "rational responses". This rests on the assumptions that rationality can generate a true account of reality and that a therapist can help evaluate the concordance between a client's beliefs and his/her reality.
A principal purpose of the Critique of Pure Reason was to challenge the claims of rationalist philosophy and to argue that what can be known to reason alone is necessarily limited. Therapists should be aware that no matter how much rational thinking is applied to problems, things may always be other than they appear. However, Kant's moral philosophy rests on the generation of fundamental rational moral principles. The problems of clients can often be viewed as problems of moral behaviour and it is argued that Kantian ethics provides a framework for understanding and ameliorating these. Rationality may be used to generate precepts for action as well as judgements about reality. This in turn resolves the paradox of autonomy. Kant argues that it is ethical behaviour that allows us to step out of the bounds of determinism - " is the moral law which leads directly to the concept of freedom".

Callender J.S. (1998). Ethics and aims in psychotherapy: a contribution from Kant. Journal of Medical Ethics, 24,274-278

- Working with the witchdoctors: A cognitive-behavioral psychologist enters the land of psychiatry

J. Hegarty

Youth Specialty Service, Healthcare Otago, Dunedin, New Zealand

As a philosopher, scientist, and psychologist with professional experience outside of psychiatric settings, and with limited contact with psychiatrists, the author found several difficulties when moving to work in a hospital system traditionally dominated by psychiatry. While apparently sharing much of the same literature and terminology it became apparent that many basic assumptions, definitions of terms, and attitudes towards treatment differed, often radically, between psychology and psychiatry. This resulted in misunderstandings and a series of situations where colleagues, believing themselves to be perfectly lucid, were talking past each other. Much of this confusion appeared to stem not only from professional hubris, from both sides, but from a lack of understanding of the theoretical basis and the basic paradigms of the sister profession. In this paper I hope to describe the basic paradigm of cognitive-behavioral psychology (also know as the scientist-practitioner model); a model which is clearly not understood by many mental health professionals. In outlining the essence of the cognitive-behavioral mode of therapy I will describe the history of its development, and illustrate how CBT is often misinterpreted, and misunderstood; Marlatt's relapse prevention model of addiction will be used as one example. In the course of this paper I will describe how CBT, although firmly based in scientific research and practice, is not a set of techniques or models, but rather an eclectic approach to therapy defined by a worldview, or attitude. I will also argue that psychiatry is not only a-scientific, but anti-scientific in its approach, and that this is the crux of much confusion between the professions.

- Psychopathology and Psychotherapy in a Systematic Dialectical Perspective

G.G. Giacomini

Institute for Psychological Sciences and Systematic Psychotherapy - CESAD - Center for Studies in Dialectical Analisys

K. Jaspers' methodological distinction between an explanatory psychopathology and a comprehensive psychopathology is fundamental in order to define the specific characteristics of the two disciplinar fields of psychiatry and psychotherapy and their dialectical relations. As we know, a psychopathological clinical symptomatology, if imputable to a cerebral disease, is pertaining to psychiatry, whereas if it is to be ascribed to conflicts of the personality is related to psychotherapy. Therefore, this methodological distinction, between explanation (Erklären) and comprehension (Verstehen) is essential, in psychopathology, not only from a theoretical point of view, but also for a clinical differential diagnosis and any consequent therapeutical implication (above all in deciding among a pharmachological or a psychotherapeutical assistance or an integrated therapeutic program as well).It should be considered that a comprehensive psychopathology is founded on a systematic theory of personality as experience of the intimate subjectivity and its historical development; this is also the epistemological basis for a systematic analytic psychotherapy aiming to fill the principles of autonomy and spontaneity of inner subjectivity. The statement is assumed that in a systematical psychotherapeutic perspective the logic of building up and developing of personality, as well as its conflictual positions and their analitical discussion, is dialectically characterized, so that an integration between the phenomenological method of empathy and a dialectical analitic methodology is requested, both in theory and in clinics. For a systematic dialectical analysis of relations among psychopathology, psychotherapy and theory of personality, a reference to the Universal Epistemological Table (UET) is indispensable.

- How specific can the psychotherapeutic intervention be?

E. Jakobsson, Ph.D.

Department of Social Sciences, Mälardalen University, 63105 Eskilstuna, Sweden

In psychotherapy research the problem of if and how the "talking cures" cures is still a controversial issue. The non-specific factors are often regarded to many to secure a rationale on empirical grounds. Some people, both clinicians and researchers, seem to be content with the fact that psychotherapy on the whole and generally speaking, seems to be effective, while others (e.g. Edward Erwin) claim that this non-specific action should and can be specified according to the scheme "the factors f1, f2, f3... in psychotheraputic intervention P is good for the disturbance D".
This paper will present a model for understanding modern psychodynamic conceptions of indications, goals and actions that implicitly shows that it should be regarded as a general means of enhancing health that nevertheless could be specified in certain ways.
The model presents some constituents of psychotherapy in terms of the clinical theories of therapeutic relations. Accordingly, it is argued that that the question of what works for whom supposedly not will get an conceivable answer by a specification of interventions according to some nosological system. Rather it is a matter of the clients identification with certian aspects and qualities in an enacted but "real" therapy relation which offers both a language and an affective experience of new ways of handling real life-problems.
It is an empirical question whether the object of this general therapeutic change - that is the client's experience of the life world in terms of more usable views on self and others - also will finction as a secondary means of resolvment of psychopathological symtoms and syndromes. It could be that yhe psychotheraputic approach in essence is one of enhancing positive mental health through the strengthening of self-reliance and coping ability.
The main indication of psychotherapy would then be stated as a need of an increased and vitalising knowledge of self in relation to others. This could also be specified as to what should be the claims on the psychotherapist.

Seminar "Problems of conceptualisation and assessment in psychiatry I"

- A Name, What's in a name? The Medicalisation of childhood hyperactivity revisited

H. Klasen

SouthWest London and St. George's NHS Mental Health Trust

Objective: Although ADHD has in recent years become one of the most common psychiatric problems in childhood, its status as a medical disorder remains controversial and the medicalisation of hyperactivity is often discussed with critical connotations, especially in Britain. This study examines the experience of parents and doctors dealing with hyperactive children, focusing in particular on the process of medicalisation. It aims at understanding what is at stake for families and doctors and asks about the role of a medical label in the therapeutic process.
Method: This is an anthropologically informed study in which qualitative semi-structured interviews of 1 to 2 hours' duration were carried out with 29 parents of hyperactive children and 10 general practitioners. Interviews were audiotaped; content transcribed and analysed according to grounded theory.
Results: Raising a hyperactive child can provoke a profound sense of alienation in parents. Family and social roles are affected as well as parents' views of themselves in their parental and social roles. Parents tended to experience medicalisation and labeling as important aspects of validation and legitimization of their experience, which gave them a sense of control and led to improved parent child relationships. Doctors felt more reluctant about the medicalisation of hyperactivity, fearing that it could lead to scapegoating the child and to self-fulfilling prophecies.
Discussion and Conclusion: While carers valued a medical diagnosis as a powerful tool bringing mainly therapeutic advantages, doctors avoided labels, fearing they would disempower families. This is an interesting development considering that in the 70ies and early 80ies medical sociologists commonly accused doctors of a tendency to medicalise unwanted behaviours, seeing patients as victims of the process. Now in the late 90ies the situation has changed. Patients have developed a more critical distance to the medical establishment and make use of a wide variety of complementary treatments. Never the less it seems that now more and more patients (as in chronic fatigue) or parents (as in this case) lobby for medicalisation of conditions, which practitioners see as not clearly medical.

- Limitations of the mental state examination: context and social construction

J.P. Watson

Guy's, King's, and St Thomas' School of Medicine, Guy's Hospital, London SE1 9RT UK

The clinical mental state examination taught, examined, and used world-wide has proven validity and reliability when used according to familiar and well-established rules. Nevertheless, the method has limitations, three of which are discussed in this paper.
First, the method is office- and interview-based; direct observation as opposed to reports of problematic experience and behaviour can only be made of phenomena which may be manifest in this way. The phenomenology of psychiatric disorders in other settings, notably at home, in the workplace, and 'in the community' has yet to be systematically described, even though much is known by expert practitioners about it
Secondly, the method assumes that abnormal experiences and the phenomena of disorder are fundamentally intra-individual in nature; the phenomenology of social behaviour in psychiatric disorders has yet to be systematically described.
Thirdly, the categories generally used in the mental state examination represent a traditional 'expert professional' agenda which is psychologically limited and might benefit from revision, particularly in relation to problematic states of awareness (consciousness), difficulties of volition and intention, and the cognitive schemas and belief structures which individuals may have about their experience and problems.

- Beliefs and superstitions as a way of psychological defense in structure of harmonious personality and in mental health disturbances

I.Ya. Stoyanova, V.Ya. Semke, N.A. Bokhan, S.A. Oshayev, D.V. Dobryanskaya

Mental Health Research Institute Tomsk Scientific Centre SB RAMSci

To have an integral idea about personality, attitudinal positions of the man needing psychological, psychiatric or psychotherapeutic care, one should have an idea about primitive mechanisms of the psychological defense manifesting as beliefs and superstitions. Similar to cases of manifestation of the psychological defense studied within psychoanalysis, psychological defense mechanisms (PDM) conditioned by primitive thinking are directed at reduction of anxiety provoked by intrapsychic conflicts and represent specific processes with the help of which self seeks to maintain personality integrative ness and adjustability.
Essence of an archaic, mystic or pre-logic thinking is in total sum of beliefs and feelings building the united system and based on the collective ideas. Collective ideas and ideas associations are ruled by the law of participation and due to the latter are indifferent toward the logic law of contradiction. Trend of the archaic thinking including attention, imagination, and sensations is "feeling" of attendance and influence of invisible forces that help or impair a man.
Under contemporary conditions of the scientific approach to study of the phenomenon of beliefs as a way of psychological defense against the background of absence of the common conceptual approaches to the problem, concept apparatus is insufficiently developed; standardized methods of psycho diagnostics are absent. Investigators of the Mental Health Research Institute conduct an experimental-psychological work associated with study of beliefs in structure of the personality in norm and in various diseases of the borderline spectrum. To realize these tasks, we conduct population investigations in groups of children under school age, schoolchildren of various age groups, students, representatives of various professional groups (nurses, physicians, teachers, businessmen, housewives) as well as urban and rural inhabitants. On the basis of clinics of Mental Health Research Institute we carry out examination of patients with clinically verified diagnoses of hypertension, ulcer of the stomach and duodenal ulcer, hysteric neurosis, neurasthenia.
Basic direction of the population investigations is recognition of the conditions under which individuals develop primitive forms of psychological defense, study of content aspect of the psychological defense, relationship toward different sides of the vital activity, intensity of manifestation as well as peculiarities of these psychological defense forms in system with the other personality manifestations.
Experimental-psychological work with patients of the clinics beyond above mentioned research program includes study of contribution of beliefs and superstitions into the internal picture of the illness. Pilot work with population and clinical sample resulted in creation and standardization of a new psycho diagnostic questionnaire - of beliefs and superstitions (QBS). Objectification of data obtained with QBS will be promoted by the application of psycho diagnostics standardized methods complex directed at the study of individual-personality peculiarities.
Besides, use of the complex of psycho diagnostic methodologies is directed at a multi-faceted study of personality with different attitude toward beliefs and superstitions. Investigations have shown that in structure of the harmonious personality of a contemporary man there is an optimal individually varied level of the psychological defense conditioned by primitive thinking. In the structure of the personality of patients with neurotic and psychosomatic disturbances this form of psychological defense is represented excessively or insufficiently.
In addition, in present investigation we have for the first time obtained the new information about correlation of primitive forms of psychological defense in persons with accentuated traits representing extreme variants of the norm.
We revealed distinctive trends in the structure of the personality of patients of various nosological belonging.

- Diagnostic practice in schizophrenia: are gender differences related to cultural bias by clinicians?

A. Hoeye, V. Hansen, R. Olstad, A. Wifstad

Studying diagnostic practice has traditionally been linked to the evaluation of diagnostic reliability, but can in our opinion be useful when discussing diagnostic validity, and, thereby, concepts of disorder. The diagnostic process includes both the patient, the psychiatrist and the diagnostic systems in use, and a possible cultural bias by clinicians may be reflected in gender differences. A study (in press) of the diagnostic process in a cohort of first episode schizophrenic patients was fulfilled in 1999 in the two northernmost counties in Norway. All first-ever admitted schizophrenic patients with three or more admissions in the period 1980 - 1995 were included. The study shows that females had a significantly longer period than did males from first admission until first given diagnosis of schizophrenia (2.6 years and 3.4 admissions versus 1.6 years and 2.3 admissions). The distribution of diagnoses were also different prior to first schizophrenia diagnosis, females received personality disorder diagnoses (the most frequent being schizoid personality disorder) more often than did males. The total latency period before first schizophrenia diagnosis shortened after the introduction of new diagnostic guidelines with the change from ICD-8 to ICD-9 in 1987, but the gender difference in latency period persisted.
Our conclusion from the study is that diagnostic practice in the course of schizophrenia showed a significant gender difference, both in diagnostic distribution and in latency period prior to first schizophrenia diagnosis. The gender differences may be due to the following:

1. Schizophrenia in females is essentially different than in males. On a continuum it may therefore be that females are in the "schizoid end" of the scale while males have more typical "schizophrenic" symptoms.
2. Males and females have the same disorder, but different symptomatology according to gender modeling factors.
3. There is a systematically biased interpretation of symptoms by clinicians.
4. A combination of some or all factors.

The heterogeneity of the schizophrenia diagnosis may implicate a lack of diagnostic validity. Pt. 1 and 2 addresses the question of gender linked diversity in the expression of mental disorders, which are not taken into consideration in the diagnostic classification systems. When gender factors in schizophrenia is discussed in relevant litterature it is most often linked to modeling, biological factors associated with femininity, such as estrogen. The possibility that diagnostic heterogeneity linked to gender is also an expression of systematic, cultural bias by the clinicians (pt. 3) has rarely been addressed. The description of mental symptoms throughout history is associated with cultural factors, as well as clinicians' interpretations in the current context. At the conference the study will be presented, with a closer discussion of the question raised in pt. 3. Hopefully this will also include preliminary results from a relevant study performed during spring 2000.

Seminar "The social construction of madness and of psychiatry I"

- Away with the fairies: Young people's stories and the social construction of madness:

M. van Beinum, H. Connery

Department of Child and Adolescent Psychiatry, University of Glasgow, and Greater Glasgow Primary Care Trust, Glasgow, U.K.

Views of teenagers have rarely been given status in the development of psychiatric services. Where their views have been investigated, quantitative questionnaire surveys have been used. We argue that such positivistic approaches are inappropriate for eliciting the meaning of psychiatric care for clients, and that questionnaire surveys are often based on the assumptions of researchers and not the perceptions of subjects. We therefore used a qualitative study design to probe the views of teenagers about the meaning, for them, of the experience of coming into psychiatric care. Central to our thinking has been a social constructivist approach, both regarding the nature of the psychiatric encounter and the research strategy.
Results will be presented from thirty open-ended qualitative interviews with recently discharged clients aged 12 to 19 attending an adolescent psychiatry
out-patient service. All interviews were recorded using audio tapes, transcribed into text and analysed for themes using NUD*IST software. Using the tree-sorting mechanism of NUD*IST, commonalities across respondents and subsidiary themes in the data were identified. Emerging theoretical constructs were tested by sequential theoretical sampling.
The results, using the language employed by the young people themselves, indicate that there is a process, across time, whereby young people, who start by expressing personal worries, enter a public discourse about madness. Private disquiets are socially constructed into public categories via a process of small ritual humiliations, including perceived stigma of psychiatric contact, utilising the power inequalities inherent in both the medical system and the status of child.

- Deconstructing utopian ambivalence: the psychiatrist as institution within the discourse of psychiatry.

E. Keirnan

Graduate School of Management, University of Western Sydney-Nepean, Sydney, NSW, Australia

The realities, myths, understanding and expectations of society towards psychiatrists, is explored through interviews with the psychiatrists themselves. A postmodern philosophical perspective is lent to the interview process and transcripts with a selection of Australia's practicing psychiatrists. The interviews center on what it is to be practicing today at the end of one and beginning of a new century. The interviewer becomes the recipient of the questions and answers, allowing the psychiatrists to deconstruct themselves through giving them voice. They question their own 'voice, terrain, purposes, and meaning' (Flax, 1990: 7). The depression, anxiety, stigmatisation and perceptions of loss of control that characterise various mental disorders emerge as also being applicable to the psychiatric profession. A common concern for psychiatry arose in a multiplicity of forms. Will the deinstitutionalisation for the twenty-first century be the removal of the psychiatrists themselves? What will be the place and where will be the space for psychiatrists in the discourse of psychiatry? Alternatively, rather than a deinstitutionalisation of the psychiatrist, will a deconstruction, a questioning of the expectation to practice with levels of utopian ambivalence reveal new spaces for the psychiatrist in the discourse of psychiatry?
Interviewer: One final question. Is there anything else that you could tell me to help me understand what it is to be a psychiatrist practicing at the end of the twentieth century in Australia, any other issues that are important to you?
Respondant: Relevance!

Flax, J. (1990), Thinking Fragments: Psychoanalysis, Feminism, and Postmodernism in the Contemporary West, University of California Press, Berkley and Oxford.

- Can postmodernism provide a meaningful discourse on the interface between madness and citizenship in a democracy?

N. Potter

Department of Philosophy, University of Louisville, Louisville, USA

According to Derrida, the language of reason is simultaneously the language of order, of the universal rationality of which psychiatry wishes to be the expression, and the language of the body politic--the right to citizenship in the philosopher's city. But this order is always already a disorder, and the objectification that language structures is never total. As Mouffe and Laclau put it, all discourse is subverted by what overflows it.
Foucault, in the History of Madness, links language as the first and last structure of madness, where madness designates a delirious discourse which is banished into non-being. But Derrida argues that Foucault's attempt to isolate madness is in error: logos, the language of objectification, is a break with madness only to the extent it adheres to it--order can only be denounced within order. Thus the articulation of madness unceasingly reiterates and reinscribes madness through the specter that haunts logos in psychiatric practice. Where Foucault claims that the psychiatrist is the delegate of societal and governmental reason, Derrida argues that psychiatry has opened itself up and that madness as unreason has dislocated itself.
The idea that language both orders and yet leaves traces includes the discursive production of the subject who, in postmodern theory, is constituted in part by its outside. The subject (of psychiatric research, of citizens in nation-states) is neither a unified entity nor a fragmented but pathological being, but a moment whose elements are never fully articulated. Hence, the postmodern subject is never fully fixed.
If we take seriously these claims, what happens to nosology? diagnosis? treatment? And how can we understand the meaning of citizenship and rights? I argue that the (never unified, never stable) interface of these postmodern claims about instability within order, madness within reason, and multiple subjectivities within citizenship, is epistemologically and politically significant both for psychiatrists and political theorists.

- Mad, bad or disagreeing?
On moral competence and the philosophical justification of responsibility

M.M.S.K. Sie

Department of Philosophy, Erasmus University Rotterdam, The Netherlands

Suppose that there is no real distinction between 'mad' and 'bad.' Suppose that bad-acting agents are simply malfunctioning ones and that this malfunctioning can always be explained either: 1) in terms of the exceptional circumstances (past or present) of the action or, 2) in terms of the impaired (mental) abilities (temporary or more permanent) of the agent. If this is the case: should we not change our ordinary interpersonal relationships in which we blame people for the things they do, are morally indignant about their wrong actions, and hold them responsible for the kind of persons they are? After all, if people literally always act to 'the best of their abilities' nobody is really to blame for the wrong they commit.1
Under a certain very plausible philosophical picture of agency, this version of the sceptical paradox is hard to avoid without controversial metaphysical implications. Although I will not defend the resulting paradox as inevitable, I will show that it is, at least, intelligible, hence, should be considered if we are concerned with the legitimacy of our daily practices of responsibility. Against this, I will argue that we cannot but hold people responsible2 for the wrong they commit, even if we accept that a clear distinction between mad and bad cannot be defended.
My argument will center on the need to allow that actions that are evaluated as wrong in fact express what we could call an 'unconditional normative disagreement,' i.e., a fundamental difference of opinion about the norms and values that should regulate our moral community. This, as I will show, is in tension with the interpretation of wrong actions as the inevitable result of impaired abilities or excusing/ exempting circumstances. I will conclude that even if we can abandon our daily practices of responsibility (against the Strawsonians*), and even if we do not know that we are free and/or to blame for our wrongdoing (against compatibilists#), it is still not wise to change our ways as long as we do not know what wrongness (and goodness) exactly is, and as long as we do not know what madness (and sanity) exactly is.

Symposium "Epistemic models in biological research"

- The schizophrenia. The contribution of the psychopharmacology to the evolution of the knowledge of a multifaceted disease

M. Balestrieri

Cattedra di Psichiatria, Università di Udine, Udine, Italia

We are still far from having an unitary psychopathologic model of schizophrenia. At the nosographic-descriptive level it is still open the debate about which are the nuclear, or primary, symptoms of the disease (the positive or the negative symptoms?) and about the role of the subjective symptoms (the basic symptoms) that recently have received new emphasis from the late exponents of the Jasper's school. The knowledge about the factors implicated in the pathogenesis of schizophrenia is even more scanty. It is generally acknowledged the presence of an organic basis, there are many evidences that testify a genetic component and it has demonstrated that the risk is greater in presence of external events of stressful, traumatic or infectious nature. The schizophrenia is currently conceived according to a model where various factors play a predisposing or activating role: the genetics, the trauma of birth or the pathogenic events in pregnancy, the relational style in the infancy, the stressful events and the social support after the development of the disease.
The role of the psychopharmacology in the advancement of the knowledge of schizophrenia is remarkable. The "dopaminergic" theory has represented a central issue in the debate on the nature of schizophrenia. The efficacy of the "conventional" antipsychotic drugs has at first brought to hypothesise a simplistic hypothesis, according to which the schizophrenia occurs in presence of an excessive dopaminergic activity in the brain. Subsequently, this model was recognised as no more sustainable on the basis of the postmortem examinations and according to the observation that the antipsychotic drugs are effective long after the block of the receptors of the dopamine, which is very rapid. This has brought to hypothesise the existence of complex mechanisms involving other receptors. Another factor that has weakened the dopaminergic hypothesis is the increasing value given to the negative symptomatology in the schizophrenia. The novel antipsychotics (termed also as "atypical"), pharmacological class created after the marketing of clozapine, constitute a class of heterogeneous compounds. Even though most of these compounds have shown a better efficacy on negative symptoms than haloperidol, each of them is characterised by a different pharmacological and clinical profile, both on dopaminergic and serotoninergic receptors. For that reason, many researchers now hypothesise that a relatively weak antagonism for the dopaminergic receptors, together with a strong antagonism for the serotoninergic receptors plays a crucial role in the therapeutic activity of the novel antipsychotics on the negative symptoms. Even more recently, a contribution to the knowledge of schizophrenia has come from the study of glutamate, a neurotransmitter involved in more of 50% of biochemical processes in the SNC.

- Clinical psychopharmacological research: logical empirism or logical fallacy?

G. Rutigliano

Neuropsicofarmacologia Università di Bari - Italy

When clinical psychopharmacological research began, it also was evident that some logical difficulties arose to face the necessity of comparing the world of clinical symptoms realized by psychiatrists like "perceived" sensations (Praecox Gefühlen e.g.) and the reality of an easy system to describe them. The solution to this problem was the emergent necessity to reduce this complicate world into a synoptical and prevalently behavioral observation of course and outcome of mental illnesses.
The answer to that necessity was the birth of DSM, considered by the majority of psychiatrists as the bible of psychiatric diagnoses.
Further, the discovery of an increasing number of molecules potentially considered as useful to care ental illness, led the reaserchers to speculate about some new instruments able to measure and to compare two or more groups of patients, either treated or not by drugs, and chosen according to the statistical rules of randomization and blindness. Those principles have been largely adopted in the majority of the so called "clinical trials", considered from economical and political aspects as "scientific trials", even if it is implicitly accepted that the "scientificity" of those experiments is with difficulties respected. In this way two logical characteristics of biological reaserch have been disattended, the first one is the reduction of a "biological model" to a model belonging to the world of the physics, the second one is the absence of any knowledge of the evolutionary aspects of the pathology and the of personality of patients, this because of the frequently too short period of observation that doesn't permit a correct evaluation of the natural outcome of the disease.
The transversal observation of mental symptomatology frequently led clinicians to a misunderstanding of the diagnostic picture, which is in this way observed only in a limited phase of the disease and of a person lifetime. For this reason it is not considered as an historical event but as a sudden irruption of a pathological disregulation of biological systems in a subject.
In the field of preclinical study of drugs the use of minimal size animals for the screening of drugs potentially useful in humans leads to some questionable aspects of logical acceptance of the emergent data.
Finally the opinion about the ethicity of some treatments which initially was considerd only useful for a brief period is revised. Nowadays those treatments have turned into real prothesic ones, from which is almost impossible to get out.

Seminar "Psychiatry and the past beyond the history of psychiatry II"

- How psychiatry represses its past

H. Malmgren

Dept of Philosophy, Göteborg University, Box 200, SE-405 30 Göteborg, Sweden

Psychiatry is very good at not remembering its roots. For example, in the recent American upsurge of interest in the Rorschach test, the European tradition is all but ignored, and in John Exner's very influential work "The Rorschach Systems", no European Rorschach system is included. This of course means that a lot of valuable knowledge is lost for the modern scientific community.
Another clear example is given by the neurasthenic and pseudo-neurasthenic syndromes, which were ignored for many years by psychiatrists but now crop up again under new names such as neurocognitive disorder and chronic fatigue syndrome. Many psychiatrists who use these terms do not know the large body of research about neurasthenia and related syndromes which was once accumulated, and they are therefore not as well equipped to handle these cases as they could be.
I will finally show that the recent "A History of Psychiatry" by E. Shorter, hailed by many, distorts the European origins of psychiatry to an unacceptable degree, while praising recent American research in an unproportionate way. In this way, his book consolidates the loss of psychiatric knowledge which has occurred, instead of compensating for it as a real history book should do.
These losses of knowledge once accumulated may give the impression that psychiatry is not a discipline where cumulative knowledge is possible. Some may even suggest that a number of Kuhnian paradigm shifts are responsible for the changes. This is however not the view taken by the present author. In the presentation, I will list a number of alternative explanations for the phenomenon which I describe.

- Hitchcock, Cavell and Capgras

S. Winfield

School of Philosophy, University of Sydney; psychiatrist

In thinking about the Capgras delusion I use ideas from Freud's writings on doubles and the uncanny and from Stanley Cavell's responses to Freud. Freud illustrates his views by reference to E.T.A. Hoffmann's story of the mechanical doll Olympia ("The Sand Man"), later incorporated into Offenbach's opera "The Tales of Hoffmann". Cavell argues that understanding and accepting the separateness and ordinariness of others is an achievement and unbearable for some people, and that doubles and automata are therefore psychologically attractive and disturbing. In Hitchcock's "Vertigo" the vulnerable Scotty meets Madeleine/ Judy and becomes trapped in a vertiginous regression to a primitive, solipsistic state in which the distinctions between what is possible and not-possible, who is authentic and who an imposter, are disrupted. Via Freud and Cavell, I suggest ways in which Scotty's experiences, and ours as we view the film, might cast light on the genesis and maintenance of the Capgras delusion.

- Psychology and Cosmology

F. Leoni

Dpt. di Filosofia, Università degli Studi di Milano)

In Eine Schwierigkeit der Psychoanalyse (1917) S. Freud listed the three serious blows dealt to mankind's self esteem by modern science: 1. Copernicus's (The Earth is not at the centre of the Universe), 2. Darwin's (Man has no special privilege in Nature), 3. Freud's (The ego is not its own master). Copernicus's blow was a cosmological one. The animal that the ancients had depicted as keeping his eyes turned upwards to the skies was now a lost creature in the Universe, wrecked on a big rock, as Husserl wrote, on which he crawled aimlessly. This doom was however looming over man well before Copernicus, prepared by Plato's most astonishing invention, the invention of the soul (C. Sini, Passare il segno. Semiotica cosmologica tecnica, 1981). Invention of that unprecedented inner space of experience, the soul, receptacle of logic's and psychology's objects: language, judgement, truth; deception, feelings, opinions. And removal of experience away from where it belonged, the world, and from the meanings and signs of that kosmos. It is not by chance that this immensly powerful and problematic tension between psychology and cosmology, between the emergence of the first and the repression of the second, while achieving its accomplishment, snapped. And that the snapping occurred where in our science's encyclopaedia the tension was highest, where psychology was directly concerned (as Husserl saw in his Krisis, 1954) and also where cosmology was concerned (as Husserl saw in his manuscript Umsturz der koperkanischen Lehre, 1934). Nor it is by chance that the snapping was first recognised by phenomenological psychopathology, that most tormented branch of psychology, which first posed interrogatives about itself and about its object, madness, in terms of its own centuries-old silent alter ego, cosmology (E. Minkowski, Vers une cosmologie, 1936; H. Tellenbach, Melancholie, 1960). Hidden, fragmentary simmetries that are yet absolutely necessary. When cosmological man declined to make room for the man of logic and psychology, the cosmological sense issue declined accordingly; experience was equated with measurement and calculation proceedings. On the contrary, when the man of logic and psychology declines - when he falls into madness, or when his general experience becomes less and less interpretable in psychological terms - the cosmological sense issue comes to surface again: has experience a cosmological meaning? These genealogical, and epistemological connections between cosmology, psychology and psychopathology are as yet, and generally speaking unexplored.

- Aligning Melancholia and Depression - Ontological Commitments

J. Radden

Is it useful to say that pre-twentieth century descriptions of melancholic states refer to the same condition as descriptions of clinical depression from the twentieth century? Part of the answer to this question rests on the degree of similarity between the earlier and later symptom descriptions. And this similarity is striking. On the other hand, the differences are also notable. however, a consideration of the balance between these similarities and differences is not all there is to the matter. At stake in this inquiry are also certain methodological or ontological factors about the sort of thing we understand mental disorder (or at least this particular mental disorder) to be. Adherence to a descriptive analysis will discourage us from identifying early melancholia and depression; but an aetiological account, in contrast, will permit the identity between thw two conditions even in the absence of strong similarities between symptom descriptions (as the case of so-called "masked depression" illustrates.) In my discussion, I explore philosophical and theoretical considerations favouring a descriptive over the aetiological analysis.

Seminar "Philosophical foundations of psychotherapies II"

- Philosophically-informed psychotherapy

E.L. Hersch, M.A., M.D.

Psychiatrist-psychotherapist in private practice; Toronto, Ontario, Canada

Psychotherapy in its various forms is still one of the world's most frequent treatment modalities in the mental health field despite the recent emphasis on pharmacology and "neuroscience." It is also the most directly philosophical of mental health approaches as its basic subject-matter is to deal with the varying "world-views," "belief systems," and "experiential worlds" of its participants, as well as with the interactional "fusings of horizons" which take place in their encounters with each other and within their societies. Perhaps nowhere else in the mental health field are the philosophical questions of epistemology, ontology, and phenomenology so obviously relevant, even if they are often overlooked or ignored. In this sense the practice of psychotherapy might even be seen as a sort of "applied philosophy."
Since our theories of psychotherapy may each be seen to rest upon definable sets of philosophical presuppositions which have a great influence upon how we practice, it will clearly be in our interest to have as much insight into these as possible. That is, as psychotherapists we should make the efforts necessary to better "know our philosophical selves." This may require us to take a more careful look at the implicit philosophical assumptions inherent to our psychological approaches, and a method of systematically doing so has been developed. A greater degree of philosophical-attunement and awareness may result in some significant re-interpretations of several of our most cherished psychological concepts. Newer psychological or psychotherapeutic theories may also be constructed and developed by beginning with particular, explicitly adopted philosophical stances and then building upon them.
Examples of the above will be provided including some from my work on the "Beams-of-Light-Through-Time" model, a psychological paradigm based upon a phenomenological philosophical grounding. Some of this material will also follow up on work presented at the First International Conference On Philosophy and Mental Health (in Spain, 1996) in which a "hierarchy of levels of philosophical inquiry and their questions" was presented. A series of "hierarchical sketches" which summarize and compare the philosophical bases of various psychological theories has since been constructed utilizing that framework. Examples of these will also be presented as time permits.

- Phenomenologicals methods in psychotherapy

F. Madioni MD, PhD, M. Archinard MD.

Liaison Division ,Department of Psychiatry University of Geneva

What has happened to existential psychotherapy (Daseinanalyse) after Binswanger?
Do the schools of psychoanalysis and phenomenology draw closer together?
Considering these questions the authors draw up the methodological basis for the practice of phenomenological psychotherapy.
Case reports illustrate the specific characteristics of phenomenological psychotherapy.
The authors argue that phenomenology could be perceived as an epistemology of psychotherapy.
The fundamental questions ramaining, however, concern the design and implementation of a formal training program for psychotherapists and the issue of establishing a specific school.

- A new psychological model for individual and social responsibility in depression, anxiety and stress

C.R.F. Sherlock MRCPsych

Bowness Clinic

This paper presents a psychological model that proposes new insights into the nature and cause of mood, neurotic and stress-related disorders (depression, anxiety and stress). It is based on extensive clinical experience and observation over the last twenty years. Particular attention is paid to the vicious cycles in which emotions drive us in thoughts, speech and actions.
These vicious cycles are thought to give rise to and maintain depression, anxiety and stress. Essentially, when we cannot have our way we feel thwarted. Consequently unwanted emotions erupt inside us. Emotion is the energy to overcome obstacles that prevent us from having our way. It is the force that enables us to get what we want, or to get rid of, get away from, or change what we do not want. Unwanted emotions can be evoked by any upsetting, painful or frightening thoughts, sensations and emotions. Whether the objects of our senses and thoughts are pleasant or not depends on us, not on the objects. We determine what is pleasant and unpleasant, what is wanted and unwanted, depending on our attitudes, mood, and disposition at the time. Normally we try to get rid of or get away from anything we dislike. Although certain emotions and sensations are universally regarded as unpleasant, we do not have to reject them. These include disappointment, frustration, annoyance, anger, fear, despair, depression, anxiety, stress, discomfort, and pain. When the urge of an emotion is not fulfilled it becomes uncomfortable for us. If it increases it becomes frightening and painful and so is unwanted. When unwanted emotions do not go away we are repeatedly thwarted and so these emotions are triggers for further unwanted emotions. The emotions and our reactions to them form vicious cycles that escalate in emotional intensity until we are incapacitated by them. We cope with unwanted emotions by trying to get rid of them or away from them and we do this in one or more of three ways: we express the emotions, we suppress them, and/or we distract ourselves from them. All three ways are counterproductive and none of them resolves the underlying problem; on the contrary, they tend to perpetuate problems and they are habit-forming. To break these vicious cycles the link between emotion (energy) and reaction (thought, speech and action) has to be broken. This means not to express the emotional energy, not to suppress it and not to distract from it, including not intellectualising it, not rationalising it and not analysing it. It means our having to adapt by learning to bear and tolerate unwanted emotions and sensations. Adaptation requires strength, courage, and, above all, willingness. Adaptation Practice is a comprehensive treatment based on these new insights. With practice the necessary strength, courage and willingness can be developed. A brief report on a pilot study, in which a group of general practitioners were taught the basics of Adaptation Practice to help them cope with depression, anxiety and stress, gives examples of how Adaptation Practice works.

- Existential psychoanalysis of mysophobia (délire de toucher, Schmutzphobie)

A. Kraus

Psychiatric Clinic, University of Heidelberg

Applying Sartre's "existential psychoanalysis" to mysophobia we are concerned with the existential symbolism of adhesive dirt in compulsive washing. The freedom of the compulsive patient is undermined by the adhesion of dirt, in that part of his being (dirt as a reification of sexual wishes, aggressive tendencies etc.) come to the exterior, starting an expansive, independent existence. The patient is thus caught into an increasingly exterior relationship to himself. Obsessional acts like washing hands are understood as attempts to get rid of this kind of material determination in order to regain his motivational freedom. The question is put if obsessive-compulsive disorders in general - from a phenomenological point of view - are founded in a kind of reification of the self.

Seminar "Problems of conceptualisation and assessment in psychiatry II"

- Two continua of dissociative experiences: a much-needed distinction

C. Krüger

Department of Psychiatry, University of Pretoria, South Africa

The distinction between state and trait aspects of dissociation is needed in view of the implicit predominant attention that has been given to trait characteristics despite evidence for state characteristics of dissociation. Evidence for the historical predominant attention to trait characteristics is found in the nature of all dissociative measuring instruments except for the recent State Scale of Dissociation that measures state characteristics.
Research on (trait) dissociation presupposes a continuum from rare to frequent dissociative experiences. Notwithstanding this trait continuum of frequency of dissociation, a continuum from mild to severe dissociative states should be recognised for a more representative understanding of all aspects of dissociation. The psychometric validation of the State Scale of Dissociation, that measures the intensity of dissociative states at the time that they occur, demonstrates empirically a state continuum of severity.
The distinction between these two continua is useful clinically and for future research as, for example, illustrated in the difference between potential neurophysiological correlates of, respectively, dissociative states at the time they occur and dissociative traits.

- Delusions as performance failures. A program note

P. Gerrans

Philosophy Program, Research School of Social Sciences, Australian National University, Canberra

Philosophy Program, Research School of Social Sciences, Australian National University Haydon Ellis offers a 2-stage cognitive model of delusional belief in which a modularised malfunction produces an anomalous experience which is then rationalised by a malfunctioning central system of belief fixation. Maher offers a 1-stage model, involving only failures of modularised input systems. Others ( Sass, Berrios) think that delusions are not really beliefs at all. Each of these theories captures something important about delusion but, apparently, they cannot all be right. Furthermore, they have different implications for the explanatory role of Cognitive Neuropsychiatry. These cognitive models of delusion are especially interesting and inportant because they offer an explanatory bridge between neurobiological approaches like that of Andreasen and phenomeological ones like that of Sass, to delusional phenomena.
In this paper I distinguish modular from central function along lines outlined by Jerry Fodor. I further distinguish competence from performance for both central systems and modules. Once this is done one can see first, that the neuropsychological investigation of delusion is of performance mechanisms not central competence. Secondly, the inconsistencies between the three accounts of delusion are explained when we see that delusion is a result of performance failures which leave central system competence intact.

- The concept of a psychiatric symptom

T. Suomela

Univeristy of Turku, Finland

This paper deals with the concept of a psychiatric symptom and its development from a historical point of view. Certain psychiatric illnesses (depression, schizophrenia), their symptomatology and the conceptual variation of the symptomatology throughout the history will be discussed.
The current concept of a psychiatric symptom will be analyzed taking into account that the patient's concept of a symptom may differ from the one the therapist has. Special attention will be focused on our current diagnostic system and the diagnostic system and the diagnostic criteria as well as on the underlying phenomena that construct the concept of a symptom and affect on the use of this concept in the clinical real life situations.

- Tardive dyskinesia

A.O. Brundusino

University of Pavia, Italy

Tardive dyskinesia is a syndrome characterized by involuntary iperkimetic movements involving the face, the mouth, the limbs and the trunk which arise during treatment with neuroleptics and which can't be attributed to other causes. Symptoms can persist for some weeks after interruption of the neuroleptic treatment, representing them a extrapiramidal complication arising after a long period treatment with such drugs. Neuroleptic can cause both an acute syndrome and a dyskinesia arising from interruption of antipsychotic drugs. Acute dyskinesia can disappear either if the treatment is interrupted or if the drug dosage is reduced. Acute dyskinesia is sensible to anticholinergic and antistaminic drugs. The cause of this syndrome can be either a decrease in dopamine in the nigra-striatal pathway or an increase in acetylcholine. Dyskinesia due to interruption of neuroleptic treatment is caused by an increase in the postsinaptic sensibility of the catecholaminergic receptor in the nigra-striatal pathway. This could bring to the conclusion that this increase in sensibility is phisiopatological basis of some kind of dyskinesia caused by interruption of neuroleptic treatment and which can normally disappear either spontaneously or with neuroleptic treatment. Tardive dyskinesia persists for three weeks after interruptionof neuroleptic treatment: it can be reversible, persistent or intermittent. In reversible dyskinesia the degree of reversibility is higher during the first three month of neuroleptic treatment interruption, while in intermittent dyskinesia, the latter doesn't seem to depend on the patient's clinical state and it hasn't been proved that it can bring to a persistent dyskinesia. Persistent dyskinesia doesn't improve if the neuroleptic treatment is interrupted and can be considered irreversible only if the symptoms persist for some years after interruption of the neuroleptic treatment. Dyskinesia can be caused also by non neuroleptic drugs as :L-Dopa, Tryciclic antidrepessant, Antiepilectis like Phenytoin, Antimarials like Chlorochine, Estrogens, Amphetamines and Antiparkinsonian drugs. This kind of dyskinesia is reversible and disappears in a few days or weeks after the interruption of the treatment.

Seminar "The social construction of madness and of psychiatry II"

- The role of the social background in the treatment of Multiple Sclerosis (MS) in Greece

D. Kountouris

Center for Neurological Diagnosis, Athens, Greece

Introduction: Our aim in this study is to find out the role of the social background and the health insurance programs in the treatment of MS patients in Greece.
Methods and Material: 625 patients who suffer from MS received a medical treatment based on mitoxantrone during the last 8 years. The patients are divided in three groups A,B,C, according to the amounts of money paid by their health insurance, whether it covers all the medical expenses or a part of them or none of the them. In the case of patients of the first group all available services were provided (pharmacological, physiotherapy, psychopharmacology). On the contrary, the patient of the other groups did not receive the same services. The results of the examinations were measured at the beginning and at the end of the treatment according to Kurtzke DSS scale.
Results: There was a significant difference between the results in the three groups. The difference between group A and group B was 1,6, between group A and group C 2,1 (P<0,05). The patients of the A group had a significant less frequency of the relapses and infections than the patients in the other two groups.
Conclusion: The success of the MS treatment besides the pharmaceutical regimen, directly depend on the social background and health insurance of the patient. We observed an direct relationship between the success of the treatment with the financial position of the patient.

- Is the society mad?

A. Romila, V. Marinescu

2nd Department of Psychiatry, Carol Davila University of Medicine, Bucharest, Romania

Despite incontestable technologic progress, the globalization of communications, the rising of economic and standards of life especially in the western world, the entire world is filled with the slogan that the world is mad. However, the psychiatry doesn't see an identity between the world of the psychiatric clinic and the society. There are still some opinions that the clinical psychiatric world is even less mad than the external world.
Relying upon our conception of normality and resocialization, the shortcoming of the external world is in the shift of the soul from idealism to materialistic pragmatism and in psychiatry the spiritual deficit is replaced with non/cognitive or pseudocognitive forms of affectivity, mainly aggression and libido. It is therefore a philosophical range disorder and not a mental illness as a matter of fact. In these conditions, the conclusion is that the mental illness of the society is a metaphor meanwhile in psychiatry it is a reality. The main problem of the psychotherapy of resocialization is if it must aspire towards mimicry of the philosophically ill society or to aspire towards surpassing of the environmental social level (which could seem don quixotesque). It turns out to the paradox that normal people of the future could be the recovered patients

- Social approaches to treatment and prevention of somatoform disorders

G.N. Khandourina

Khabarovsk Region Railway Hospital, Khabarovsk, Russia.

The growth of depressive disorders has been noticed all over the world .The public demand for high individual achievements and the need to correspond to high social standards promote this problem. Attempts to meet these standards may be demaging to the personal interests and constitutional-biological possibilities of the person. In half of cases these problems appear in the form of somatoform disorders and patients deny the presence of psychological and emotional problems. The majority of them visits general prtactitioners, unwilling to turn to psychiatrists. I have examined 270patiens with somatoform disorders in the neurological department. There were many young people in this group (under 35), 77 % were women. In half of the cases the patients had cranio-cerebrel traumas in the past, encephalopathy or pathological climacterium. Personality disorders have been noted in the 80%. Personal' and family' frustrations provoked somatoform disorders in the majority of cases. So, a combination of biological, psychological and social factors plays an important role in the development of somatoform disorders. Biological therapy and psychotherapy have been given at the neurological department.These patients need further psychoprophylactics and social support in order to achieve positive results and prevent relapses. The psychoprophylactics concludes by self-regulation relaxation strategies, including progressive muscular relaxations, respiratory exercises, meditation, as well as methods of biofeedback. The correction of the small-adaptive characteristics of personality and interpersonal relations is also necessary. As for social factors, its correction can be realized with the help of the following conditions:a) the atmosphere of tough competition existing in society should be replaced by an atmosphere of helping and cooperation, b) attempts to achiev of top social standards in the plan of personal successes and consumptions should be replaced by orientation towards the correspondence of internal criteria to individual, biological possibilities of the person's; c)cooperative circumstances helps to promote person's abilities. Medical co-operative societies may solve the problems of prevention and cure of the somatoform disorders.The state cannot duly guarantee work of psychotherapy seryice, the private practitioners are not interested in this. There were many such organizations in the Far Eastern republic , which existed until the mid-1920s. Regrettably, there are no medical co-operative societies in the Russian Far East at present. There is no information about co-operative activity before the formation of the USSR and about modern coops, acting as members of the International cooperative alliance (IC?).

- The philosophical significance of R. D. Laing

S. Raschid

London, UK

R.D. Laing's focus in his writings, and therapeutic work, on 'schizophrenia' is consistently on the concept (and reality) of the Person. The conceptual matrix/matrices needed for the study of persons is/are necessarily distinct from that/those used in the study of biological organisms. Human beings can be studied in the two different modes of person and/or organism. In the realm of psychopathology this statement can be 'translated' thus : is psychosis to be understood (solely or exclusively) as the manifestation of biological dysfunction, i.e as the expression of a Kraepelinian disease-entity or as a disorder of the Person?
This consideration returns us to the central conceptual issue - what, or who, is a human being? This profound issue has been raised either only very marginally, or not at all, in modern psychiatry - on account of an equally profound process of repression in modern intellectual culture (this thought is inspired by Martin HEIDEGGER) . The predominant, but wholly philosophically unclarified, assumption underpinning contemporary modern psychiatric theory and practice is that human beings are simply, or essentially, to be studied and understood as biological organisms (or systems).
The cultural and historical background to such modes of thought is that of the extraordinary, and at times spectacular, development of the natural sciences. This has led unwittingly to the mechanical extension of natural scientific ways of thinking to major areas of (human) intellectual endeavour- areas which would not normally come within the purview of the natural sciences - (F. A. HAYEK The Counter Revolution of Science 1955). This insight can be developed with reference to the seminal Heideggerian notions of seinsgeschick ('The destinings of Being') and gestell ('The enframing').
On such premises it will be argued that the purportedly scientific statements made under the banner of 'Biological Psychiatry' need to be exposed as being essentially pseudo-scientific. They may be correctly characterised in terms of Michel FOUCAULT's complex analysis of 'discursive formations', and the interconnections of discourse systems with the non-discursive practices of social power structures, (i.e the essential connection between knowledge and power).

Plenary session

- Preventing severe mental illnesses: new prospects and ethical challenges

K.F. Schaffner, M.D., Ph.D.

University Professor of Medical Humanities, George Washington University, Washington, DC, USA

Severe mental illnesses devastate millions of lives worldwide. Exciting recent developments in functional psychoses, including schizophrenia and bipolar disorder, are offering hope that such illnesses can be identified and treated early. Early treatment promises better outcomes for both the affected individuals and their families. Such treatment aims at reaching patients during their first "psychotic break" as well as attempts to identify at-risk individuals during the pre-illness or "prodrome" period. These "early intervention" projects also point toward the possibility of true prevention for those at-risk of psychoses from genetic and/or environmental factors.
But the studies needed to determine the safety and efficacy of such interventions raise a series of significant ethical and regulatory questions, that if not adequately answered, will impede progress in this vital area, as well as potentially harm human subjects and their families. Most studies include low doses of new antipsychotic drugs. Are such drugs safe for those who will never really experience true psychosis? Will early intervention recruitment attempts stigmatize subjects and generate unnecessary family concerns? How can participants who may have their decision capacity compromised, and may also be adolescents and even children, provide true informed consent? Are subjects' confidentiality adequately protected? Do the double-blind designs of some trials afford sufficient closely monitored protection for those actually developing psychoses?
A recent conference, organized by the author, was held in Washington, DC involving most of the leading psychiatrists, scientists, and ethicists working in this area, including speakers from Australia, Norway, and the Netherlands. The questions raised above were intensively discussed but require further analysis. This paper reviews these issues, including the conceptually problematic notion of the "prodrome" in schizophrenia and other psychoses, and projects future developments in early intervention.

Symposium "Consciousness (awareness) and insight in psychopathology"

- Consciousness, awareness and insight in psychopathology

M.L. Bourgeois

IPSO. Université Bordeaux II. 121 rue de la Béchade, Bordeaux, France

Awareness of disease was central in the conceptualisation of insanity (alienatio mentis), especially among French alienists of the XIX century (T. Hammanaka, 1997). At the turn of the century, with the emergence of psychoanalysis, the interest focused rather on the unconscious (for Freud, man in general has a very little degree of consciousness). Nevertheless, insight became a cornerstone of the theory and psychodynamic treatment of neurosis.
Curently, there is a renewal of research in the domain of awareness among psychotic patients. Most of schizophrenic and manic-depressive patients during acute phases have very limited awareness of being sick. Poor insight is generally conceptualized as having at least three principal components:
1- unawareness of symptoms; 2- unawareness of the need for treatment; 3- unawareness of the consequences of the disorder (causal attribution is also important). It is associated with poor medication compliance, poor outcome, greater impairment in psychosocial functioning, and possibly heightened suicidality (X Amador et al 1998). Several rating scales had been designed to measure unawareness (JP MacEvoy et al 1989; AS David et al 1992; IS Markova et G Berrios 1992; X Amador et al 1994, 1998) Poor insight is one of the 12 signs and symptoms that were "especially discriminating between schizophrenia and other psychiatric disorders". It is a major element of psychosis, observed in the majority of patients. Poor insight is a complex and multidimensional phenomenon. It can be considered as a psychological defense (denial) or as a neuropsychological deficit (related to frontal dysfunction), it could also be related to the level of education and intelligence. Finally, anawareness of disease should be systematically assessed and measured. It must be the target of treatment either psychological and/or pharmacological. Some of the new antipsychotic drugs improved awareness.

- Insight and auditory hallucinations

J. Naudin, G. Stanghellini, M.A. Schwartz, O.P. Wiggins, J-M. Azorin

Université de la Méditerranée, Marseille, France; University of Firenze, Firenze, Italy; Case Western Reserve University, Cleveland, USA; University of Kentucky, Louisville, USA

Auditive Hallucinations (Ahs) are here defined as "reports of experiences attributed to an alien voice in direct relation with a self-consciousness' disorder". By its content, AH has to be related to moral insight. As a disorder in the self's feeling about itself, AH implies both misattributions and meta-cognitive beliefs. In AH, Meta-cognitive beliefs had been related to a weak self-esteem. This paper aims to discuss what it happens during voices: are Ahs either palliating or rendering intelligible in trivial terms the deficiency of the self? The authors point out that the hallucinatory content has as its dual object both the modifications in the intentional processes caused by the primary process and the quality of the relation of the self to the surrounding world.

- Models of consciousness in schizophrenia

P. Boyer

Hôpital de La Salpétrière and CNRS, Paris, France

Brain mechanisms exist that normally allow us to recognize our thoughts, whether bizarre or unwelcomed, as being self generated. It has been proposed (Feinberg, Frith) that precisely this mechanism was deranged in schizophrenia. Schizophrenic patients are not aware of their inner speech or of moving their arm by their own will when they mention that they are hearing voices or that an alien force cause their arm to move. What is remarkable is that normal subjects are not doing the same mistakes in their attributions. Hence we must hypothesize that normal subjects are informed by their own neural circuits that their motor cortex or that their sensory areas have been self-stimulated. Such an internal monitoring of sensory and motor commands has been considered either as a "feed-forward" control (preparation; Mac Kay) or as an "internal feed-back loop" (Evarts) leading the subject to know that his effectors have been activated. A lot of studies have been conducted to better isolate which neuroanatomical and functional circuits could correspond to this feed back loop. Nevertheless we can not completely identify this self-awareness mechanism to the process of consciousness. Self awareness is only one aspect of consciousness and incidentally it can occur quite automatically. Usually the internal feed back of motor acts is far below the conscious level. The process of consciousness in schizophrenia, if disturbed, is so at a much higher sensory-motor integrated level, where information processing (memory) interfere with motor mechanisms. We must keep in mind that the internal feed back loop does not seem to be dysfunctional for schizophrenic patients during childhood. Consequently the role of non neocortical areas (basal ganglia, hippocampus, thalamus) in information processing must be reconsidered to propose relevant models of alterations of consciousness in schizophrenia.

- Psychotraumatic stress and consciousness

F. Lebigot

Hopital Percy. 101 av. H. Barbusse, CLAMART, France

Psychic traumatic stress put the subject at the most primitive level of his personal history and functioning when the infans had not yet acquired the language.
This experience put him in contact with what can be called the "primal" or "originary". This aspects of the traumatic experience could explain the estrangement from other persons. He becomes a stranger who had met a forbidden extreme experience of "genuss". The effraction of the psychic limits induces culpability and a behaviour which aims to exchude himself from the inter-human common bondage. This multiple faceted suffering will appear to him as an enigma, hopefully an enigma to be deciphered.

- Phenomenological insight and psychiatric experience

D. Pringuey

CHU Pasteur, Nice

Phenomenological insight (intuition) is a largely helpful concept for explicating the bases of psychiatric experience. Following Husserl, intuition is not a revealed experience but rather a rigorous method for describing the movement of intentionality. This method allows a better understanding of clinical experience as an intersubjective one (Tatossian). It leads to ground the psychiatric diagnosis on the notion of ideal types (Wiggins & Schwartz). In psychotherapy, it allows a wider horizon of interpretations based on both concepts of taken-for-grantedness and openness of experience. Our definition of insight focuses then on the intentional experience of the Self and the World rather than an exclusively Ego's experience.

Symposium "Agency and context in schizophrenia: Anglo-American and continental approach"

- The disturbance of mental agency in schizophrenia

T. Fuchs

Psychiatric Clinic, University of Heidelberg

From a phenomenological point of view, the so-called "first rank symptoms" of schizophrenia may be derived from a fundamental disturbance of intentional mental acts. The structure of intentional consciousness implies self-referentiality, a sense of agency, and the integration of the sequence of moments into an "intentional arc" as outlined by Husserl in his "Phenomenology of the consciousness of internal time". All these characteristics of the acts of perceiving, thinking, willing and acting may be disturbed and altered in schizophrenia. The synthetic and sense-bestowing processes effective in perception are seriously damaged. Thinking and acting occurs without self-referentiality, and the unity of consciousness over time is threatened by the break-down of the intentional arc.
Schizophrenic experiences of reference, persecution and control may thus be explained by an "inversion of intentionality": With the paralysis of the patient's own intentional activity, the direction of his mental acts is reversed and turned against him, as if coming from the outside. Instead of actively perceiving, thinking and acting, he is being perceived, related to, thought of, and acted upon by others. This externalization may finally be interpreted as an overpowering by the "implicite other" as an essential component of human subjectivity.

- Neural correlates of agency. Do they help to explain schizophrenic experience?

H. Walter

Department of Psychiatry, Ulm, Germany

Current cognitive neuroscience offers new methods and data to explore the neural correlates of agency. I will give a short survey of competing neurocognitive theories based on studies with normal as well as neuropsychiatric patients. I will show that different theories appeal to different levels of explanation, ranging from neurotransmitters up to the contribution of the right versus the left hemisphere. After presenting an integrative account of what the mechanism of agency could consist in I will discuss the question how far such theories can help us to explain schizophrenic experience. I will argue that psychopathology plays a central role for any attempt to formulate a neurobiological theory of agency.

- Perception, action and context in schizophrenia: cognitive and phenomenological approaches

A.L. Mishara

Anglo-American cognitive and Continental phenomenological approaches to schizophrenia converge on certain topics. One of these is that patients with schizophrenia experience alienation with regard to their own agency and a corresponding loss of sensitivity to context, i.e. "common sense," which guides appropriate action. Remarkably, there are similar current debates in both traditions whether this disturbance is due more to an exacerbation or dysfunction of attentional processes (from above, as it were, an Apollonian disturbance) or more a disturbance to automatic processing (from below, a Dyonisian disturbance). In the phenomenological approach, some authors (Sass, Cutting) argue that there is a hyper-concentration which results in the morbid objectivation of experience from above. Other phenomenological authors (Binswanger, Szilasi), however, point to a breakdown in perceptual processing from below as part of prodromal delusional mood. Binswanger describes a "loosening" of the schema formation which normally enables past experience to impact present consciousness of the perceptual object and the transition from perception to movement in an ongoing process of self-transcendence. Along similar lines to the phenomenological debate, cognitive approaches have been divided whether the dysfunction lies more with conscious, explicit processing or more with automatic, implicit processing, for example, in comparator models which enable the distinguishing of self-generated from externally generated movements. The present paper attempts to integrate these different findings and theories by proposing a disturbance to the perception action cycle or Gestaltkreis (von Weizsaecker) between perception and action.

- Function and dysfunction of a comparator system proposed as selecting the contents of consciousness

J.A. Gray

Institute of Psychiatry, University of London

A comparator system, comparing quite generally the current state of the perceived world with its predicted state, was initially proposed as forming part of a suggested neuropsychology of anxiety, and subsequently extended to an account of the positive symptoms of psychosis (the system being functional or hyper-functional in the former case, and dysfunctional in the latter). Recently, it has been further proposed that the contents of conscious experience consist in the outputs of the comparator system (after a second pass through the perceptual systems that provide the initial input to the system), tagged according to their degree of match or mismatch with prediction. This hypothesis is able to account for the lateness with which perceptual experiences enter consciousness, relative to the speed of behavioural response to the initiating stimuli. The hypothesis can also throw further light upon the positive symptoms of psychosis. In this form, the comparator hypothesis resembles earlier suggestions that the relations between automatic and controlled processing are abnormal in schizophrenia.

- "Furtive abductions". Schizophrenia, the lived-body, and dispossession of the self

L. Sass

Rutgers University

Persons with schizophrenia often experience certain characteristic alterations of the lived body that undermine normal structures of bodily subjectivity and knowing. Aspects, features, or dimensions of bodily existence that would normally be inhabited lose their natural status as part of the tacit background of awareness, and instead are experienced as existing at a remove or in the outer world. What would normally be experienced as part of the self takes on characteristic of external objects. In this hyper-reflexive state, the planes and cavities of the lived body, or its sensations of solidity and flow, tension and release, come to occupy the focus of awareness. As a result, these phenomena take on qualities that R.D. Laing aptly described as "a kind of phantom concreteness": they seem unreal, distant, dreamlike and unfamiliar, but also (and even simultaneously) somehow exaggeratedly precise, material, electric, or hyper-real. I introduce some concepts from the philosophers Merleau-Ponty and Michael Polanyi that are useful for clarifying these developments.
Useful examples can be found in the research interviews carried out by the German psychiatrists Huber and Klosterkoetter on the so-called "basic symptoms" of schizophrenia. Perhaps the most vivid first-person accounts occur, however, in the writings of Antonin Artaud, a writer who suffered from schizophrenia. I consider these altered modes of experience by examining certain uncanny alterations of the lived-face. Artaud describes experiences in which what would normally be tacit experiences of one's own face as felt from within (e.g., patterns of kinesthetic awareness and vectors of tension) come to seem to be objectified to the point where he experience his own face as a kind of nervous membrane that floats, mask-like, away from his head.

Seminar "Philosophical foundations of psychotherapies. III"

- Penser la mutation

J.-P. Royol

Docteur en Psychologie Clinique, Hôpital d'Arles (13) France, Département de Psychiatrie

La psychiatrie se propose non seulement d'apaiser les souffrances psychiques mais aussi de provoquer chez le sujet une forme de mutation interne lui permettant de mieux vivre.
Se pose immédiatement la question de la suggestion-manipulation.
L'auteur propose de dépasser cette problématique grâce à une innovation conceptuelle = l'objet exogène. Dans le travail de dessaisissement qui porte de l'angoisse et de la violence fissionnelle vers la représentation, l'émergence d'un objet inattendu choisi par le patient, objet concret ou psychique, en dehors de la prise en charge signe l'apparition de la discontinuité.
Il s'agit de saisir la portée énigmatique de cet objet rival dans la marge de l'idéal technique aménagé comme de l'appareil théorique. Cet objet au sens large échappe aux catégorisations théorico-cliniques et augure une mutation.
Les limites du cadre thérapeutique génèrent un ailleurs, un rapport nouveau à l'objet, rapport qu'elles portent en négatif, l'investissement d'une vérité contenue dans cet objet choisi, la vérité d'un fantasme structurellement atrophié.
Le choix de cet objet est référé à une gestuelle psychique motivée par l'actualisation d'une ambivalence créatrice jusqu'ici ligotée dans les symptômes.

- From the psychoanalysis to the social psycology: a current perspective of the Operative Group by Rivìere-Pichon Enrique

A. Maio

Unità Funzionale Psichiatria Adulti, ASL 3 Pistoia - Italy

Psychiatry in modern culture seems to move more and more from an individual to a community approach especially from a psycho-dynamic point of view. In a sense, we should consider that all the theories psychoanalytics derived, have always proposed a dual model (bipersonal model/leader-group) which has been transferred to the group therapies themselves, even if these two techniques have been considered as different fields using different instruments. Actually psychiatry knowledge, according to a close social and thought trends factors implication, is imposing a progressive overcoming of this dichotomy in order to make a synthesis between theory and practice. From this point of view is interesting to review E. Pichon-Revìere studies and works. He was a psychiatrist, social psychologist and psychoanalyst in Argentina (Ginevra 1904-Buenos Aires 1977) though the political contest of his country and personal ideology,(before Bion literature), had already structured his own conception on Groups. The Group Process focused on inner group developing from the birth, but one of the most important aspect is represented by the concept of "Task", coming from social psychology theory, which is the key in the group situation where all the expressed interests and the primary elements of the individual history, of the members converge. The task consists indeed in facing the object of knowledge (anxiety and basic depression), that have become more open to access because of the break down of a dissociative and stereotyped model that functioned as a stop in the reality learning process damaging the communication nets with it.
Task, in a sense, makes dynamic the group situation and goes out from the setting bipolarism.
Basic topics of changement are then related to the overcoming of the epistemology obstacle in order to create a working-space to make members "learn to think" (active adaptation) and "refuse the stereotyped models" (passive adaptation).
Pichon-Rivìere theory discloses a modern research of the origin and relation between personaliy structure and social structure that may allow a real crossing and in some way integration, from paychoanalysis to social psychology. What appears a very current cultural event is the study of this relation focusing on the concept of "Link-Structure" that takes the place of the freudian instinct and makes possible a real operative pluridimensional approach of the human sciences with particular attention to the application of psychological and psychoanalytic knowledge to Community Mental Health, and above all prevention.

- Hermeneutic problems of the psychiatrc listening

C.F. Muscatello

The author analyses the different possibilities of reading a "clinical text" from the point of view of the most recent developments of the hermeneutics after Heidegger. He investigates the numerous possibility of "listening" to a text and suggests a way that might somehow preserve the words, guarding them with all potential meanings. This "listening"attidude reminds of the hermeneutic considerations of the late Heidegger, aiming at an unexhaustive interpretation of the words, accepting their natural permanent reticence. The refusal of thorough explicitation and the consequent efforts to define what was later called "hermeneutics of listening" aim mainly at defending and guarding the obscure truth contained in the text, fully aware that the blinding light of rational explanations might level ane homologate everything. The late Heidegger is paradoxically intent on never seizing the object of his search (the Truth, the Being), but on defending and guarding it as naturally unspeakable. He opposes a "going around" to the scientific and metaphysical attitude of seizing and revealing the truth. Only renouncing and withdrawing from a claim of possession allow to approach the inexpressible alteritas of a text, core of all hermeneutic problems and of the pshychiatric listening above all.

- A Course on Philosophy and Psychoanalysis

S. Winfield

School of Philosophy, University of Sydney; psychiatrist

In 1997 the School of Philosophy at the University of Sydney initiated a course on philosophy and psychoanalysis for second and third year philosophy undergraduates. This paper describes the course and its rationale. Over the duration of one semester, the course aims to give students a basic understanding of Freud and his intellectual influences and to introduce them to some key philosophical responses to psychoanalysis: for example those of Popper, Sartre, de Beauvoir, Habermas, Grunbaum.
There is a degree of strain in teaching psychoanalysis in a philosophical context, and there are difficult decisions to be made as to what to include and what to exclude. This paper discusses some of the challenges encountered in design and teaching.

Seminar "Ethical and epistemological issues in psychopathology"

- What is adolescent autonomy and how can clinicians promote it?

A. Stewart, T. Hope*

Highfield Adolescent Unit, Warneford Hospital, Oxford; *Oxford Centre for Ethics & Communication Skills in Health Care Practice, University of Oxford.

In working within the area of adolescent mental health, the possible conflict between adolescent autonomy and paternalism is faced on a regular basis at many different levels. In this paper various definitions of autonomy as applied to adolescents will be put forward, including discussion of the components of occurrent and dispositional autonomy and their relevance to adolescents.
A number of factors may impede the development and expression of autonomy, including individual factors such as mental illness and cognitive distortions, family factors such as a coercive or restrictive upbringing, factors relating to therapist style and factors within society. A model for promotion of autonomy will be presented, taking into account the different aspects of dispositional autonomy.
Although promotion of autonomy is the ideal, paternalism may be justified under certain circumstances. These include situations where the paternalistic act will prevent serious harm, where the benefits outweigh the risks, where the young person is clearly incompetent to take a decision themselves or where there is mental illness. The difficult balance between promotion of autonomy and taking a paternalistic approach will be discussed. Clinical material will be drawn on throughout the paper to illustrate the points made.

- Dissociative identity disorder and intrapersonal justice

W.H. Wilcox

Department of Languages and Philosophy, Utah State University, Logan, Utah

The phenomenon of Multiple Personality Disorder (now Dissociative Identity Disorder) has attracted considerable philosophical interest. Typically, philosophers interested in MPD have thought that it raised or clarified issues having to do with the philosophy of mind and personal identity. Furthermore, the controversy about whether MPD is real and, if so, how its reality is to be understood, raises issues within philosophy of science, metaphysics, and epistemology. These issues are not my focus. They focus on the "multiple personality" aspect of MPD, whereas my interest is in the "disorder" aspect. Why is MPD a form of psychopathology, or more broadly, why is it viewed as disorder rather than order? Of course, those with MPD do frequently suffer forms of psychopathology, notably serious depression. But here the pathology is the depression, which may be brought about by the MPD, not the MPD itself. Is there something pathological about MPD itself, even if it does not lead to depression, anxiety, and other unpleasant conditions? Is there something intrinsically pathological about the condition? I shall suggest that MPD in its most common manifestation is in fact a disorder, though not necessarily a disorder of the psyche; rather I shall suggest that it is a moral disorder. In particular, MPD might be considered a form of injustice. Since MPD develops as an initially successful form of adaptation to harsh conditions, it can be considered a mutually beneficial scheme of cooperarion among the "identities or personality states" (DSM-IV) involved, but the "identities or personality states" who benefit from the condition tend to differ from those who bear most of the burdens of the condition. This line of thought leads to two further questions I shall consider, one more philosophical and the other more directly pertinent to psychiatry. First, what sort of entity can be thought to be owed duties of justice? Is a mere personality state, as opposed to a person, such a being? Second, if MPD is considered as a form of moral disorder, what implications would this have for acceptable forms of treatment?

- Grammatical reflection on schizophrenia

I. Izídio da Costa

Department of Clinical Psychology of the University of Brasília/Brazil and CAPES-Foundation of Brazilian Ministry of Education

In current mental health studies, 'schizophrenia' represents, at the same time, a challenge and a problem. It is a challenge because it demands more and deeper studies and analyses. It is a problem because the complexity of its so-called phenomena and the lack of clarity of its diagnostic criteria have produced imprecision in its treatment, in its understanding and, as a consequence, in its theoretical approach.
This paper intends to analyse the concept of 'schizophrenia' and the consequences of its usage. From the construction of the concept and its empirical bases, its subsequent incapacity to approach the complexity of the spectrum of people called 'schizophrenics' will be argued. This incapacity is concerned to the fact that does not exist one 'schizophrenia', but several 'schizophrenias'. Each individual diagnosed as schizophrenic has a history, a particular and emotional experience different from others. Thus, we could say that 'schizophrenia' exists insofar as individuals are diagnosed as such.
The imprecision of the original concept reduces the understanding of the individual and his relationships, the complexity of this kind of human being and limits the diagnosis and treatment of the 'illness'. Thus, the consistence and the empirical basis used for the construction of the concept are questionable. Subsequently, the current empirical base became equally an accumulation of insufficient and imprecise facts/concepts.
It will be argued that it is necessary to substitute the symptomatologic approach to the structural one. Rather than being merely descriptive and classificatory, it is necessary to adopt postures (procedures, theories, philosophies) that consider the internal life, the development and the individual's relationship with their environment. For this, first the use of concepts should be questioned and second the clinical procedures have to be adapted, reformulated and transformed to include the complexity of the main aspects that constitute the human being life, 'normal' or 'schizophrenic'.
We claim that 'schizophrenics' should be redefined as possessing their own semantics, an attribution and a use of own meanings, different from the context in which they find themselves. In this sense, we can say that the called 'schizophrenics' are, in fact, 'bearers of other meanings'.

Seminar "Philosophers on madness. The dialogue between philosophy and psychopathology I"

- The influence of Ludwig Wittgenstein Asperger's syndrome on Philosophy in the 20th century

M. Fitzgerald

Department of Child Psychiatry, Trinity College, Dublin 2

Ludwig Wittgenstein was possibly the greatest philosopher of the 20th century. He met all the Gillberg criteria for Asperger's syndrome (Gillberg, 1991). His difficulties in "affective contact with people" (Kanner, 1943) had a major impact on his philosophical writing and indeed on the course of philosophy in the 20th century. His first book the Tractatus Logico-Philosophicus (Wittgenstein, 1922) focussed on language as a mirror of reality - the 'picture-theory' of philosophy. He believed that only objective facts could be spoken of. In this book he failed to achieve what Hobson (1998) points out an infant can achieve that is a disembedding of "the infant from an immediate, unreflective concrete apprehension of the environment". His research on language was in the 'autistic mode' like the current researchers in autism who focus exclusively on cognitive factors.
Nevertheless persons with Asperger's syndrome or High Functioning Autism can grow, develop and become aware of the social context and of people, even if this awareness is limited and there is always a deficit in social reciprocity evident in their behaviour. This growth and maturation in a person with Asperger's syndrome is seen in his second great work The Philosophical Investigations which now emphasised social context and language as a 'tool' and what he called the 'language-game' (Wittgenstein, 1953). Even his 'tool' theory of philosophy showed an inability in Piagetian terms (1936 / 1977) to do what Hobson (1998) points out that is the abstracting of objects from the immediate actions on objects. The language game remained entwined with the object of the game. It was not until he was about 40 years of age that he was able to move from an exclusive focus on himself and language to see the social context and the increasing complexity of social relations.
This paper will discuss the impact of his psychopathology on his philosophy.

- Forgetting familiar faces: Wittgenstein on the disease model of dementia

J.C. Hughes

Newcastle City Health NHS Trust, Newcastle General Hospital, UK

Prosopagnosia is an inability to recognize faces. It is a symptom that can occur in dementia, as shown by a case history.
It is a distressing symptom for relatives.
There is a sound physical, pathological basis to prosopagnosia. It seems, therefore, as if the disease model furnishes us with a solid explanation of failure to recognize familiar faces.
The disease model provides a physicalist account of prosopagnosia. My question concerns how this physicalist account of a psychological state should be interpreted. One way of understanding the failure to recognize a familiar face is to adopt the position of extreme physicalism (as in the churchlands). I shall argue that this position does not give us the requisite normativity that such mental states show. Instead, there is a wittgensteinian analysis of intentional, psychological states that accounts for the physicalism of the disease model, but which still allows room for the normativity of such states. This allows a fuller understanding of prosopagnosia and dementia

- Delirium and reason in kant's criticism of pure reason

E.M. Coleclough

II Catedra Of Phenomenologic And Existential Psichology - (Dra. M.L.Rovaletti) Department Of Psichology, University of Buenos Aires, Argentina.

This work points out some of the matters that arise from Kant's statements in reference to reason's caracterization And function in the trascendental dialectic. If it is in the Nature of the reason to escape from the limits of the experience, in its search of the unconditionated and to Originate "illusive objects" or the "trascendental illusion", How to difference the "normal delirium" of the philosopher Or the artist of the "extravagant" or "pathologic" delirium ?
If the subject sets up the empiric object as well as the Trascendental one, which are the criterions to define the Existence of a "real" object ? In order to lighten the reach Trascendental one, which are the criterions to define the And sense of these questions by trying an approach to actual Phenomenological psychology, l. Binswanger's conceptions will have to be taken into account.

- Unconscious, consciousness and history

M. Galzigna

University of Venice, Italy

Starting from a genealogy and a historico-critical epistemology of the science of psyche, the present paper focuses on a theme wich, from the beginning of the nineteenth century, strongly characterized early psychiatry. This theme, sistematically ignored in the subsequent development of clinical psychiatry and psychoanalysis, deals with the relationship between the mind and the world, between the psyche and its socio-historical and cultural context.
Pinel's and Esquirol's concept of moral disease and Freud's concept of psychological censorship are two crucial historical points of reference for wohever wants to re-propose and develop the heuristic value and the therapeutic productivity of this relationship.

Plenary session

- Abolishing subjectivity: generalising Wittgenstein's insights about expression

R. Harré

Georgetown and American Universities, USA and Linacre College, Oxford, UK

Psychology has been framed, explicitly or implicitly in the two structural polarities: inside/outside and subjective/objective. While it is easy to see that behaviourism allowed the legitimacy of only one of each pair current cognitive psychology preserves these distinctions in more subtle ways. The mind, therefore is conceived as hypothetical in the sense that subatomic particles are hypothetical. However Wittgenstein's account of the expressive uses of language shows he holism between the private and public aspects of the mental. Psychological phenomena therefore have their primary mode of being as properties of symbolic exchanges rather than as individual mental states. The argument will develop the joint action point of view through analyses of some commonplace psychological phenomena, such as remembering and classifying.

Symposium "Understanding and psychiatry"

- The limits of understanding

L. Hertzberg

Department of Philosophy, Åbo Academy University

It is often claimed that the difference between the natural sciences and the study of humanity can be captured in terms of the contrast between explanation and understanding. This way of articulating the difference, however, understates the difference, since it neglects the wide variety of uses of the word "understanding". Sometimes understanding is an intellectual achievement akin to knowledge: thus, one may claim to understand something when one has found the correct interpretation for it. Here understanding is a neutral relation which can be verbally articulated. Failing to understand something, in this sense, means getting the interpretation wrong or giving up the attempt to interpret. However, sometimes understanding and the failure to understand will constitute a more basic relation, more akin to (though not identical with) acceptance and rejection. In these contexts the absence of understanding is not a failure of interpretation but is expressive of one's relation to the purported object of understanding: thus, saying that one does not understand expresses the conviction that there is nothing there to understand, or even a refusal to understand, rather than a failure to interpret. An instance of this use is the classical complaint, "My wife doesn't understand me". This paper explores the relations between understanding as intellectual achievement and as a basic relation. It is argued that non-understanding as a basic relation is relevant in connection with psychiatric disorders, and may even be considered constitutive of them.

- Art in individual and collective schizophrenia and art about these phenomena.
A dialogue at a report from a therapy with a manifestly schizophrenic woman.

A.-H. Siirala, M. Siirala

Therapeia Foundation and Therapeia Society (IFPS)

A report from a therapy:
A woman, hospitalized at the age of 18 with the diagnosis schizophrenia,  after a psyçhoanalytic therapy attempt of 6 months during which she remained mute, came 7 years later, out of her own initiative, to ask for intensive psychotherapy with a new therapist. She was convinced of  thus becoming able to leave behind her the repeated hospitalizations which she found deeply humiliating. She expressed two main goals for her future: to continue her academic studies in order to get a meaningful profession and to reach a psychic health allowing her to found a family of her own. After 8 months of therapy, three times a week, she was accepted as a student to a well known school of pictorial art, as one of the few selected from numerous applicants. This provided her with the fundamental experience of becoming identified as a person with a unique, irreplaceable being containing also a remarkable artistic talent.
The artistic dimension in this patient's life did not form a refuge for her to escape from becoming the very subject of her being. Rather it gave her the chance to become identified in the social context as a person of her own, one with the possibility to enter into meaningful contact with other people.
This case opens up the perspective for the fundamental relationship of art with schizophrenia as an illness-fate, as to its genesis, upholding and - on the other hand, for a space and place for its basic human appeal becoming heard and shared with the vicariously sick individual. Psychosis is a relevant and even needed reaction to our schizophrenically split societies and cultures. It is art in the history of mankind that has time and again opened up the perspective for this. Art is needed in order for therapy to take place among us, ín the fundamental sense of the word. In the history of mankind, literature, music and pictorial arts have furnished us with basic insights long before their entrance into medicine and its psychiatry, even long before Sigmund Freud.

- Understanding Delusion?

A. Ballerini

"Understand" is a key word in clinical psychopathology, since Jasper's' methodological lesson. Among different possible hermeneutic models of understanding, psychopathological tradition is based on an understanding that intends to find the "lived world" in individual experience (in the form of experience) which is possible to approach through identification with the other person (Einfuhlung). But, as we know, from the observer's point of view the failure of understanding is just the brand of delusional experiences. Where there is true delusion there is no understanding; where it is possible understand there is no delusion, as K. Schneider and G. Huber write in a conclusive manner. However, it is useful to keep in mind not only the "static understanding" but also the "genetic understanding", i.e. how the delusional experiences are tied to each other and to a persona's life history.
Using the heuristic device of genetic understanding in the delusion, the "comprehensible" and the "incomprehensible" become the extreme points of a continuum. In this continuum, many factors modulate the observer's position. With reference to Kretschmer's thought about the connection between personality and emotions like shame - anger at delusion's genesis, we studied some delusional disorders using a lasting therapeutic approach (A. Ballerini, M. Rossi Monti) and we were able to undeline some areas of comprehensibility also in the presence of primary delusional experiences.

- Identification of schizophrenia before diagnosis: "... behaviour without understandable reason"

V. Räkköläinen, M.-L. Heinonen

In DSM III-R there were given nine items, i.e. specific modes of behaviour, in order to identify the "prodromal" stage of schizophrenia before proper diagnosis could be justified. The list is a collection of behaviours seen on the border of what is considered as "normal", but with the common denominator "without understandable reason".
However, is it possible for the prevailing medical culture to define what is understandable behaviour? Views about what is understandable in schizophrenic or preschizophrenic behaviour have been changing also in psychoanalytic culture. We discuss about these questions, also with clinical material from psychoanalytic treatment of a prodromal case.

- Misunderstanding schizophrenia

E. Iso-Koivisto

How an acute psychosis turns to chronic schizophrenia? According to Roger Barrett treatment of acute psychosis serves as an initiation ritual to otherness, being maybe less human than humans although living among them. No ritual leading back to original status seems to exist, but schizophrenics-to-come are caught in a liminal position, having lost their former status and not getting anything instead.
A Finnish semiotician, Eero Tarasti has written about different conceptual categories of understanding. His final conclusion is that maybe the best definition of understanding is that misunderstanding has ceased.
It has been very common to deposit assumption and theories born from ideological , political or economical passions of the cultural epoque to schizophrenics, who seldom fight back or succeed in defining themselves in the community. A very concrete example of this kind of misunderstanding might be US air force attack to the psychiatric hospital of Grenada. Maybe also well-meaning psychotherapeutic approaches can became a new method of misunderstanding schizophrenia, as may have happened sometimes among the postmodern movement.

Symposium "The right to be authentic: personal identity, social norm and psychiatric nosolology in post-soviet Russia"

- Personal Identity from the Existential-Phenomenological point of view

T. Schevelenkova, PHD, vice-professor

Institute of Psychology, Russian State University for Humanities, Moscow, Russia

The paper describes the phenomenon of personal identity, with clinical illustrations, and indicates its significance for abnormal psychology. It notes the difference between modern psychoanalysis and existential-phenomenological modes of thinking in abnormal psychology and indicates their significance for the study on personal identity. It argues that personal identity can be seen as a kind of existential a priori, which create a type of inner personal wold, a mode of interpersonal relations and a special body-image. Some conceptual difficulties entailed in formulating such alternative are discussed and nontraditional suggesting for addressing this problem are offered.

- "Clinical reality" as a typical pattern of psychiatrist's mentality

N.A. Zorin

Moscow Research Inst. for Psychiatry Russia

The term "Clinical reality" (CR) is a widely spread international psychiatric cliche implying that the idea that CR is something objective, independent of our consciousness reality and sometimes even materialized reality.(The "objectivity" is supposedly granted through the "clinical method"). For such a clinician diseases seem to exist apart from our consciousness, and the history of knowledge formation is perceived as a gradual but unavoidable approach to the truth. But "objective reality" is not available to us in an "objective" state. Clinical observation is always receded by the knowledge of what should be observed. That is an exogenetical inheritance transmitted through the school. The illusion of the "objective knowledge" of a disease is supported by: 1) an unwritten convention that psychiatric deviations must exist - a class of issues that in any system of reasoning have to be accepted a priori; 2) Mutual consent of most psychiatrists acknowledging the presence of a mental illness, in some "crude" clinical cases. All disagreements and arguments concerning the name of disease arise are later put down to the "defects" of observation. Such conviction is also a derivative of senses, perceptions, certain intuitions (e.g. "Vigor vitalis" by old author's etc.). For psychiatrists it is a perception of a certain distinction "unlikeness" of patients e.g."Gefuhl"), which being blended with its logical comprehension (e.g. "Praecox") i.e. is significated and creates a phantom of CR. "Objective knowledge" is no more than "packed", "archived" perceptive probes, unconscious patterns of well digested, hence subjective, theoretically loaded knowledge. Languages and reactions schemes they contain are form-creating matrices of thinking, behavior and perception(F. Bacon. Whorf. CR like any other classification built on its foundation is a variety of subjective reality. Moreover: ossification as a form of conventional notion once arisen will form this reality. However, all these assertions make sense only when you oppose objective reality and subjective one. In the mental space there exists only one reality - reality of the cognizing mind and it is always true.

- Psychiatry and religion new mutual relation

B. Voskressensky

The Russian State Medical University, Independent Psychiatric Association of Russia

The all-round learning of mutual relation between spiritual experiences and mental disorders has become possible in Russia only from time of Perestroyka. At a constantly operating seminar " Psychiatry and the problems of spiritual life " (the name has been denizen from the book of D. Melehov), joining the psychiatrists, psychotherapeutists, psychologists, people of church and representatives of public organizations problems "Doctrine and mind", "Sin and fault", "What the mental disorder is", "Patient and it illness" etc. are discussed. On these questions the course of the lectures is read, the conferences will be carried out. A ultimate goal of such activity is to open potential of the man (patient, client), suffering by mental disorder (or having a psychological problem) or/and inclined to spiritual search (in particular - of the believer) more full.
From the same positions in a number of orthodox spiritual arrivals and psychiatric hospitals the therapy, diagnostic, psychotherapy and rehabilitation will be carried out.

- Ontogenesis of corporality and mythology of the disease

A. Pavlichenko

Graduate Student, Russian State Medical University

Corporality has been treated in a different way in the history of human self-knowledge. There has always been a desire to do without this category using other concepts. Transformation of philosophy into a classical science with its tendency towards general objectification resulted in Corporality being outside. Philosophy reduced Corporality to biological and sociological analysis. Corporality turned out to be ignored by psychology either, as it treated Corporality as an archaic form of vital activity. Corporality acquired another meaning in Vygotsky's cultural and historical conception. Corporality is included into a broad context of human knowledge. Corporal phenomena are socialised through adoption of the system of signs. The satisfaction of the vital needs by the mother in ontogenesis has a function of interpersonal communication. The stage when the communicative meaning of corporal phenomena prevails coincides with the symbiosis period. Later the communicative meaning starts to weaken but it may be actualised and even cause development of conversion disorders. Next comes the period of the psychosomatic development that is characterised by appearance of another type of activity. It is imitation activity. The child imitates ill adults that later may result in actualization of learned symptoms in chronicle disease. Acquisition of speech skills is a major task in a third period. The child starts considering his body through the meanings that a word has. Corporal phenomena of an adult person are most complicated. In case of a disease ?orporal sensations do not only mean perceptive tissue but a disease as well. Formation of the secondary meaning of corporal sensations is connected with adoption of the cultural views on the disease. According R.Bart ideas can be interpreted as classical myths. In this system sign (corporal sensations) which is an association of perceptive tissue and corporal structure becomes a denotative in the myth of the disease and is transformed into a symptom. The same mechanisms are the basis of the treatment. Treatment is a process of turning myth inside, from the secondary semiological system (the myth of treatment) to the original one (body language). Any treatment is a sign process and a doctor working in the system of myth has to posses the qualities that are defined by his understanding of the disease. The tendency of medicine towards demythologization should be considered wrong. One should learn to decipher secret myths and create necessary mythological systems.

- From the pathography to the existential psychiatry

V. Palmova

The Moscow State Medical University

Each psychiatrist, basing his experience not only on the obvious symptoms or categories, which with the course of practice became obvious and definite to him, finally comes to the philosophic orientation on the aggregate existence of man. We need the concept of completeness and desire to interpret our object of research as a unity: biological, personal, living in peace with the others and at the same time indefinitely spiritual. The empiric studies of the definite material lead us to the conclusion, that there is no definite "Structure of Human". The contemporary psychiatry needs methods, allowing to maximally approach the essence of human, the existence of man.
In our disposal there is such a method - pathography. The facts of the mental disorder are given solely in the categories of psychiatry, which create merely the form, while the essence of man will be revealed by self-objectivation by means of creation.
The poetry of Hölderlin is based on the intuitively correct ontological surmises. The world of the personality and the elements, characterizing the human essence may be captured from his language. The poetic comparisons carry the definite existential meaning. The language itself, as manifested in these comparisons, captures the definite element, lying deep in the ontology of man - namely the ability for the downward direction. The analysis of the pathography inevitably leads us to the methodologic basis - the existential analysis (Dasein-analysis, Binsvanger). It gives us the opportunity to understand the man both as the creation of nature, and at the same time as the socially determined, historical creature. The Dasein-approach, manifesting the situationally-oriented existence among the real, through the throw of the Dasein, the man is viewed not merely as a psycho-pathologic realty, but as the media for transcendence. This method allows us to reveal, to decipher the hidden correlation between the disease and the realization of the spiritual opportunities, between madness and the wisdom of humankind.
Hörderlin, his personal existence may be analyzed as the manifestation of spirit, where the disease in its specific modus of life - autism, the being, traced out during the analysis, will influence his realization. During his whole life he tries to find his place in the world, but because of his mental peculiarities his Dasein becomes absolutely thrown and finds itself totally unable to sense any responsibility: to allow the events, occurrences, fate, relations between people simply to be. His existence, viewed as the projection of the force to be in this world, as the force to overcome the existential anxiety, suffers constant loss. In each moment his existence is separated from its place in this world and may rely only upon itself. His Dasein holds the constant experience of conflict between the alternatives of life and death, the ideal and the reality, nature and fate.
His existence reveals itself in the act of creation in the form of dissatisfaction, the feeling that the world is incommensurable to his knowledge and his spirituality, in the insatiable desire for unity. Dasein remotes itself from its corporal involvedness to become absolutely free as a "spirit". Inspiration becomes the only opportunity to refrain from falling. Belief is realized in it - belief, which will move all the psychic mechanisms and impart to them the historical and personal meaning. In the created world outlook the myth of the poet will be formed, in which his existential freedom will be realized.
My aim is to show the place of the existential approach in the psycho-pathologic research context. The scientist, possessing the facts, at the same time does not loose attachment to the life of man - the bind, expressing itself in the philosophy. Thus the essence of man will be revealed not in the objective schemes, but in the infinitive potential, in the eternal inner contradictions, in the desire to be "the individual in its highest sense".

Seminar "Time, space and psychosis. The phenomenology of psycothic symptoms"

- Vampires in Psychiatry

B. Kelly

Adelaide, Meath and National Children's Hospital, Tallaght, Dublin 24, Ireland

In the past, "clinical vampirism" was used as a diagnostic category in psychiatry. Review papers were devoted to the topic in journals such as The Archives of General Psychiatry and the Journal of Nervous and Mental Disease. A recent case is described, concerning an East European male with schizophrenia, who believed he was turning into a vampire and needed to drink blood in order to stay alive. He did not want to harm anybody, so he presented to a general hospital in search of the hospital's supply of blood for transfusion. Classical and contemporary literature on vampirism is reviewed, providing numerous clinical examples of psychotic illnesses featuring vampiric delusions and vampiric behaviour. The importance of transcultural factors in determining the content of delusions is emphasized. Many authors have linked "clinical vampirism" with schizophrenia. The attack of the vampire reflects many of the psychodynamic theories of schizophrenia. For example, the schizophrenic has considerable needs to be fed by people who may have deprived him in the past, reflected in the vampire's craving for oral nourishment in blood. Following the attack of the vampire, the victim becomes a vampire too, reflecting a significant loss of ego boundaries. According to mythology, vampires do not cast reflections in mirrors, and schizophrenics commonly have sensations of reduced visibility. In these and other ways, the myth of the vampire provides a valuable psychodynamic and phenomenological model of schizophrenia.

- What methodology for understand voices ?

I. Banovic

Psychologist; C.H.U. Sainte Marguerite, Marseille, France

DSM IV defines hallucinations as "a sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of relevant sensory organ". This definition fails to distinguish pathological and mystic experiences. Moreover, it does not give adapted consideration of cultural beliefs. M.Liester (1998) reserves the term hallucination to pathological experiences by adding two criteria for including medical context and excluding religious experiences. However a relative perspective implies to consider both cultural and pathological voices as meaning process.
This perspective implies to consider voices as meaning processes. Psychoanalytical and behavioral paradigms are criticized in order to better define the methodology for entering the phenomena. We developped three assumptions:
1/ schizophrenia and msytic experiences sign a breaking in the everyday life;
2/ understanding the meaning of voices has to be related to their explanation of the basic study of mind;
3/ meaning is better understood with a dimensional approach;
The author explorates these concepts by using an enunciative analyse of speech and dialogues. It will be expected a difference in the localization in time and space between people with schizophrenia and mystic.

- Schizophrenia as a temporal mode of beeing : an existential "ante-festum"

D. Pringuey M.D., F.S. Kohl M.D., S. Thauby M.D.

Academic Department of Psychiatry and Psychological Medecine, CHU Pasteur BP69 06002 Nice cedex 1 France

Against the standing view which ascribes schizophrenia to an impairment of the spatial constitution of being, mainly on hypothetical topological aspects of a formal dissociation, we would argue the practical interest to clinically consider schizophrenia as a special form of human temporality and keep a perspective where symptoms are an attempt for the patient to establish oneself in existence.
We will describe the clinical components of an essential type of existential impatience, characterised by a painful and elusive "now" which states the very prime moment of the constitution of the person.
Clinical impatience reflects the permanence of excessive efforts towards individuation which unceasingly indicates a dynamic process of building up the self, starting from the non-self and particularly from the other, showing the emergence of any relation with the self on the
ground of the relation with the other from the relation the other involves oneself.
Schizophrenia distinctly displays the two generally linked constitutive moments of "being oneself" for all of us, an "unending coming up to oneself", difference of identity, and a "continuous maintenance of mode of being", identity of difference.
Existential impatience is not only an irritability of a formal order. Existence itself is impatient in the schizophrenic experience and hasten to reach the human goals while trampling on an "ante-festum" temporal mode, a before-the-feast temporal structure which is dominated by the shiver of an unknown future, a sign for a basic quest for a task. Schizophrenic "ante-festum" is both a standing fear of being unable to come up to oneself and a desperate effort to reach this unknown future.
If psychopathology claims to settle that "order" and "measure" would constitute the two fundamental anthropological bases of human beings, impatience of existence draws the emblematic figure of a disorder of measure as a referential motion of the birth of any temporalisation.
Therapeutic principles gain to be based on a praise of patience and will be focused on a care for building the past. The main objective come to reach maieutics of the self from the relationships in the community set and with the care-givers, on a daily structured accompanying frame.

- Time as Self-anticipation. The case studies of epileptic seizures

N. Depraz

Collège International de Philosophie

An article was published recently in Nature Medecine about the possibility of anticipating Epileptic Seizures (Cf. " Epileptic Seizures can be anticipated by non-linear analysis " by J. Martinerie, C. Adam, M. Le Van Quyen, M. Baulac, S. Clémenceau, B. Renault & F.J. Varela, Nature Medicine, volume 4, number 10, octobre 1998, p. 1173-1176.)
According to the authors, it is possible to anticipate a Seizure 2 to 6 minutes before its occurrence; being anticipated through third-person indicators lying in the cortex of the subject, it is then possible to deviate the Seizure from its habitual route.
Besides the therapeutic advantages of such a discovery, the authors also mention en passant (at the very end of the article) the possibility to develop the ability for the epileptic subjects to become themselves aware of the coming Seizure before its very occurring.
Instead a third-person anticipation, we would then have to do with a first-person pre-reflexive anticipation, what I call here "self-anticipation".
How is it possible to become self-aware of one's own Seizures before it occurs and then to make it deviate oneself from its route?
Our purpose is here to lay out the phenomenological features of such a self-anticipation. What kind of pre-reflection is involved here? Which sensory modalities are at work? What is the emotional component of self-anticipation? What sort of self-attention to oneself is required in order to become aware of it before any thematized awareness generated by the Seizure itself?
Our main contention is that such a temporality of self-anticipation is originary emotional. Far from relegating emotion in the background, such a highly embodied time is also intrinsically affective. The sort of self-awareness epileptic subjects have of themselves is therefore first and foremost an emotional self-awareness.

- Phenomenological understanding of psychosis

K.D. Keller

Department of Communication, Aalborg University, Denmark

By the application of Merleau-Ponty's phenomenology, it is aimed in this paper to contribute to the illumination of intentionality in psychosis. In his close investigations of intentionality in perception, the body, and language Merleau-Ponty laid open a structuring of meaning which, however incoherent it may be, is sociocultural structuring and which we never escape in our own experience and practice.
What characterizes any phenomenological approach is the attempt to conceptualize in as close connection with the actual experience of the phenomena as possible. Thus, we have to look for the intentionality in the psychosis, the ways in which tensions and strivings for the structuring of meaning are apparent. The seemingly 'wild' and 'chaotic' expressions of intentionality in psychosis are not so very surprising on the background of Merleau-Ponty's explications of intentionality. Psychosis has to do with angst in a sense which has been explicated by Kierkegaard, Freud, and many phenomenologists. Angst challenges our self-understanding together with the understanding of reality.
It is possible to apply different kinds of phenomenological understanding and conceptualization in accord with Merleau-Ponty's philosophical position. We may distinguish between a structural, an a priori and a dialectic understanding of human experience and practices. The application of these approaches implies a constructive criticism of traditional phenomenological views of psychosis and points to new implications for therapy and care in relation to psychosis.

Seminar "Mental disorders and biomedical science"

- On "biological psychiatry"

P. Hoff

Dept. of Psychiatry and Psychotherapy, Technical University of Aachen, Aachen, Germany

The paper will focus on the theoretical and epistemological foundations of what is usually called "biological psychiatry". In the first part, the historical perspective is discussed, especially the emergence of biological hypotheses on the etiology and pathogenesis of mental disorders in the 19th century, exemplified as well by concepts (e.g. degeneration theory) as by authors (e.g. Emil Kraepelin). The second part will outline the development up to the year 2000, focussing on the problems that do result from the manifold meanings of the term "biological" in a psychiatric context. The range of meanings includes clear-cut empirical laboratory studies, questions of clinical psychopathology and nosology and even an anthropological framework. Before using it, it is necessary to clarify the meaning of this important term in order to avoid severe misunderstandings.

- Challenges of the technoscientific world: the concept of man in the light of biomedical advance

J.L. Polonuer

Dept. of Phenomenological and Existential Psychology, University of Buenos Aires, Buenos Aires, Argentina

Taking Heidegger's "The question concerning technology" as a starting point we are in a position to wonder about the meaning that both the technological development, and the advance of science have in today's world, and how 'the human'(menschlich) may express itself within this frame of reference.
If the world is an horizon of signifiés, how do signifiés constitute themselves within a technically-configured world? Since we live in a world corporally, which is the body current science has built for us?
We wonder whether the motives driving the current biomedical science to grasp a wider knowledge could not be only fostering a more and more efficient need to dominate. As Heidegger insists, that is the decision which eventually became the destiny of Western spirit: an unlimited thirst for domination upon both world and the things. A craving for control and certainty avoids every possible type of anxiety thus masquerading as a false, onthological safety. Technology, however -such as every human activity, is exposed to an ethical examination which forces us to devise what are the new forms of humanity and freedom it is able and willing to offer us. This leads us also to wonder up to which point objective science criteria will be in a position to relieve human suffering and by which means is biomedical science able to keep technical efficacy without losing sight of human authenticity. This is the "danger of technology" that involves the dilemma: to either dominate life or respect our human nature.

- F W Sperry between Neurophysiology and Philosophy

R. Vizioli, L. Orazi

VI Chair of Neurology University "La Sapienza", Rome

In line with one of the topics of this congress (history of ideas) the authors devote their contribute to the scientific personality of F. W. Sperry, Nobel prize for Neurophysiology. In his classic paper of 1980: "Mentalis yes, dualism no" Sperry made some revolutionary statements considering is long background of neurophysiologist and used for the first time the word "interactionism" stating that mind is a production of matter but acts on matter. in other words as neurophysiologist he has no doubts that brain is the basic structure of mind but, and this point is revolutionary, he, as philosopher of mind accepts that mind play a leading role in modifying brain.

Before him another Nobel prize for Neurophysiology: Sir John Eccles said that the brain caused in the scientiphic world some unrespectful gossip about the hypothesis that Sir John Eccles had a "mystic involution" in his old age.

The authors stress the difference between the unrealistic hypothesis of Sir Eccles and the ideas of Sperry and will try to give some example of the fact that Nobel Sperry is the most authoritative rapresentant of a possible integration between mind philosophy and Neurophysiology

- 'The New Genetics' and biological reductionism: psychiatry, determinism and free will entering the 21st Century

D. Sullivan MBBS MBioeth MHealthMedLaw MACLM

Honorary Research Associate, Monash University, Australia
(and in August 2000, Bethlem & Maudsley Mental Health NHS Trust, London, UK)

Putative genetic and biological aetiologies for various mental illnesses and behaviours dominate research literature and popular media. New techniques for imaging the brain and mapping the human genome have focussed attention on the structural anomalies and functional brain-states of abnormal behaviour.
Base deterministic interpretations of these scientific findings view them as causative of mental illness and indeed of 'aberrant' behaviour. Such reductionism has significant social consequences, and invokes once more the debate between free will and (biological) determinism.
This paper explores aspects of moral responsibility which ramify from 'the new genetics' and current biological psychiatry. Social and legal repercussions of determinism are discussed, and the nature of 'free will' is reinterpreted in the light of current psychiatric knowledge. It is contended that the simplistic determinism implied by these developments should be resisted; consequences of the 'hard-wired' viewpoint are discussed, and their problems explored.

- Agency, brain imaging and psychopathology

S.A. Spence

Senior Clinical Lecturer in Psychiatry, University of Sheffield, The Longley Centre, Sheffield, UK

In this paper we present data from a series of related brain imaging experiments, using positron emission tomography (PET). These studies examined the functional anatomy of volition in neuropsychiatric disorders (including schizophrenia, depression, Parkinson's disease, hysteria and deliberately 'feigned' dysfunction).
We used 15 Oxygen - labelled water as a radiotracer and regional cerebral blood flow as an index of local synaptic activity. Statistical parametric mapping (SPM) was used to analyze data: acquired while subjects performed voluntary hand movements, or generated words, in a PET scanner.
A number of brain regions contributed to the performance of consciously chosen, or 'willed', actions in normal 'controls'. In particular, left dorsolateral prefrontal cortex (DLPFC) was activated when controls chose which direction to move in, or which word to say, compared with generating movements or utterances specified by the examiner.
In neuropsychiatric disorders affecting action-generation there was a consistent implication of DLPFC dysfunction.
Indeed, this focus of dysfunction distinguished those with 'hysterical' motor symptoms from those control subjects who were asked to deliberately feign disorder.
'Agency', the subjective sense of 'possession' of an act, was disordered in those patients experiencing the schizophrenic symptom of 'alien control'. In these patients we demonstrated reversible dysfunction of the right inferior parietal region.
Hence, there is congruence between the concepts of 'action' and 'agency', as used in philosophy, and their cognitive instantiation in neural systems. These systems may be demonstrably modulated by psychopharmacological agents (particularly through the dopaminergic and serotonergic systems).

Seminar "Philosophers on madness. The dialogue between philosophy and psychopathology II"

- A naturalistic interpretation of the concept of delusion

A. Almér

Dept. of Philosophy, Goteborg University, Sweden

This paper discusses the part of the DSM-IV definition claiming of delusion that it is "[a] false personal belief based on incorrect inference about external reality".
To get an applicable interpretation of this definition of delusion one has to get a clear conception of inference in thought and perception. I shall take the starting point in the following question raised by Millikan (1997): "[...] what would constitute that a mind or a brain was using one method of marking sameness rather than another." That issue precedes the empirical question of how the brain/mind actually represents that two or more of its representations are of the same object or property. The first issue concerns how to understand what it means that the brain/mind uses two representations to represent identical individuals or properties. Millikan shows how these questions connect with issues concerning the understanding of inference in thought and perception.
I shall apply Millikanps analysis of what she refers to as "mediate inferences" to the case of delusion as defined by DSM-IV. One of the conclusions arrived at is that delusions should not be conceived as false beliefs but as empty of content.

- The Language of Psychosis in the Twentieth Century: From Phenomenological to Illocutionary Approach

J. Zislin MD

Kfar Shaul Mental Health Center, affiliated with the Hebrew University Medical School, Jerusalem, Israel

As strange as it may seem, psychiatrists contrary to psychoanalytic have seldom made attempts to analyze the significance of language in mental illness. This is particularly surprising in view of the fact that language is their principal instrument in attempting to assess the condition of patients. Psychiatrists tend to interpret language in a phenomenological manner. But here the following should be noted: when language is looked upon as an instrument/symptom the linguo-philosophic principle is being ignored. Clearly, another approach to the understanding of psychotic speech is needed, one that takes into account the role of language in the generation of psychosis. Our idea that the speech act theory makes it possible to realize it. According to the illocutionary acts theory (J. Austin), a distinction should be made between utterances that constitute statements or descriptions, and utterances that constitute acts of creation. It is assumed here that psychotic discourse should be viewed as an illocutionary act and that language itself is able to create a new psychotic reality. The peculiarities of this approach are the following: Psychotic discourse can be defined ignoring true-false dichotomy.
b) In the frame of the theory a new vision of the thought - language - reality triad language itself has the power to create a new psychotic reality.

- Linguistic reflections of recovery: first person pronoun usage and semantic positions of patients

C.W. Van Staden

Department of Psychiatry, University of Pretoria, South Africa

A report is given on the synergistic utilisation of philosophical and empirical methods in a study of first person pronoun usage by recovering patients. The philosophical component was an extension of the work by Frege and the logic of relations. It distinguished semantic usage from syntactic and pragmatic usage of first person pronouns. Semantic usage of first person pronouns was described analytically according to the expression of occupancy of distinct semantic positions in relations, called the alpha and the omega positions. Criteria were proposed to identify the alpha and the omega positions as, respectively, positions of the owner and the accidental of a (Fregean) relation.
An analytic examination of 'recovery' yielded the hypothesis that occupancy of the alpha position is taken up and occupancy of the omega position is relinquished during recovery. This hypothesis was empirically tested in statistical comparisons between 10 recovered and 10 non-recovered patients for change in syntactic, pragmatic and semantic usage of first person pronouns between commencement and termination of psychotherapy. Eighteen thousand and forty-three verb phrases in 80 transcribed sessions were linguistically analysed. Results revealed that recovered and non-recovered patients did not differ significantly in the change of their syntactic and pragmatic usage of first person pronouns between commencement and termination of psychotherapy. However, they differed significantly in the change of their semantic usage insofar as the frequency of the alpha semantic position increased highly significantly and that of the omega semantic position decreased significantly among recovered patients as compared to non-recovered patients, thus supporting the above theoretically derived hypothesis.
Potential applications in medical practice in which the semantic positions of patients are tracked during treatment may result in improved understanding, monitoring and enhancing of recovery.

- Further reflections on the contemporary mental and physical illness distinction: Socrates and Euthyphro

K. Hammond

University of Glasgow, Scotland

The concept of piety was the issue in the Socratic dialogue titled Euthyphro. Piety was not clearly established. The dialogue is typically aporetic. The concept was important because it had social importance in Athens at that time. I argue in this paper that we have a similar situation with concepts of mental and physical illness. They are both important for individuals and for the societies they live in. But our concepts of mental illness (as a failure of action) and physical illness (as a failure of function) do not seem to hold in many situations, just as Euthyphro's concept of piety as doing as the gods do, did not hold in many situations of fourth century (BC) Athens. Socrates made the point that the gods did some very different things and that the young Euthyphro had to do some reasoning for himself if he was to establish what activities really could count as pious, and therefore just, in the actions of the gods. There can be no evading this kind of reasoning in each case that is open to interpretation. So I argue that there can be instances of mental illnesses that are a failure of function (whatever that is taken to be) and physical illnesses that are a failure of action. Does all this then mean that physicians and psychiatrists should abandon their different concepts of illness because they are loose and only of use in the more social or non-professional contexts? In following Socrates I argue that caution should be taken with these concepts. I ask about the role of these concepts in the physicians and psychiatrist's work with particular cases of mental and physical illness. Is the psychiatrist or physician to work with the disorder as it presents itself in the ambiguities of the patient, or is she to start with the relative clarity of concepts of mental or physical illness? I argue for neither but cite the two recent cases in Scotland of the apotemnophilia ('imagined ugliness') that gained treatment in leg amputations as complicating the issue and something that should be reflected upon with great care.

- Consequences of subject notion (Gadamer versus Lacan) in psychiatric praxis

D. Padro Moreno

Hospital Civil de Basurto (Servicio de Psiquiatría)

If certainly wisdom was before philosophical knowledge, it's from the latter where our actual procedures comes from. Astonishingly for nowadays, one of the concepts more developed in the Modern Age, was not known in the Classical Age. Depending on the subject's notion we manage in our clinical work we will take different relationship approaches between doctor and patient. We will analyze Gadamer's proposition of the subject's notion realized by him in his New Hermeneutics. Based on hermeneutical's circle, relation process is in a symetrical and reciprocal basis. In an opposite sense for Lacan relationship betweeen subject and the Other though in the circle is never reciprocal, but clearly asimetrical. The consequences of both types of approaches will be analized around a delitious tail from Saramago. In this way we can appreciate that knowledge's philia in reality praxis is always developed by love's

Plenary session

- Form and content, the role of discourse in mental disorder.

G. Gillett

Any mental disorder is given form by a set of factors which often make it recognisable as a pattern of manifestations in terms of behaviour, neurological symtpoms, and conversational activity. It is plausible that the form of a psychiatric disorder is, in many cases, a causal result of a certain disease process. But in addition to this and in parallel with it there is content to a psychiatric disorder which may take the form of genuine llife problems contributing to stress or depression, or some meaningful constellation of life events that can only be dealt with by adopting the solution available through a disorder. I will examine two cases, the one case concerns a person with bipolar disorder who commits suicide, almost certainly for reasons to do with a dysfunctional life relationship and its effects on him. The second case is a young woman with anorexia where we are forced to take seriously the meaning of food and eating to her in order to understand her suffering from this disorder. I will use the insights generated from these two examples to explore the ways we can conceptualise the relationship between the causal structure of the mind and the discourse which the mind inhabits. The result is a profound synthesis of the nature of psychiatric disorder as it is seen from within the framework of discursive psychology.

Symposium "Reductionism"

-Ontological reduction and integration in psychiatric genetics research

J.Z. Sadler

Department of Psychiatry, UT Southwestern, Dallas, TX, USA

Kenneth Schaffner has characterized biomedical theory as built around overlapping and interacting "levels of aggregation" which in turn are characterized by particular varieties of "ontological reduction." Ontological reduction is the simplifying of complex phenomena into descriptions apropos to a particular research theory, procedure, or program, or "level of aggregation." Ontologically-reductive statements can be generally described as reflecting the form "the phenomenon is little more than an example of general explanation Y." As a specific example: "Schizophrenia is little more than the consequence of a collection of variant, and suboptimal, alleles."
In this paper I sketch the psychiatric genetics research program, using schizophrenia as an example, as a series of progressively more-abstract levels of ontological reduction. That is, I describe the ontological reductions involved in conceiving the "mad" individual in ordinary life to the level of a schizophrenia "allele" or epigenetically-profound set of alleles. For instance, in shifting one's ordinary-life (lifeworld) conception of an "oddly-behaving person on the street" to "a mentally-ill individual" one has performed a "level" of ontological reduction; that of placing a generic description of odd behavior into a medical-laden realm of "illness" or "disease." Such kinds of reduction occur at various points in a research program, as one moves from commonsense explanation to progressively more theoretical and abstract explanation. (Graphic representations of the levels of reduction will speed my discussion.)
Implications of each level of ontological reduction are also briefly discussed, and what is ontologically "lost" in the reduction process is noted. For example, when we move from commonsense concepts of "madness" to medical concepts of "illness" we tend to marginalize (ontologically) positively valued aspects of the madness experience. Good examples of these "positives" from madness include their revelatory experiences illustrated by plays like "Equus" or the aesthetic insights from so-called "outsider" visual artists like Henry Darger, Adolf Wölfli, or Martin Ramirez. These consequences of the various levels of reduction will also be shown to illuminate other problematic perceptions of the psychiatric field, including stigma as well as anxieties about genetic explanation of mental disorders.
Further, careful examination of the ontologically-reductive levels of the psychiatric genetics research program will also show early signs of ontological integration (anti-reduction), characterized by the borrowing of findings and concepts from non-molecular fields in psychiatry, like neuroscience and neuropsychological testing. Public-scientific understanding of both reduction and integration trends in psychiatric genetics should help diminish worries about research in this field.

- Reductionism and historiography

G. Gozzini

Subjectivity is a methodological keyword in the understanding of recent and important trends in Italian historiography: microhistory and gender history, which are connected by the rejection of structural determinism (olism). One way of developing this category (the traditional method of historicism) is to underline the qualitative idea of the unity and centrality of human nature. At the same time, the debate among social scientists about the possibility of methodological individualism and neoclassical rationality offers an alternative pathway. Following the work of philophers like Elster, of economists like Sen, and sociologists like Giddens, the paper focuses on the main historiographical consequences of that debate: the connections and contradictions between macrostructural and microindividualist explanation, the growing complexity of individual rationality and the varying influence of social norms.

Soggettività è un termine chiave per comprendere le tendenze più recenti ed importanti della storiografia italiana: la microstoria e la storia di genere, che sono accomunate dal rifiuto del determinismo strutturalistico (olismo). Un modo di sviluppare questa categoria (quello dello storicismo tradizionale) consiste nel sottolineare l'idea qualitativa dell'unità e della centralità della natura umana: lo storico e gli uomini che formano il suo oggetto di studio appartengono allo stesso genere umano, il che permette di rivivere e comprendere (che è cosa diversa dallo spiegare) il passato. Ma il dibattito degli scienziati sociali attorno alla possibilità di un individualismo metodologico e di una razionalità neoclassica offre una strada alternativa. Seguendo l'opera di filosofi come Elster, economisti come Sen, sociologi come Giddens, il paper si concentra sulle principali implicazioni storiografiche di tale dibattito: i nessi e le contraddizioni tra spiegazione macrostrutturale (clima, demografia, economia) e spiegazione microindividuale (razionalità, legami comunitari, culture), la crescente complessità della razionalità individuale e l'influenza variabile delle norme sociali.

- Complexity and formalism

A. Sanesi

The main goal of the scientific method is to create hypothesis, models and theories suitable to comprehend the Universe. We talk about mass, energy or time because they help us face the comprehension of the complexity of our experiences. There is an issue as old as Science: do scientist make up or discover the laws of Physics?
We can just make suppositions about the fact that laws of Nature exist independently from our culture or, on the contrary, whether we are imposing these laws as a rough approximation of Nature itself. History of Physics is pervaded by a strong character of reductionism, that is the belief that each set of complex phenomena can be enclosed and explained just by using few simple principles. From this point of view reductionism is based on Occam Razor:
'Pluralitas non est ponenda sine necessitas'
If we interpret this principle as 'Considering the simplest hypothesis', the problem becomes what the meaning of 'simple' is. Despite this issue has been deeply discussed, the leading opinion in Physics seems to be reducing the interpretation of specific phenomena to a unique mathematical scheme. From an historical point of view there are a few fundamental steps along the way of reductionism
From Keplero's and Galileo's laws to the Universal Law of Gravity
From the laws about electricity and magnetism to Maxwell's laws
From Maxwell's laws and from Michelson and Morley experiments to Relativity
The effort Feynmann made to understand the fundamental value of the principles of Nature, led him to a new original interpretation of Quantum Mechanics.
During the last years the GTU theoretical scheme seems to take place, known as the unified field theory, where all the natural phenomena are supposed to be enclosed. By the end of the 60's, it was proved that the electromagnetism can be mathematically combined with one of the four fundamental forces of Nature, the weak interaction nuclear force.
The fact that such unification was not just formal has been proved some fifteen years after, when the existence of a particle, responsible for the mediation of the weak force, was discovered; in the mathematical formalism such particle plays the same role of the photon in Electromagnetism.

- Reductionism in the philosophy of mind

S. Nannini

Reductionism is an epistemological theory whose clearest formulation was given by those logical empiricists who defended physicalism. Among the privileged examples of reductions of theories one can mention the reduction of thermology to classical mechanics through thermodynamics and the reduction of chemistry to physics through Bohr's theory of the atom. Following the example of the different opinions that one can have with regard to the relationship between biology and chemistry also the so called 'mind-brain problem' has been seen according to all the possible combinations of ontological/methodological reductionism/antireductionism: ontological and methodological antireductionism (dualism or pluralism); ontological and methodological reductionism (materialism, identity theory); ontological reductionism and methodological antireductionism (functionalism); ontological antireductionism and methodological reductionism (scientific emergentism). To sum up, the ontological and methodological reductionism of the identity theory has been rejected either completely by dualists or partially by functionalists. However, there is a third way to reject methodological reductionism though accepting ontological reductionism: eliminativism. This theory is an extreme contemporary form of materialism and naturalism according to which, although it is true that mental states are not reducible to brain processes, that is not due to the fact that mental states are not physical or to the fact that they are functional states that can be implemented by different brain processes but to the fact that mental states do not exist under the description given to them by folk psychology. This does not mean that the mental does not exist at all but simply that concepts like for example belief, desire, intention, passion etc. are too crude if one wants to found a scientific psychology on them. The most striking objection that has been advanced against naturalism and materialism in all its forms is that there is an aspect of every subjective experience that cannot in principle be reduced to a natural (physical) process. If I see and smell a rose no neural process in my brain can be identical to the experience that I have of seeing its redness and smelling its flavour. However, materialists and naturalists have replied that the consciousness of 'qualia' might not be the knowledge of immaterial phenomena but the way in which the brain monitors some of its own processes. The possibility of reducing mental states to brain processes and substituting psychology by neurosciences is still very disputable. However, whereas forty years ago the discussion between the identity theorists and their opponents was developed only by means of arguments a priori and conceptual analysis and was devoted to establish the mere logical possibility or impossibility of such a reduction, nowadays neuroscientists give philosophers - by means of their 'brain images' (P.E.T., functional magnetic resonance etc.), EEG layouts, theories on the sensorimotor-coordination of animals and human beings, clinical cases that show a certain correlation between psychopathologies and brain lesions etc. - many examples of the kinds of neural activity that might be identical to phenomena which in our everyday language we usually describe as mental.

Symposium "Psychopathology and responsability"

- Responsible Psychopaths (and Other Emotionally Impaired Moral Agents)"

P.S. Greenspan

Psychopaths lack the normal capacity to feel moral emotions such as guilt based on empathy with the victims of their actions. They also apparently can't keep track of their own interests consistently over time and therefore are unable to learn from punishment. In effect, they fail to empathize with themselves at other times, and in that sense lack an emotional prerequisite for full rationality.
Evidence for attributing psychopathy to genetic or early childhood causes of serotonin shortage may be said to undermine free will in these cases. However, psychopaths still may possess a sufficient degree of responsibility to allow for legal punishment, even if somewhat mitigated in comparison to normal agents.
Most philosophers think that psychopathy undermines responsibility on the grounds that it rules out knowledge of right from wrong. But in terms of legal prerequisites for responsibility, what's important is that psychopaths lack a kind of behavioral control: the ability to inhibit a proscribed urge on the basis of emotional "marking." This ability might be impaired even in someone who shares the basic linguistic capacity humans have to form and apply moral concepts. Emotional impairment rules out knowledge only in the more demanding sense of understanding the importance of moral concepts.
Psychopaths may still deserve our negative moral reactions, even if they can't change in response to them. Forms of personal condemnation aimed toward exclusion rather than retribution--contempt or revulsion, rather than anger or resentment--count as alternative variants of blame that are appropriately directed toward agents manifesting bad qualities of will, even as a matter of motivational deficit rather than deliberate choice.

- Evil and Moral Competence: What Psychopaths Can Teach Us.

S. Dwyer

There is a tension in our pretheoretic views about the evil person. On the one hand, we find it almost incomprehensible that a fellow human being could consistently violate moral rules, often take pleasure in doing so, and evince no subsequent guilt or remorse. This makes it tempting to think that the evil person is simply beyond the moral pale; he is not a member of the moral community and thereby cannot be held morally responsible for his wrong-doing. On the other, we are bothered by the evil person. We do not think that he escapes our censure and we are reluctant to entirely exclude him from blame. In sum, we think of the evil person simultaneously as one of us and as not one of us. But this is not a coherent position. If we seek rational and effective medical and legal strategies for dealing with evil, we will need some framework within which this fundamental tension can be resolved.
For sake of argument, I adopt the following incomplete (but useful) characterization of the evil person: someone one who consistently breaks moral rules and experiences no remorse or guilt in doing so. The characterization has a strategic point. It is often used to describe individuals diagnosed with anti-social personality disorder, or as I shall refer to them, psychopaths. My aim is not argue that psychopaths are evil. However, our reactions to the psychopath bear a striking resemblance to our reactions to the evil person: we find their behavior and psychology puzzling - even alien, but we are not ready to give up on them completely.
Over the years, philosophers have tried to provide an account of psychopathy. The prevailing view, expressed in different ways, is that the psychopath is impaired with respect to his moral knowledge (Duff 1977), or in his capacity to experience empathy (Deigh 1995), or in his capacity to form and act on a certain class of beliefs (Fields 1997). Each of these theorists take it that the psychopath's lack of moral motivation - allegedly manifest in the absence of guilt or remorse - is evidence that the psychopath is not morally competent. Further, given the common and plausible assumption that moral competence is a necessary condition for moral responsibility, it is argued that psychopaths are not morally responsible agents.
My aim is to argue against this received view about the nature of psychopathy. I defend the idea, shared by most philosophical writers on psychopathy, that there is a necessary connection between moral belief and moral motivation. But, drawing on a model of the development of moral competence I have developed elsewhere, I argue that the psychopath is, contrary to the received view, morally competent. As such, he is, prima facie, a proper recipient of attributions of praise and blame. Finally, I explore the possibility that there is a substantial overlap between the psychiatric class of psychopaths and the vernacular class of evil persons, and I suggest that we resolve our initial tension regarding the evil person in favor of the thought that he is a member of the moral community and not a mysterious alien.

- The Gallows and the Lust

E. Mordini

Psychoanalytic Institute for Social Research, 11, Passeggiata di Ripetta, Rome, Italy

"Suppose that someone says his lust is irresistible when the desired object and opportunity are present. Ask him whether he would not control his passion if, in front of the house where he has this opportunity, a gallows were erected on which he would be hanged immediately after gratifying his lust." (I.Kant, PrR 30)

"Ich bin alt und will für ihn sterben, denn er hat Frau und Kirner" (I'm elderly, I want to die in his place, because he is married and he has sons). These were the words with which the polish priest, Maximilian Kolbe, saved Francis Gajowniczeck, taking his place in the list of prisoners destined to be executed by the SS in July 1941, in the concentration camp of Auschwitz. "Ihr werden eingehen wie die tulpen" (We shall dry them as tulips) said the guards to the prisoners. Two weeks after only four prisoners on ten still survived, between them Maximilian Kolbe. They were killed on August 14, by an injection of phoenic acid.
The actual problem of evil is that Kant was definitely wrong. No gallows can prevent committing the evil; no gallows prevent pursuing the lust. Likewise, good can be pursued in spite of any gallows. Obviously, in the economy of evil and good one should consider even the gallows, but it can't be done in a simple manner. The gallows can be either a reason for committing the evil or for committing the good. This is the aporia posed by psychopath. Are psychopath persons who commit the evil because they are mad or are they mad because they commit the evil? What is the relationship between evil and madness? Against any form of politically correctness, is eventually madness a form of evil?
Raine and colleagues suggested that positron emission tomography (PET) may be able to identify criminals. PET brain imaging was conducted on 41 murderers pleading not guilty by reason of insanity and 41 age- and sex-matched controls. Murderers were characterized by a specific PET pattern and authors conclude that their findings show "a network of abnormal cortical and subcortical brain processes that may predispose to violence". The issue of human responsibility vis-à-vis neuroscience has been widely debated. For instance, on the basis of brain imaging techniques, Spence argues that conscious free will is incompatible with the evidence of neuroscience. If free will exist, it is a miracle, but, as Chesterton wrote, "The most incredible thing about miracles is that they happen".

- The puzzle of non-autonomous intentional action

C. Perring

Assistant Professor, Department of Philosophy, Dowling College, Oakdale, Long Island, NY, USA

It is difficult to find a satisfying account of how an action can be performed by a person with full knowledge of relevant information and under no physical constraint or coercion from another person, and yet fail to be autonomous. Yet in many cases of psychopathology, such as addiction, compulsive rituals, mania and possibly even personality disorders, we are often inclined to describe a person as not in control of her actions, in contrast to the way a healthy person normally acts autonomously. Some libertarian and existentialist antipsychiatrists have suggested that the notion of non-autonomous intentional action is confused. They have argued that it is a conceptual truth that intentional action, at least when performed without coercion from another person, is autonomous.
Some feminist theorists have attempted to defend the idea that women's action in a patriarchal society is frequently non-autonomous because her desires are inauthentic, being formed by a sexist upbringing and societal pressures.
Sometimes they invoke an analogy or even a direct parallel with brainwashing to explain how women's intentional action can fail to be autonomous.
I argue that the puzzle of non-autonomous intentional action is a pressing one for those trying to understand the moral psychology of mental disorder. While the arguments of antipsychiatrists are question-begging, they raise urgent issues. Our practices of ethical praise and blame depend on the possibility of non-autonomous action. The defense of the possibility of non-autonomous action by feminist theorists has some intuitive appeal, but needs further elaboration and defense. We currently do not have a well-accepted and sophisticated theory of non-autonomous action, but instead rely on undefended intuitions.
In this paper I survey recent philosophical work on autonomy and explain how it can be used to support the coherence of the concept of non-autonomous intentional action. In particular, I shall set out some proposals made by Alfred Mele and Bernard Berofsky and I shall apply their theories of autonomy to psychopathology.

Seminar "Evolutionary models in psychopathology"

- The Sexual Competition Hypothesis for Eating Disorders

R.T. Abed

Department of Psychiatry, Rotherham District General Hospital

A hypothesis is presented for eating disorders, based on Darwinian theory, that contends that these syndromes, together with the phenomenon of the pursuit of thinness, are manifestations of female intra-sexual competition. It is suggested that eating disorders originate in the human female's psychological adaptation of concern about physical attractiveness which is an important component of female 'mate attraction' and 'mate retention' strategies. It is argued that present-day environment of Western countries presents a range of conditions which have led to the overactivation or the disruption of the archaic female sexual strategy of maximizing 'mate value'. The present hypothesis deals with the ultimate level of causation and is, therefore, compatible with a range of theories of proximate causation. Although the present hypothesis is not directly testable, it makes predictions that are testable and refutable. Arguments and evidence is presented in favour of a range of predictions that arise from this hypothesis. It is suggested that the sexual competition hypothesis has more explanatory power than existing evolutionary theories of eating disorders.

British Journal of Medical Psychology (1998), 71, 525-547

- Using selection theory to understand the effects of culture, cognition and biology in psychological disorders

W. Mansell

Department of Psychiatry, Warneford Hospital, Oxford, UK

In society we are continually adapting to new technology, customs, laws, roles in life, and most importantly of all, to one another. Following Daniel Dennett and other writers, four methods of adaptation will be described: inherited instincts; trialanderror learning; cognitive learning and the use of language and other symbols.
Models of cognitive therapy (e.g. Beck, 1976) explain how our beliefs are involved in psychological disorders. Meme theory (e.g. Blackmore, 1999) accounts for how information spreads through a society and influences peoples' beliefs. Hysterias are examples of how a psychological disorder can spread quickly through a society via memes. Meme theory and cognitive theory complement each other to help explain the spread of hysteria. It is possible that many of the beliefs which put people at risk of psychological disorders may be spread as memes.
When different beliefs compete to direct our behaviour, we experience emotion. To put it dramatically, our emotions are the battleground of our beliefs. They represent an unstable state in which beliefs compete with one another by speedily evolving or recalling new 'weapons', such as thoughts, memories, images, body states and different perceptions of the current environment. To the extent that these stimuli are experienced as involuntary and distressing, the individual will experience a psychopathological emotional state (see W. Mansell (2000). Conscious appraisal and the modification of automatic processes in anxiety. Behaviour and Cognitive Psychotherapy, Volume 28, Number 2). During psychological treatment, the therapist is, in effect, a selective breeder of new, more adaptive, beliefs. Because learning inevitably involves error, the therapists creates an environment where extreme beliefs and behaviours are accepted, but also continually tested against the world. The consequential reduction in conflict between beliefs and goals allows recovery (e.g. Lauterbach, 1990).

- Human Altruism, Genes and Psychosis

V. Murray*, J. Barnes

*Department of Psychiatry, University of Edinburgh, Morningside Park, Edinburgh EH10 5HF; Drs Barnes & Graham, The Surgery, 14 Hillington Road South, Glasgow G52 2AA

While intelligence and language are generally held to be the major components of human uniqueness, the marked capacity for altruism may have been the key to the evolutionary success of modern humans. Altruism in evolutionary terms describes an individual acting to increase another's survival fitness at the expense of their own fitness. Thus the origin of altruism is difficult to account for in evolutionary theory, but once established, altruism is advantageous. Reciprocal altruism, whereby reciprocal acts are repaid, demands that individuals meet repeatedly, can remember who helped them in the past, and can recognise and guard against cheaters. Indirect reciprocal altruism supposes that being perceived as being altruistic increases the likelihood that the individual will be in receipt of altruism from a third party in the future. Evolutionary altruism provides the foundation of human society, and the need for rules to punish cheaters. Altruistic behaviour can be considered a complex trait with an underlying genetic basis and a large environmental component.

Psychosis is also a complex trait, and many different theories have been proposed to account for its persistence across all human cultures despite a likely evolutionary disadvantage. Kraepelinian division of the psychoses pervades modern psychiatry, compartmentalising research and obscuring features common to people with psychosis as a whole. Research involving people with a broad range of primary psychoses has permitted clinical observations which would otherwise be overlooked. The authors have noted, both in psychiatry and general practice, as a group people with psychosis and their relatives appear to be more altruistic than usual. If the trait of psychosis and altruism co-evolved, this may account for the persistence of psychosis. Genetic advances make identification of predisposing psychosis genes likely, but it would be dangerous to alter the balance of such genes in the population, if this also affected the tendency to altruism. Of more immediate relevance, an association between psychosis and altruism could profoundly change society's perception of people with psychosis, and perhaps redress the stigma associated with these illnesses.

- A common mode of operation in nervous systems with differing levels of evolutionary complexity

S. KarakaB1*, Y. Örs,2*

1 Department of Experimental Psychology, Hacettepe University, Ankara, Turkey* ; 2Department of Deontology Ankara University, Turkey*;

A paradigm change has been declared in brain electrophysiology. This change involves the renaissance of the oscillatory activity as the valid response of the brain. Contemporary research repeatedly shows that the electroencephalography (EEG) and the event -related oscillations of the brain have a higher explanatory value than time-domain event-related potentials (ERP).
The universal nature of the brain oscillations is manifested over the evolutionary spectrum. The nervous systems of species ranging from the aplysia to the humans show oscillatory activity within similar frequency ranges. In this respect, frequency responses in particularly the alpha and gamma ranges have already been demonstrated over species of differing complexity.
As we know, there exist functional as well as structural levels of organisation in living systems that have developed in the course of their evolution. Although there has been a definite, essentially one-directional complexification in this process, we observe that certain characteristics at lower (molecular/subcellular) levels have persisted throughout evolution as common properties between otherwise immensely different animal species. We would expect, certainly, that such lower-level structural similarities between different species do indicate a functional significance as well.
In the case of the nervous system, reaching its organisational climax in the human brain, inter-species resemblances at the level of electrophysiological responses should point to a common functional significance in terms of evolution, and imply an overall dynamic meaning for the individual. This point which might possibly be called evolutionary psychophysiology could also have psychiatric implications.

Seminar "Delusion"

- The negative and positive element of delusion - a new Jacksonian concept

Ph. Portwich, A. Barocka*

Department of Psychiatry, University of Erlangen; *Hohe Mark Hospital, Oberursel (Germany)

This contribution presents a new psychopathological concept of the structure of the psychiatric phenomenon delusion in terms of John Hughlings Jackson's (1835-1911) model of cerebral disorders.
Jackson started from the theory that the brain is hierarchically organized in layers. Each layer represents a certain level of human evolution. The highest layer is more complicated developed than the more primitive layers below and it determines the functional level of mental life. Jackson stated that the general pathophysiological mechanism of cerebral disorders consists of two components that create the clinical symptomatology: the primarily highest layer is destroyed and its function is lost ("negative symptom or element") and a lower layer attains to the surface of psychic life ("positive symptom or element").
Modern psychiatry adopted the terms positive and negative to describe two different groups of schizophrenic symptoms. According to this dichotomic symptomatology, delusion is regarded as a positive symptom.
We transfer Jackson's pathophysiological concept from neuropathology of the late 19th century to modern psychiatry and suggest an explanatory psychopathological concept of the structure of the phenomenon delusion that implies a negative and a positive element: The negative element of delusion is considered to be the supposed underlying neuropsychological impairment. The positive element comprises the individual personality and biography that create the delusional idea, e.g. persecution.
This concept provides a more profound understanding of the structure of delusion. Furthermore, it is able to integrate the vast number of single theories on the genesis of delusion.

- Alterisation and Ego Constitution in Delusional Experience: the History of

F-S. Kohl, D. Pringuey, F. Cherikh, S. Thauby

Clinique Universitaire de Psychiatrie et de Psychologie Médicale, France

Mary-Magdalene is a young patient referred by the police to our department for a psychotic episode. She was founded wandering in the city not even remembering her name. Slowly she revealed pieces of the history of her existence. Six months after our first meeting, she was able to express her understanding of what happened to her. She expressed a wide mystical delusional experience. She had the intuition that she came from another planet, that her family was a fake one and that God and the saints imposed on her this experience for redemption of her sins.
The story of Mary-Magdalene questions the problem of the constitution of identity and thus the constitution of the other. The standing up of the self requires the constitution of the other and its relationship with him. To stay up, to stand up our patient needs to relay on the other. She needs the other because without the other there is no existence possible. This other is constituted by two generic figures of father and mother, one of a mighty God, one of a matrix whom did not give her birth.
Relying on Husserl theory in the fifth Cartesian meditation we would like to show how the genesis of alter ego is made through appresentation based on similarity between the body of the other and the body of our patient.
We would also try to show how this understanding was a key point in the establishment of a true therapeutical relationship based on a comprehensive understanding of the other, disposability, the acceptance of the intrinsic liberty of the other.

Husserl E. Méditations cartésiennes. Librairie philosophique J. Vrin: Paris, 1996. 256p.
Tatossian A. Analyses phénoménologiques de la conscience délirante. In Psychiatrie phénoménologique. Pp. 11-25. Acanthe : Paris 1997. 241p.

- Method, Metaphor and Meaning in Madness

O. Reichard

Consultant Psychiatrist, Private Practice, Burwood NSW Australia

Objective: To use a multi-axial approach to characterise and manage 'madness' more efficiently and yet more humanely; as it demands and allows such a course.

Method: Philosophical conceptualisation, using both its analytic and synthetic functions and considering ontological, epistemological and methodological aspects to achieve a more comprehensive, critical and concise diagnosis and therapy.

Results: The 3 Categories of Consciousness in which we normally perceive the 'realities' of our world are mixed in madness:
1) Consciousness of the things of the physical world, outer reality (the Umwelt): reached by the sensory channels.
2) Self-consciousness, the inner world of the Self (the Eigenwelt): reached by introspection.
3) Consciousness of our fellow beings (the Mitwelt): reached by empathy.
It is the differential of these 3 categories that we need to preserve for our sanity and their mis-selection is the core of schizophrenia.

Diagnostically, 'madness' (this ataxia of the mind) must be analysed parallel as
1) Deviation of behaviour (its phenomenology)
2) as a Deficit in the highest integrative mental functions
3) as an emotional Defence to this disintegration.
It has been conceptualised also from 3 different vantages:
1) The psychotic mental state
2) the potential that it carries: the traits
3) the trauma: as it is an extreme traumatising experience to its posessor, nay to to others.

Conclusion: Therapeutically alientation is the most in-sane approach to madness. The self has to be supported and Integrated by: A Multi-Axial Dynamics (M.A.D.) based on Phenomenology, Personality and (Human) Ecology using the Morphogenetic Metaphor of Mind in a New Paradigm of Psychiatry.

Seminar "Philosophers on madness. The dialogue between philosophy and psychopathology III"

- Wittgenstein, Madness and the Will to Metaphysics

D. McManus

Department of Philosophy, University of Southampton, United Kingdom

If in life we are surrounded by death, so too in the health of our understanding by madness. (Culture and Value, p50)
This paper will argue that the work of Wittgenstein can be understood as oriented around an awareness of the ineliminable threat of madness and of the distorted manner in which this threat is acknowledged in philosophy. Wittgenstein shows how forms of collapse that we might well think we know all too well as species of mental illness are what are actually at stake in philosophical reflection on meaning, though caricatured there as species of error. In its mythology of judgments that provide the foundation of the intelligibility of our thoughts, such philosophical reflection strives to confront the fear that our thoughts might collapse into incoherence while at the same time disguising that fear as something rectifiable through the careful exercise of our judgment.
Throughout his development, Wittgenstein maintained a critical perspective on metaphysics which, I will argue, saw our conviction that metaphysical doctrines are intelligible as expressive of a desire to see the coherence of our thoughts as something that we might protect through due diligence and, correspondingly, to see the descent into incoherence as a species of error. While it is possible to assess whether particular combinations of signs are meaningful within a particular language, it is not possible, Wittgenstein argued, to assess about whether a particular thought is, as such, coherent:
[I]n order to be able to draw a limit to thought, we should have to find both sides of the limit thinkable (i.e. we should have to be able to think what cannot be thought).
Tractatus Logico-Philosophicus, Preface p3
However, speculative philosophical theories about the fundamental structure of reality, of the mind and of meaning would seem to make possible just such an assessment of which thoughts are coherent. For example, one might argue, as Wittgenstein himself has been thought to argue, that it is an isomorphism between the objects that make up facts and the elements that make up thoughts that allows thoughts to describe facts. That such explanations can be derived from such metaphysical speculation - which would help to execute what we already maintain is an incoherent and hence ultimately illusory task - shows that the intelligibility of such metaphysical claims can only be apparent.
This critical perspective informs the treatment of metaphysical themes in Wittgenstein's work, early and late. For example, in the Tractatus, one reads that 'I am my world' and 'there is no such thing' as '[t]he thinking, presenting subject' (TLP 5.63-631). What these shocking claims articulate, I will argue, is the incoherence of a critical perspective from which the meaningfulness of our existence might be viewed. That intelligibility is something which embraces ourselves and the 'world' within which we dwell. When we imagine our stepping outside of that world, we imagine a relationship towards that intelligibility that simultaneously questions it and takes it for granted - the very recognition of our thoughts and utterances presupposes their meaningfulness and yet that meaningfulness is what we would pretend to be able to assess in adopting that supposedly external perspective. From that perspective we would witness the impossible, mythical 'fact' about which the sane are right and the insane wrong.
Wittgenstein's later work confronts the difficulty embodied in seeing how this perspective on metaphysics can be correct. From a variety of different points of view, our life with meaning can appear unintelligible without the kind of metaphysical underpinning that Wittgenstein would have us believe is an illusion. For example, denied the kind of objectivity that a metaphysical realism would seem to give our language use, that use can appear arbitrary and our correcting of 'the rebellious pupil' unjustifiable. What is this sense of fixity and how can the demands it appears to ground be reasonable if the kind of metaphysical underpinning we crave would provide an impossible touch-stone for the sane?
In his later work, Wittgenstein traces this confused sense of the arbitrary to a number of different sources of illusion. A crucial cause of this anxiety is a failure to appreciate the fundamental heterogeneity of rule-following. Wittgenstein attacks the notion that we have any real understanding of 'Meaning-as-such', 'the-Normative-as-such' or 'Language-as-such'. Wittgenstein rejects efforts to identify 'what the essence of language is', 'what is common to all these activities, and what makes them into language' (Philosophical Investigations, sec. 65). Rather 'these phenomena ... are related to one another in many different ways [a]nd it is because of this relationship, or these relationships, that we call them all "language".' Similarly, there is no such thing as 'Understanding-as-Such'. There is instead a set of capacities that overlap more or less and which, by virtue of those relationships, we label 'understanding'. Rules are features of particular practices and, crucially, to understand what it is to understand those practices we must examine those practices and the modes of explanation that they themselves exploit. In this way, Wittgenstein 'domesticates' normativity, making it accessible only to a 'domesticated' understanding.
This view is easy to misunderstand as inviting a shocking parochialism. It can seem to make the charge of incoherence a mere matter of convention, a reflection of the particular lives we lead and no more. This impression is indeed correct but it seems problematic only as a result of a failure to appreciate fully Wittgenstein's point of view. If 'seeing the other person's utterances and actions as intelligible' is a matter of finding it possible to co-operate with them in particular determinate practices, their 'incoherence' will indeed be a matter of our finding it impossible to locate them within our practices. This will seem to be an insubstantial basis for this weighty assessment only as long as we fail to follow one of Wittgenstein's other prescriptions, that we 'look and see!' The kinds of practice in question are 'giving orders, and obeying them; describing the appearance of an object, or giving its measurements; ... asking, thanking, cursing, greeting and praying' (PI 23). Beneath the seemingly wilful conservatism in our despairing of 'those who cannot take part in our practices', we should instead see them as 'people who can't give orders, describe objects, ask, thank, curse or greet'. Our despairing assessment is a reflection of the particular lives we live. But to say 'and no more' suggests a failure to appreciate the depth of those practices within us. Our assessment rests upon a 'matter of convention' in the sense that there is no metaphysical explanation why our lives have to take the form that they do. But this is no 'mere matter of convention' because the charge of unintelligibility, of insanity, has for us as much weight as our lives themselves.
Far from rendering the charge of 'incoherence' merely conventional this perspective restores the full, concrete horror that it denotes. Moreover, philosophy now appears as a wilful rationalism which, motivated by the fear of madness, attempts to falsify that fear by converting it into a fear of error. The philosophy of language presents the failure to learn the rules that we use as an incapacity to spot the fact or feature that determines the character of those rules. This vision allows us to cover over what is at stake when we attempt to understand one another and what it is that happens when that effort fails. Wittgenstein's later emphasis on the mutual dependency of rules and lives shows both the limited extent to which those rules may be 'legitimated' and how much weight hangs on these (now embarassingly) concrete and localised judgments. Rather than a mere inability to apply certain labels, an inability to learn 'language-games' can be the devastation of lives, and recognizable forms of devastation at that. To be unable to learn the 'language-games' of intention, of psychological ascription, or of moral evaluation, for example, may be to live blighted lives that we may yet recognize as corresponding to species of mental illness. Projects that lie within the heart of the philosophy of mind and language may then represent attempts to substantiate a comforting but hopeless mythology of insanity and of a means to its mastery. We may see here another interpretation for Derrida's provocative proposal that '[p]hilosophy is perhaps the reassurance given against the anguish of being mad at the point of greatest proximity to madness' (Writing and Difference, p59).

- Towards the essence of the family roles

J.F. Jacko

International Institute for Interpersonal Communication, Liechtenstein

Family roles are: parental roles of motherhood and fatherhood, spousal roles of husband and of wife, and the role of a child.
Motherhood and fatherhood are roles that we play in relation to our children. The role of a child is played in relation to parents. Husband and wife are roles that parents play in relation to each other.
Parental roles can be played in a natural (biological) way, when we conceive a child, give birth to it, or feet it. In this case we speak of natural (biological) motherhood and fatherhood. But - what is more important - we can also play these roles in the spiritual way, when we educate a child. In this case we speak of spiritual motherhood and fatherhood. This is why also persons who have no natural children can be spiritual parents. By analogy, it can also apply to spousal roles and the role of a child. There can be natural and spiritual spouses and children.
In this essay I try to show the contents of the family roles. I try to show the essence of these roles, not their deviations or possible modifications.
I am aware of the fact that this is a very delicate and complicated topic. I do not want to impose any viewpoint onto my reader. The text is to provide a posint of departure for a further discussion.

- Intentionality and vulnerability

S. Spinelli

Psichiatra, C.S.M. di Arona, ASL 13 Regione Piemonte

Intentionality is a theme upon which philosophers of the mind have discussed since the beginning of time, and the roots of this problem spread way back to the down of human thought. The attempts made to reach an unequivocal and operational definition of the concept - through the different points of view - have probably run into the constituent feature of intentio that is its dynamic aspect borne from the interaction, and the continuous relation between man and the world, between man and his personal history, between the ambitions and the possibility of fulfilling them in the world-of-the-life that is his own.
Following a brief introduction of the subject from a philosophic point of view, Mundt's proposal of a theoretical model of intentionality disturb is described considering how this could integrate, instead of opposing with the vulnerability model, so to constitute a lively and meaningful criteria of interpretation, directed toward the individuation of the most specific (and authentic) therapeutic-rehabilitative programs effective for every single case.
Finally how an instable intentionality, considered as a disturbed constitutive function of one-self and the surrounding world, can, with the integrative of a basic symptoms evaluation, so as to measure an alteration of the experiential function, help the clinician to recognise and treat precociously schizophrenic spectrum disorders.

Brief Bibliography

BLANKENBURG W., (1971), La perdita dell'evidenza naturale, tr. it. Raffaello Cortina Editore.
MERLIN G. - BORGHERINI G. (a cura di), (1991), La sindrome di apatia schizofrenica tra concezioni fenomenologiche e mondo delle scale, Cleup Editrice, Padova.
MUNDT C., (1985), Das Apathiesyndrom der Schizophrenen, Springer Verlag, Berlin, Heidelberg, tr. it. Cleup Editrice, Padova, 1990.
ROSSI MONTI M. - STANGHELLINI G., (1999), Psicopatologia della schizofrenia, Raffaello Cortina Editore.
STANGHELLINI G., (1997), Antropologia della vulnerabilità, Feltrinelli, Milano.

Plenary session

- Phenomenology and Psychosomatics

M.L. Rovaletti

CONICET and Dept. of Phenomenological and Existential Psychology, University of Buenos Aires, Buenos Aires, Argentina.

By dividing the field of the human, the psyche-soma dualism ended in sectorizing diseases into organic illnesses, and psychic illnesses. Eventually, however, the so-called 'psychosomatic disorders' that, apparently, had broken up such a pattern have been converted to a new corpus pineale just as Descartes would have done. The body is reduced to a mere instrument of psyche, and the subject is reduced to a mere onlooker of illness he or she tries to remove one way or the other.
Conversely, phenomenology understands that, first of all, the body is 'the body I am' (Leib): the body is the place for communicating with other people, and the place for performing exchanges with things. It is through the body that the world affects us, and it is by means of the body that we display all our significations onto the world.
In everyday life people are just unaware of their bodies. Whenever anxiety busts out, however, the body makes a massive comeback, giving expression to the complex dialectics of the speaking subject through his or her body. Anxiety pertains to a pre-category order of the body, to the unfathomable depth reason is unable to pierce. At the bottom line of a great majoriy of psychosomatic disorders there lies an intersubjective anxiety conveying a conflict between the loss of an object and the obstacles thus hindering the personal growth. Reason, as a reflexive conscience is unable to solve the conflict -reason is not even aware of conflict, reason does not even perceive any likely relationship among disorders and such or such situations. The body, as an 'operating intentionality' (Merleau-Ponty), as a pre-reflexive access to the world, as a pathos life experience (Lang), will irrupt and see to it that conflict is solved, and conflict-linked anxiety are transformed. Body and its great reason -as Nietzsche would have said, solves everything its way.
A bodily 'geography', so to speak, causes motives, and influence zones to diverge, and each one is summoned back at a given moment, as well as differently. A 'phenomenological anatomy' will try and reveal a link existing among live events and the different regions of the body. Hence, localized impact points on one part of the body give evidence about a person as a whole instead of giving evidence about a sectorized attack to either an apparatus or organ.

Plenary session

- Mental disorder as an excuse

E. Matthews

Department of Philosophy, University of Aberdeen, UK

The "insanity defence" is a familiar part of most legal systems, but "insanity" is a legal, rather than a psychiatric concept. How far can we use the concept of "mental disorder", which is more typical of psychiatry, in a similarly exculpatory fashion? That depends largely on how far we can map the latter concept on to the former in relevant respects. The insanity defence is often supported by reference to Aristotelian conceptions of involutariness, which at first sight involve two criteria: lack of knowledge of relevant features and lack of control over one's own behaviour. But Aristotle's examples do not suggest that ignorance and lack of control in themselves excuse, but only when they are themselves exusable, and this seems to be the case also when they are applied to the example of insanity (as seen, for instance, in the famous case of M'Naghten). Different sorts of examples of typical mental disorder often cited as diminishing responsibility are examined to see in what ways, if at all, they meet the Aristotelian criteria so interpreted. It is concluded that only some of them in fact do so, and that the relevance of psychiatric expertise to legal decisions is more complex and subtle than it is often thought to be.

Plenary session

- Incomprehensibility

M. Heinimaa

Department of Psychiatry, University of Turku & Department of Philosophy, Åbo Akademi University, Turku, Finland

This presentation belongs to a series of papers that investigate the logic of some central psychiatric concepts like "psychosis", "delusion", "insight" and "understanding". The key theme of these investigations is the importance of the grammar of "understanding" and concepts related to its demise ("incomprehensibility") in describing these psychiatric concepts. In this paper, the logic of incomprehensibility is investigated with reference to Ludwig Wittgenstein, Cora Diamond and Peter Winch. It is shown that incomprehensibility is not a stable attribution on which we could build either psychopathology or psychiatric activity. The implications of these findings to our understanding of psychiatric conceptualisations are drawn.

Symposium "Evil: psychopathology and philosophical approaches"

- Moral reasoning in individuals with personality disorder

G. Adshead, S. Nicholson, E. Skoe

Personality disorder is a medical term denoting significant interpersonal dysfunction, and failure at social relationships. There are categories of personality disorder, such as antisocial personality disorder, which are characterised by rule breaking behaviour, and sometimes violence towards others. It has sometimes been argued that individuals with antisocial personality disorder are less able to reason morally, and it is this failure in their capacity to reason morally which contributes to their unpleasant and antisocial behaviour towards others. We present the results of a pilot study looking at moral reasoning in men and women with personality disorder in a maximum security hospital in England. We hope to show that there is a range of levels of moral reasoning. Moral reasoning is assessed using the Ethic of Care Interview (Skoe 1993) which we will argue is more appropriate for individuals with personality disorder, than other tools for assessing moral reasoning.

- The social construction of evil in a forensic setting

T. Mason

This paper is a product of serendipity. It explores how ward based psychiatric nurses in one Special Hospital attribute the notion of 'evil' to deviant activities. Staff were asked to read and make comments about a series of vignettes, abbreviated offence scenarios, from which emerged the construction of a taxonomic order of evil. These explanations of evil were then juxtaposed alongside their counterparts from theodicy. Deviancy attributed to extreme psychoticism is not credited with being an evil act, such individuals having a primordial contract of innocence. In contrast, extreme crimes committed by those with a psychopathic disorder are considered evil. An evil act is seen to be one which transgresses a `natural boundary'; the product of purposeful action after the accumulation of stages of `reality testing'; and, finally, a consequence of the extinction of moral bonding leading to residual instinctive behaviour.

- Do we need evil?

C. Brown

The fact that there is a right way to behave and a wrong way to behave is one of the rare universals of Human society. Anthropologists have studied the similarities and differences of the rules that structure human behaviour - and what happens to those that break the rules - in many different places. Common themes emerge of taboos, witchcraft and evil contrasting with other, harmony and social cohesion.
In our own society, such dark superstitions have supposedly been banished by the electric light of modern science. But certain people continue to commit atrocities that are unexpected and often inexplicable. When positive explanations break down, evil returns as a popular model of causation.
Such recurrent themes often serve a useful purpose. In western society today, the reporting of brutal crimes attracts huge media interest with whole communities entering into moral discussions through the vehicle of an individual case. Everyone has an opinion of the boundaries of right and wrong. Extreme actions throw ordinary behaviour into sharp relief. Perhaps we need these examples of evil, to be horrified by and to control. If we didn't have monsters to lock up, they may move in next door.

- The Medea tragedy, updated

E.P. Trager

On Friday, March 6, 1999, at 11:08 a.m., the police department in Naperville, Illinois, an upper middle-class suburb of Chicago, received a chilling phone call. The caller was Marilyn Lemak, estranged wife of a local physician, who had just learned that her husband was dating another woman. "My three kids are dead and I wanted to be dead too, but it didn't work. I did it." On the night of November 4, 1997, in Little Rock, Arkansas, Christina Marie Riggs, a single mother abandoned by her husband injected a large dose of potassium chloride into one of her children's neck, gave him an injection of morphine and smothered him to death. Shortly thereafter, she smothered her second child to death with a pillow. She then wrote a suicide note and attempted suicide but failed.
Five years earlier in 1995 in Spartanburg, South Carolina, Susan Smith, after being rejected by a lover whom she felt did not want the responsibility of rearing her children by a former marriage, drove her children to a ramp on the edge of a nearby lake. She then lowered the hand brake, jumped out of the car just before it hit the water, and watched as the car with her two children strapped in the back seat sank into the depths of the lake.

On July 12, 1995, in Spartanburg, South Carolina, Susan Smith was sentenced to life in prison. On February 14, 2000, the mothers of Naperville, Illinois picketed the courthouse where Marilyn Lemak had been charged with first degree murder, demanding that she be found innocent by reason of insanity and get proper treatment for her mental illness. On May 2, 200, in Little Rock, Arkansas, Christina Marie Riggs, 28 years old, was executed by lethal injection.

How can these three cases whose similarities are so striking have such different outcomes? This paper will attempt to deal with this question as well as with the uniquely American tendency to transform a moral dilemma into a medicolegal issue with scientific trappings. It will also attempt to show that though the psychological motives of these three women were remarkably similar, the moral perspectives of the communities in which they lived, were quite different.
The modern mind seems to believe that when moral judgments are phrased in scientific language, they become less arbitrary and more humane. Thus, the moral dilemma of distinguishing between sin and sickness, illness and evil, becomes transformed into a medical and legal enterprise in which psychiatry and science are invoked to determine criminal responsibility. There is the notion that responsibility is a state of the individual that may be discovered by employing the proper scientific methods of investigation. According to this view, the determination of criminal responsibility is not an ethical and moral dilemma, but a scientific problem. Therefore, the solution to this problem is to be found by using scientific techniques for discovering and identifying the state of responsibility.

Seminar "Ethics and authenticity in society"

- Madness and Immoral Sense: Recent Concepts of Mental Illness and Problems of Ethics

P. Trnka

Assistant Professor of Political Philosophy, Memorial University of Newfoundland, Canada

Much contemporary analytic work in philosophy of psychiatry has focused on defining mental disorder (Clare 1980, Fulford 1989, Wakefield 1995, Clark 1999) and in doing so has done much to clarify the evaluative as well as factual dimensions of normal and abnormal thought, feeling, and action. Recognizing the importance of intentionality and values in judgements of normality and abnormality has lead to broad notions of mental illness which (as Fulford has argued) are best seen not as putting psychiatry at odds with general medicine but rather as creating the model of understanding of illness in general. In this essay I shall argue (a) that this contemporary view of mental illness, conceived as dysfunction of intentional and normative rationality, is conceptually highly defensible; and, at the same time, (2) that this view raises highly complex, perhaps irresolvable empirical problems in terms of distinguishing cases of mental illness from idiosyncratic or unethical behaviour. The analysis of mental illness or madness in terms of a failure of reason is fairly well established, though irrationality regarding norms and values is less readily accepted as a component of mental illness. The reason for scepticism regarding the latter is obvious: including unreasonable values in the definition of mental illness threatens to conflate illness and badness of an ethical sort; doing so would jeopardize the scientific standing of psychiatry. Yet it is to such an impasse that recent work regarding definitions of mental disorder has brought us. The impasse has been dealt with differently. Some, e.g., Wakefield, include values in disorder but conceive of them as subjective harms distinct from scientifically conceived dysfunctions. Others, e.g., Fulford, incorporate normative malfunction in their analysis of illness and defend such views by resort to notions of the 'ordinary' or 'normal' state from which illness may be reasonably distinguished. Neither of these strategies succeeds, I shall argue: the first accepts a subjective view of norms that is philosophically weak and the second accepts an uniform notion of the ordinary that is historically and culturally weak. Including the value dimension in mental illness and illness in general is an important conceptual advance in philosophy of medicine; at the same time, the difficulties in distinguishing between certain illnesses and different or unethical behaviour should not be played down. The challenge for views of mental illness now lies in a general consideration of the relation between physical, psychological, social, ethical, and political dimensions of normality and abnormality in personal life and conduct. The complexity of such inquiry shows the need for new methods of thought and the dangers of philosophical and scientific complacency. The analytic tradition in philosophy of psychiatry may here benefit from views in what has, up to now, been a radically divergent tradition, e.g., the social and political philosophies of madness (e.g., Foucault 1954, 1965; Deleuze and Guattari 1972, 1980). How such an encounter may be beneficial will be suggested in closing.
This paper will attempt to show that this notion is fundamentally flawed. Discovering and identifying a state of responsibility is not like discovering and identifying a brain tumor. Rather, it is a moral judgment about a perstechicalon's motives and behavior. The significant issue, therefore, is not a scientific or technical question of who is or who is not responsible as a result of a mental illness. It is really a philosophical question of who should and who should not be punished. Science and the law can be used to distract rather than enlighten when modern society does not like to confront moral dilemmas. Though Euripides wrote MEDEA well over 2,000 years ago, it is still being performed today. Perhaps it is modern society's way of indirectly acknowledging this dilemma.

- Moral responsibility and personality disorder

A. Bray

Central Sydney Area Health Service

The question of whether human beings can reasonably be considered responsible for their actions in a deterministic universe has occupied philosophers for millennia. This paper discusses philosophical theories of responsibility, from Aristotle to the present day. The issue is of particular relevance to psychiatry, as psychiatrists often encounter patients who appear unable to behave responsibly. I will consider the nature of responsibility and the function of this concept in our society, in order to examine the question of whether people with severe personality disorders should be held responsible for their actions.

- Agency and Akratic Actions in Existential Psychotherapy

M.C. Chung

University of Sheffield, Institute of General Practice & Primary Care, Community Sciences Centre, Northern General Hospital, Herries Road, Sheffield, S5 7AU, England

The aim of this paper is to challenge one notion of agency that existential psychotherapists propound. To put it very simply, this notion of agency suggests that we are free agents who choose to create, and are responsible for, our own destiny. In this paper, I argue that this notion of agency in fact reflects the Socratic paradox in which agents cannot knowingly choose the worse of two available alternatives. Rather, they always choose what they think best. I then follow by arguing that the notion of agency is problematic because the possibility of "akratic actions", i.e. weakness of will, has been ignored. I argue that akratic actions should not be optional in therapeutic practice. As the possibility of akratic actions is considered, one can make dubious the existential psychotherapeutic framework of agency. I argue that to do so would bear important implications for therapeutic practice.

- Ethics and psychiatry: to look like "The authentic ones"

A.O. Brundusino, G. Longo

University of Pavia, Italy

Being able to feel the others' sufferings arises from the meaning of acting as psychiatrists. Ethics consists in being called to give account of ourselves, of our values, of the projects for our lives; psychiatry will live "the others" only by giving right to different, but anyway righteous, ways of life. The deepest requirement is that of reciprocity, which states that the other one is similar to myself and to the others; the phenomenologic path which was given room by a suffocating psychiatry states the respect for the other, without distinction between healthy and ill subjects. Every psychiatrist should start from himself; knowing this could be an answer to the questions and worries rooted in the lack of care to the other one, who is different from me, but similar to me.
Looking like "The Authentic Ones" means a challenge to mental disease which should uproot definitively W. Griesinger's theory, considering mental disease as a disease of the brain. The dialogic approach in psychiatry is an existential relationship and involves a living research about psychic life. It is impossible to face and treat a psychotic patient without putting yourself at stake as a person, without coming into contact with the psychotic elements which all of us have.
It is a matter of quantity, but surely everyone has always some neurotic, and even psychotic elements (bion).
The dissociated patient needs to feel accepted; perceiving the detachment makes him feel worse. The moral ideal of authenticity lets us face the difference in terms of comprehension and not of explanation. The phenomenologic analysis starts from human presence (dasein) in its originary being-in-the-world state, assuming the patient's point of view, to rebuild the unrepeatable meaning of his presence for himself and for the rest of the world, the unbreakable unity of life and reality. The call to be authentic is part of the discomfort which passes through the tension coming from accounting for others' authenticity. A main feature of human life is then discovered: that it is essentially dialogic. The symptoms lose their label of unhealthy deviations to assume the Heidegger's meaning of existential failure, of missed realization of the countless possibilities characterizing every human life.
"Absolute authenticity of feelings belongs to psychosis, and burns every social mask" (Borgna).

Symposium "Shame and social anxiety"

- The experience of shame as organizer of psychopathological disorders.

A. Ballerini


Shame is an abnormal predominance of the interpersonal world over the Self. The centre of gravity of life is shifted outside: the other person's judgement rules the Self. The Mitwelt dominates subjectivity. This is the essential aspect of "social phobia" that expresses the insecurity of the Self. But the vulnerability to shame, like the insecurity of the Self, is possible at different levels. One level concerns the ontological foundation of the Ego (trascendental Ego), the deficiency of which could be the matrix of psychotic experiences. Another level is the ontic position of the Ego (empirical Ego) in the context of "natural experience", and it could be the level in which "social phobia" appears.

Seminar "The suffering body: somatic pain and somatoform disorders"

- Pain perception, body image, communication habits

F. Brogi, M. Cerretini, G. Di Piazza, M. Del Sole, L. Luccarelli, V. Migliorini, M. Nitti

University of Siena, Department of Psychiatry (Direttore Prof. Castrogiovanni P)

Human psychic suffering often takes the form of a somatic symptom. Physical pain, which can be found in every psychiatric diagnosis, is sometimes the only symptom of a disorder. In that case the soma asserts itself as an experienced-body (Leib) and the somatic perception became private communication through the body image. That kind of pain seems to be functional if compared to more "mental" conditions, such as depression. Patient suffering psychogenic pain follows different courses: fantastic metaphors describe a symptom absorbing the human being and his being-in-the-world; or an indefinite feeling unwell winds through important life events. By a few psychopathologic considerations we think possible to set the phenomenon into the field of the delusional experiences, at least in some respects. This suggests a defensive function as to more severe psychopatologic developments.

- Psychotic dimension in algic disorder: subtype or nuclear feature?

M. Cerretini, F. Brogi, G. Di Piazza, M. Del Sole, L. Luccarelli, V. Migliorini, M. Nitti, P. Castrogiovanni

University of Siena, Department of Psychiatry

In case of algic disorder, clinicians pay few attention to psychopatological course from mental contents to algic somatization. Studies on the personality, found out conflicts between an ego-ideal being independent versus precocious needs of dependence (1). The psychoanalitic school uses terms as "psychotic core" of personality to indicate residues of symbiotic contents associated to presymbolic mental activity and primitive defense mechanisms; psychopatology connected with physical suffering may be splitted and crowned in the above-mentioned areas; alexytimic trends could be an epiphenomenon linked to a lack of symbolization and to a confusion between Self and object (2). Psychopatological research about basic symptoms, individuated transition sequences toward delusion of somatic control; first stage's features are circumscribed and migrating algic sensations, motor weakness and stiffness (3); these symptoms may be phenomenically similar to those of algic disorder. Our aim is the study of psychotic dimension in a sample of patients with algic disorder using questionnaires as the italian version of "Experimental World Inventory" (EWY) (4) and of "Bonner Skala fur die Beurteilung von Basissymptomen" (BSABS) (5).
1. Blumer D, Heilbronn M.: Chronic pain as a variant of depressive disease. Journal of nervous and mental disease; 170, 381-406; (1982) Taylor GJ: Medicina psicosomatica e psicoanalisi contemporanea. Roma, Astrolabio, 1993
2. Klosterkotter J: Cosa hanno a che fare i sintomi base con i sintomi schizofrenici? In: Stanghellini G (a cura di): Verso la schizofrenia, Napoli, Idelson Liviana, 1992
3. Padovani F, Zorzi B: "EWY-Inventario del mondo esperienziale", Firenze, Organizzazioni Speciali, 1981
4. Maggini C, Dalle Luche R: Scala di Bonn per la valutazione dei sintomi di base (BSABS), Pisa, ETS, 1992

- Structural Prerequisites for a Symptom Shift between Psychosomatic and Depressive/Schizoaffective Disorders

H. Lang

Institute of Psychotherapy and Medical Psychology, University of Wuerzburg, Germany

The phenomenon of symptom shift is well known since a long time. In "Beyond the Pleasure principle" Freud for instance states: "We also know (...) that severe disturbances in the distribution of Libido like in melancholia may be lifted temporarily by an intercurrent organic illness (...)". Among many others Kerman described a shifting between asthma and affective disorders. The phenomenologic pioneer of psychosomatic medicine v. Weizsäcker was speaking of an "alternation" or "mutual representation" between mental and somatic disorders. Schur regarded organice diseases as "somatic equivalents" expressing severe mental disorders. These examples suggest a similarity in the structure of psychosis and psychosomatic illness. Such a structural connection is also supposed by Lacan who states a defiency in the emergence of the "paternal metaphor" and an unsymbolized relationship with reality in both conditions. The 'concretistic' thought and the absence of a genuine 'transitional object' in both, the psychotic and the severely ill psychosomatic patient, appear to point to a comparable 'basic fault' in the function of symbolisation. Why the reaction to this primary symbolisation "defect" takes the form of a psychosis in the one case and that of a severe psychosomatic disorder in the other and why these responses can alternate in one and the same patient is very much the question. Case reports as the history of a young female patient who originally suffered from schizoaffective psychosis, who later on under therapy developed gastric ulcer, then neurodermitis and finally showed features of an neurotic-depressive emotional state can illustrate these theoretical considerations.

- Gender Features in the Treatment of Somatoform Disordes

G.G. Beskrovny, MD; G.N. Khandourina, MD

Khabarovsk Region Railway Hospital, Khabarovsk, Russia

Pseudosomatic disorders often prevalent in general medical settings. There is a kind of patients with physical complaints meet diagnostic criteria of ICD-for affective (cyclothymia, dysthymia), anxiety, adaptation impairment, conversional and somatoform (somatized, hypochondriac and steady painful) disorders. Routine therapeutic management results in the chronic course of the disease, unreasonable hard-to perform and expensive labs and treatment. Further, the primary disorder accompanied by iatrogenic anxieties leads to long-term disability.Patiets fail to respond to treatment either at the mental hospitals or somatic centers. They need care combining pharmacology and psychotherapy. Over the last 12 years we have been managing such patients in general hospital. They are mainly middle aged females having middle or low social status.The majority of the disordes are psyhogenic. But the patients are unable to recognize their true causes. The psychogenic character resembles a reflexive response to a stressful situation. This mechanism seems to be close to "reflex arch" term. The fixation of the disturbances is likely to result from minor socialization, insufficient self-comprehension and self-regulation. Along with drug therapy modified narcopsyhotherapy aimed at motivation such as autogenic training and meditation, activation to change the situation. The state of trance coursed purposely with medication enables the patient to feel his own resource. Getting beyond the limits of common consciousness inhibits the left hemisphere where logic and estimation predominate. A woman faced to live in compliance with males, logic regulations is unable to solve her problems with reasonable means. Gaining access to the right hemisphere known for its intuition. It is possible to change the scale of values. The work with active imagination enables the patients to experience inner phenomena at fantasy level, to comprehend the symbolic sense of the symptom, "the vital scenario" (E.Bern). The sense of safety and altered world outlook give new perspectives to solving existencial problems and putting forward definite goals.What is the sanogenic mechanism of simbolic virtual examination of the problem situation? Whether it is insight, catharsis, reframing or behevioral investigation is not clear. However, an altered mind is of benefit in breaking emotional set capsule, that makes these emotions more accessible to both the patient and the therapeutist. An altered mind allows these emotions to be taken as a bridge to a real life.

Seminar "Stigmatisation and destigmatisation"

- Psychological Dimension of a Sociological Problem: Stigmatization

K. Arikan

Depts. of Psychiatry and Consultation-Liaison Psychiatry, Cerrahpasa Medical Faculty, University of Istanbul/Turkey

Today, much of the attention is not on the psychotherapeutic and/or pharmacotherapeutic advances in psychiatry. It is the stigmatization that has a pivotal role in the practice and theory on this respect.
Stigmatization is basically a sociological concept. Stigmatized people have been kept away from almost all of the social networks. Therefore, it is not only an issue of medical interest but also ethical, and legal problem.
Tremendous effort has been spent to overcome the obstacles emanating from the stigmatization. However, much of them have not been yet proved to be enough to satisfy what has been expected. One of the reasons might depend upon the transcultural aspect of the issue.
On the basis of our previous findings of a study conducted on Turkish population showed us that personality characteristics of each individual has its own impact on the stigmatization. Therefore, it can be claimed that, although stigmatization is a sociological concept, it can not be concluded precisely without taking psychological factors into considerations.
On the basis of this finding, the practical meaning of psychological dimension of stigmatization has been discussed.

- Stigmatization and destigmatization: might a multidisciplinary approach be valid?

H. Dogan

Department of Medical Ethics, Cerrahpasa School of Medicine, University of Istanbul/TURKEY

Stigmatization has been a long lasting discussion subject of psychiatry without reaching a clear resolution on the issue.
The unresolved aspect of the problem remained to be of tremendous importance, basically because of shadowing the marvelous advances of psychiatry in the last century. The advances of psychotherapy and psychopharmacology in the era of science became applicable and highly therapeutic for desperate patients while insufficient on the other hand, because of the magic power of stigmatization.
The aim of this presentation is to describe and discuss the term 'stigmatization' from a transdisciplinary point of view (sociocultural factors, science of psychiatry, ethical and legal points of view) and to describe different strategies for destigmatization.
In this study, the results of different descriptive studies on sigmatization conducted on Turkish population by the department of psychiatry and liaison and consultation of Cerrahpasa medical school is analyzed in terms of sociocultural factors, ethical priority of values , rules and principles of ethics versus science of psychiatry.
In conclusion, for destigmatization , besides psychiatric and psychological evaluations, a multidisciplinary approach to the subject looks to be inevitable to be able to take the advantage of the advances of psychiatry.

- Suffering in schizophrenia

P. Schönknecht1

1Department of Psychiatry, University of Heidelberg

The suffering of the schizophrenic patient is mainly determined by psychotic content. From delusions and hallucinations the patient develops strong feelings of anxiety and danger. This experience is almost ununderstandable outside the context of the schizophrenic distortion. A fast and effective neuroleptic and anxiolytic treatment of psychotic symptoms is generally recommendable. In addition, a specific psychotherapeutic management of delusion has been proposed. Nevertheless, suffering doesn't end after acute psychotic symptoms have disappeared. In many cases, with the development of so-called deficits as a result of the disease process a new career of suffering starts. But this suffering is of a different nature. It results from a clash with non-schizophrenic experience and cognition. A precise analysis of different aspects of suffering in the course of schizophrenia, can help us understand why schizophrenic patients are often unable to follow therapeutic instructions optimistically. Poor compliance often develops on the background of newly experienced deficits in social skills and social communication. Apart from the individuality of suffering, we understand suffering as a function of environment. In this context, an anthropological and ecological perspective is helpful to elucidate how we should communicate with schizophrenic patients after acute episodes, to reduce suffering and to promote the individual's specific abilities.

- Soviet Sluggish Schizophrenia: Clinical Sign or Social Stigma?

E. Bezzubova, M.D.

Russian State Medical Institute/ University of California, Irvine

Each epoch, culture, society brings its own image of the mad person, expressed as a constellation of clinical signs and social stigma that lie outside of normality. This paper considers so-called "sluggish schizophrenia " (SS) The nosology here is emblematic of the "soviet type" of science-society relationship. Beyond political oversimplification the story of SS opens the way to see multidimensional interweavings and tragic conflicts between science and propaganda, personal authenticity and state regulations, moral ideals and autocratic reality. On the one hand SS was developed in the context of and rooted in Grundstimmung Stoerungen and Bleuler's "latent schizophrenia" schizophrenic-spectrum, covering developmental distortions, disorders of personality, pseudoneurotic states and mild schizophrenia. On the other hand the social dimension of SS can be examined in terms of totalitarian suppression of individuality, of any personal properties under a monoideological stamp. Methodologically the SS-conception substituted "mad" for "bad," replacing clinical categories by social-cultural notions. Oddity, bizareness and withdrawal are at the core of the schizophrenic spectrum. At the same time they are close to social terms designating a variety of asocial or antisocial behavioral patterns. The next step leading to political abuse of SS is different from substitution, and is based on the old slogan: Those who are not with us are against us. The image of the patient with SS and the image political dissident were quite close. "Heboid schizophrenia" (HS), claimed in the late 70s in Russia as a special type of SS is a clear example of intellectual deficiency, cultural confusion and political provocations around clinical-social misunderstanding. Its diagnostic criteria, clinical descriptions and social expression are discussed. Clinical-social analysis of the three most popular personages of soviet underground literature meeting the criteria of three subtypes of HS are presented. It is concluded that the SS-story shows the contradictory drama of clinical-social interference and deficiencies in psychiatric methodology and ontology.

Plenary session

- Towards a psyche for psychiatry

R. Meares

Department of Psychological Medicine, The University of Sydney, Australia

The notion that a disruption of the sense of personal existence is the basis of mental illness is a fundamental one. Nevertheless, it has been neglected in the disciplines of psychiatry, psychology, and even psycho-analysis, for most of the 20th century. This deficiency leaves a vacuum at the heart of these disciplines. A clear idea of what we mean by the sense of personal existence, or self, is necessary in making theoretical formulations, of a more than trivial kind, which might provide a framework for the understanding of various mental illnesses.
This state of "mindless" psychiatry and psychology is a consequence of a major shift in western consciousness which took place just before the First World War.
In this paper, this shift is illustrated by a number of art works. It being assumed that personal expressions in the artistic, philosophical, psychological, scientific, and political spheres are manifestations of more than an individual mind, but also reflect aspects of the communal consciousness.
The second part of the paper outlines the system of self, which was being outlined before The shift, most notably by Hughlings Jackson and William James. The Jacksonian model, which Depends upon the evolution of the prefrontal cortex, resembles modern conceptions, eg. that of Damasio. It is helpful in understanding a large number of mental phenomena. They include dissociation and borderline states.

Plenary session

- Phenomenological-anthropological approach to diagnosis and classification

A. Kraus

Psychiatric Clinic, University of Heidelberg

Modern diagnostic systems in current use such as ICD-10 and DSM-IV rely upon operational criteria and decision-making algorithms, features that have resulted in significant changes for clinical diagnostic practice. With this modern diagnostic approach, new clinical entities have been created while other diagnostic categories have been abandoned. What have been the benefits and drawbacks of this modern approach to diagnosis? Diagnosis has always involved a more comprehensive, holistic consideration of the patient and not just a simple assessment of symptoms. The phenomenological-anthropological approach in psychiatry seeks to make scientifically accessible the intuitive grasping of the patient as a whole being in relationship with the world and others.
The following questions are considered:
1. What characterizes the phenomenological approach to diagnosis and how is this approach distinguished form the symptomatological-criteriological nosological model?
2. Is the notion of illness in psychiatry the same or different as that in other branches of somatic medicine?
3. Are the diagnostic entities in psychiatry to be conceived as real or nominalistic or rather as ideal types or types of essence which can only be understood via a phenomenological approach?

Symposium "Social Psychopathology"

- Melancholia as a desynchronization

T. Fuchs

Psychiatric Clinic, University of Heidelberg

Starting from psychopathological analyses of lived time in melancholia, the paper first examines the continuous processes of synchronization effective in biological as well as social life. These processes enable the individual to compensate for states of shortage, to adapt to changed circumstances, finish with past events and reconnect with the present. Examples of such resynchronizing processes are regeneration, sleeping, dreaming, forgetting, remorse or grief.
Melancholia is then interpreted as the result of a desynchronization, i.a. an uncoupling in the temporal relation of organism and environment, or of individual and society. With the processes of resynchronization failing, the person falls out of common environmental time. This conception allows to draw a parallel between chronobiological and psychosocial results of research. Moreover, it offers the possibility to understand not only the psychopathology but also the triggering of melancholic episodes on the basis of a disturbance of time. The consequences for a "resynchronizing therapy" are demonstrated.

- Philosophical Underpinnings of Empathy

H. Lang

Institute of Psychotherapy and Medical Psychology, University of Wuerzburg, Germany

In empirical therapy research the notion of 'empathy' plays a central role as a basic factor of the therapist's attitude. It has been introduced and emphasized in psychotherapy especially by Carl R. Rogers' client-centered-therapy. Rogers means by it the therapist's capacity to accurately receive the client's emotions and to understand them in their personal significance. By using the concept of 'precise sympathetic understanding', Rogers explicitly refers to existential and dialogical philosophy. There is no doubt that phenomenology, hermeneutics and existential philosophy have provided the essential framework for the concept of empathy. So, for instance, for Husserl the notion of 'empathy' revealed to be important to achieve an understanding of the Other. In the sense of Scheler, Heidegger and Buber's philosophy of encounter the concept of empathy would be misleading if it presupposes the idea of a monadic subject which tries to throw a bridge to another equally monadic subject. These authors argue that the Other is already present by virtue of the fundamental structure of human existence as one's being with others. From that point of view empathy is not considered as an instinctive or merely intuitive capacity, but as a phenomenon which includes man's insertion into an universal community of language (Gadamer) as a necessary prerequisite. A similar position is held by structuralist writers like the ethnologist C. Lévi-Strauss or the psychoanalyst J. Lacan. For the latter, like for Hegel, it is the experience of the Other which constitutes human subjectivity.

- Psychopathology of common sense

G. Stanghellini

U.O. Sperimentale di Psichiatria, Dipartimento di Salute Mentale, Università di Firenze, Florence, Italy

It is well established by psychopathological research that disorders of self experience are among the main features of schizophrenic prodromes in a pathogenetical sense. Disorders of the phenomenal self, as "lack of ipseity" (the vanishing of the feeling of distinctiveness between the self and the outer world) and "hyper-reflexivity" (the monitoring of one's own life entailing the tendency to objectify parts of one's own self in an outer space) are considered key phenomena of schizophrenic vulnerability.
In this paper, I argue that the analyses of the disorders of phenomenal self catch only some dimensions of schizophrenic vulnerability since they mainly focus on the pathological changes in subjective experience of an isolated self and disregard the fact that the self is not purely personal. Because our existence is fundamentally tied to a social existence, the feeling of one's own self and the sense of "reality" of an experience are products of intersubjectivity, and not only a private process based on introspection or reflexivity in which one is engaged in an idiosyncratic way.
I assume that the breakdown of the social self, that is the crisis of the optimal relatedness to common sense, is one of the main roots of the schizophrenic's vulnerable condition. In the central part of the paper, I develop a definition of 'common sense' useful for psychopathological research. I contrast the view held by phenomenological psychopathology to the view of cognitive psychology. The latter represents the crisis of common sense as the consequence of the lack of "social knowledge" (a data-base of constructs to typify one's self and external reality), the former conceptualises it as lack of "intuitive attunement" (the affective-conative capacity to be connected with the others and to get involved in their life). Building on, and extending, contributions of the phenomenological tradition, I attempt to demonstrate that intuitive attunement is the basic pre-requisite for establishing one's sense of "reality" (feeling familiarly related to one's environment) and for establishing one's sense of "ipseity" (the sense of existing as a subject of awareness). In the last part of the paper I show the importance of the concepts 'lack of attunement' and 'antagonomia' (the rejection of conventional knowledge and intuitive attunement, experienced as dangerous sources of loss of individuality) in order to establish a comprehensive theory of schizophrenic vulnerability. I finally discuss the implications of this view for empirical research and clinical management of schizophrenic vulnerability.

- Rationality and Consciousness from a Process Perspective

M. Weber

Centre de Logique, Université Catholique de Louvain

The purpose of this paper is to exemplify the usefulness of the dialogue between the psychological sciences and speculative philosophy. Although it argues from a broad phenomenological perspective, its technicalities belong to the field of process thought, as carved by the later Alfred North Whitehead (1861-1947). It proceeds in two main epochs.
First, it sketches the various semantic layers embedded in the concept of everyday (or " normal ") consciousness and contextualizes their interanimation. Two complementary conceptual waves are respectively hierarchized : on the one hand, " awareness ", " self-awareness ", and " self-consciousness " ; and, on the other, " intuitive awareness ", " global awareness ", and " social consciousness ".
Second, focusing on the strict correlation existing between " normal " consciousness and " normal " rationality, it proposes an analysis of the usefulness of reason in the clinical context.
The conclusive moment specifies the necessity of using an " altered rationality " for the treatment of " altered states of consciousness ".

- Subject and Identity: Suggestions from psychiatric Practice

R. Dalle Luche

Servizio Psichiatrico Diagnosi e Cura ASL 1 MASSA CARRARA

The modifications of the sense of Self (self awareness, self experience) are ubiquitarious in the different psychotic conditions: in early phases of schizophrenic and schizophreniform disorders they reveal themselves as feelings of estraneity of psychic acts and functions, dissociation in an observing and observed ego, loss of personal identity, and in an increasing introversion and a compensatory iperryflexivity (depersonalization states); in full blown psychotic conditions, acute or chronic, the impairment of reflexivity and insight sustains delusional misidentifications of Self or a complete loss of a true I, which becomes a mere grammatical figure (depersonation states). In depressive disorders depersonalization concerns affective and volitional aspects of I (feeling of having no feelings, inconsistency of projects and achievements); in manic states the lack of reflexivity is pointed out by impulsivity and diminished self-control.
Viewing these clinical disorders from a subjective perspective allows to elicit relevant issues about the construction of the sense of identity (of having an I) which should to be taken into account in the up to date debate on the philosophy of mind.

Key Words: Self experience, I, Myself, Ipseity, Identity, Psychosis, Depersonalization, Depersonation

Symposium "Critical Psychiatry"

- Strategies for living with mental distress... user-led research in practice

A. Faulkner, V. Nicholls

The Mental Health Foundation

The 'strategies for living' project is a user-led programme of research, training and dissemination, focusing on:
. documenting and disseminating people's strategies for living with mental distress, through research, publications, newsletters and networks
. encouraging and promoting user-led research in mental health, enabling service users to set the research agenda and to carry out their own research.

The project has been going for three years now, and our own research is completed and reported in: 'Strategies for Living: a report of user-led research into people's strategies for living with mental distress'. We have also been supporting six service users/user groups to conduct research in their own local areas, through providing training and support as well as small grants for costs and materials. Throughout this process, we have endeavoured to ensure that our research is user or survivor-led, and have given considerable thought to what this means to us in practice, and to the ethics of user-led research. Our session would address the following issues:

. Why conduct user-led research? including such issues as: having the power to ask the questions, asking different questions?, independence, defining outcomes, person-centred, taking a wider view of mental distress and mental health treatments
. What is user-led research? including: defining the project, having control over funding, developing research skills, professional research allies, on-going support, dissemination, informing participants about process and results, including marginalised groups
. Some of the lessons we've learnt, e.g. what it means to be a service user/researcher (boundary and identity issues), support and supervision, taking time, how to respond to needs identified in the course of research.

The presentation would address these issues from the perspective of the Strategies for Living project research, as well as the research we have supported.

Symposium "Philosophy of psychotherapy in Russia"

- Philosophy of psychotherapy in Russia: Introduction

F. Vasilyuk

Moscow Institute of Psychology and Pedagogy, Moscow, Russia

Retaining great variety of schools in psychotherapy reflects its immature stage of development. The natural base of psychotherapy is the philosophic anthropology and the theory of personality. The legal development of those themes in the Soviet Union had not been possible for a long time. The theory of psychotherapy had been substituted by the naturalistic mythology of quasi-Pavlov physiology and practice had been limited by authoritarian hypnosis and suggestion. The leading psychiatric school of the country had rejected psychotherapy.
The proposed symposium presents a number of philosophic problems of psychotherapy based on the Russian material: hopes of Russian psychotherapy (synergetic psychotherapy based on Eastern-Orthodox anthropology), interaction of psychotherapist and clergyman in one or different persons and special importance of this problematic in gerontopsychiatry, image of therapy and philosophy of Martin Heidegger, implementation of ethnofunctional and psychoanalytical approach. The participants of symposium are the heads of big psychotherapeutic centers of different orientation, which will ensure wide range coverage of the theme and active discussion.

- Toward the synergetic psychotherapy: a history of hopes

F.E. Vasilyuk, Ph.D., O.V. Filippovskaya, Ph.D.

Moscow Institute of Psychology and Pedagogy, Moscow, Russia

A doctor puts his hopes ultimately not in drugs themselves, but rather in the response of a patient's body to them. A teacher does not believe that his explanations alone will create knowledge in a student's head, but hopes for a responsive process of understanding. In what do professional psychotherapists put their hopes? That is, what is the productive process which will ultimately be responsible for the psychotherapeutic effect?
In the pre-Freudian period, the primary method of psychotherapy was hypnosis. It was assumed that the doctor knew better about what the patient should do, think, and feel, and that the success of the treatment depended on whether the patient could put his trust in the doctor and be adequately suggestible. The mechanism of trust-suggestibility was responsible for the results of the therapy.
In psychoanalysis the main hope is the healing power of awareness which frees the person from the dictatorship of blind unconscious forces. On the philosophical level, this hope can be understood as the freedom of consciousness. Initially discovered through psychoanalysis, the new psychotherapy eventually produced systems quite unlike psychoanalysis, in which freedom of will becomes the hope of psychotherapists. (An example is the status given to the phenomenon of spontaneity in psychodrama)
In the post-war psychotherapy, there came another radical shift of psychotherapeutic hopes - a shift to the processes of the patient's experiencing.
Synergetic psychotherapy, based on Eastern-Orthodox anthropology, makes prayer the basis of the whole therapeutic process. Prayer is understood to be an internal activity which can exist in both manifest and latent form. It can be cultivated or suppressed but remains irreplaceable, immanent to the human existence. Prayer does not eliminate but, on the contrary, fulfills the past's (newly transformed) psychotherapeutic hopes: the fullness of trust, the depth of awareness, the spontaneity of action, and the authenticity of experiencing.

- Gerontopsychiatry. Meaning of life as psychotherapeutic problem

N. Voskresenskaya, M.D.

Independent Psychiatric Association of Russia, Scientific Center for Mental Health of the Academy of Medical Science of the RF

Advanced age - the time for summing up, the time for suffering, illnesses and losses. Only the system of spiritual values can oppose growing failing of body and spirit. However, character's changes, depressions and failing of memory and intellect hamper this work.
Hence it is especially important to correlate the continuity of spiritual values, which embody the meaning of life (personal wellbeing and health - family life - feasible social activity - values common to all mankind - religion faith), with emotional image of a patient, with features of his character such as epileptoid authority, oriented to oneself, and hypochondria and iatrophilia, oriented outside, and hyper-sociality; the unique character of accumulated experience of life and egocentric position of a hysterical personality; the idea of bearing Cross and love of God for asthenic and depressive patients; immortality of spirit for some schizoids and so on.

- Clergyman and psychotherapist or clergyman-psychotherapist?

B. Voskressensky, M.D.

Independent Psychiatric Association of Russia, Russian State Medical University

Clergyman and psychiatrist is different even if two specialists are combines in one person. Clergyman deals with spiritual matters (proceeding from trichotomy spirit - soul - body), saves the soul of a sinful layman. Doctor-psychiatrist treats patient (here we mean the faithful patient) and mental disorders. That is why there is no ground to talk of orthodox, catholic or protestant psychiatry.
Meanwhile the border between spiritual and emotional is mobile. This is especially evident in psychotherapy, where a doctor has to take into account a system of values of a patient. This can be done with the greatest success having the experience of own religions church life. The modern principle of partnership doctor-patient and ancient image of wounded Aesculapius find in this substantial expression. Should a specialist-psychotherapist be a layman or a clergyman is decided individually.

- Ethnofunctional approach in preventing drug dependence

M.S. Radionova, Ph.D.

Moscow City Center for the Prevention of Drug Dependence, Moscow, Russia

Not only are drugs ruinous to the brain, but they render the dependent culturally disadapted. Drug dependents are distinguished by emotional immaturity, alexitymia, diffuse identity, and ethnofunctional discordances. Preventive measures must be taken beginning in infancy. The normal development of a child replicates the philogeny of a respective culture, including the mythological, religious-ethical, and technotronic-scientic stages. When this succession is upset violently, ethnofunctional disontogenesis ensue. The child suffers emotional shock due to failure of the ethnocultural filter. Such children are computer-literate, but are not familiar with fairy tales, which play a harmonizing psychotherapeutical role (B. Bettelheim, 1980): fairy tales are replaced by surrogates in the form of television soap operas and Barbie dolls.
Ethnofunctional approach was used to design and conduct a psychological class for children four to five years old. Prior to the beginning of the classes, toys that were out of tune with the children's natural birth milieu and domicile, technotronic toys, and television, were withdrawn.
The classes had a natural-mythological orientation and involved behavioral, intellectual, and emotional processing of the mythological attitude toward the four elements - water, air, earth, and fire - and then toward respective Orthodox Christian entities (Earth - Holy Virgin, Water - Holy Paraskeva). Data acquired in the reference and experimental groups were studied using the Rohrschach and Lucher tests and observations of the teachers and psychologists. Considered were the agitation and neurotization parameters and other patopsychological disturbances.
During 30-day studies, in terms of these parameters the condition of children in the reference group aggravated steadily, whereas in the test group their condition improved or remained at the same level while their mental outlook and interest in nature broadened, and their contacts with the teachers, parents, and with each other improved.

- The therapeutical model in the structure of the philosophy of M. Heidegger

A. Sosland, Ph.D.

Independent Psychiatric Association of Russia

1. There is a hidden medical model According to L. Wittgenstein: Philosopher treats a question like a physician - an illness.
2. Diverse schools in psychotherapy often appear "at the tail" of the urgent philosophical discourses. So the philosophy of F. Nietzsche influenced the development of psychoanalysis and A. Adler's individual psychology. Gestalt-therapy is based on the holistic philosophy of J. Smuts and partially on the phenomenology of E. Husserl.
The influence of M. Heidegger's book "Being and Time" on various areas of today's scientific knowledge is well known. The fundamental ontology of M. Heidegger has influenced the development of psychotherapy very strongly. Daseinsanalysis was created as the ideology and as the psychotherapeutic school institution under direct supervision of M. Heidegger.
4. The philosophy of M.Heidegger is "suitable" for the psychotherapeutic discourse, because the fundamental ontology of M. Heidegger contains the latent "medical" structure. Such concepts as "Verfallendes Dasein", Angst, "das Gewissen als Ruf der Sorge" and so on describe the certain fundamental ontological pathology and simultaneously in this capacity online a therapeutic strategy.

- Myth in neurotic love

A. Bondarenko, Ph.D.

Kiev State Linguistic University, Chair of Psychology

Love is a complex personal relationship, whose value seems to be considered essential in the cross-cultural context. At the same time love is a special concept, which belongs to the so-called non-distinctive concepts, i.e. it may have an indefinite number of definitions. Neurotic or traumatic love with a certain obsessive or addictive tendency to suffer from the non-satisfied need of being needed is also a complex experience with its own phenomenology and myth. In a well-known Sternber`s triangle theory (1986) love has three main components: passion, intimacy and commitment. In case of neurotic love the configuration of this symbolic figure is being deformated and a personal myth, a behavior pattern, an intrusive symbol or fixated image of the beloved object form the center of gravity which supports the neurotic fixation. Our controlled studies show that in descriptions of the personal myths, done by victimized with the traumatic love subjects some principal symbolic incarnations of the beloved figure are reproduced. These are the images of the animals (i.e. a cat, a dog); the archetypal images of Artist, Poet, Hero etc. which are attached to core predications "I am afraid (to lose him/her)", "I am suffering without him/her", "I am living for him(her)". These self-programming core predications together with emotionally, sensorically or visually feedbacked memories are fused into indivisible syncretic cognitions which structure drives and behavior in a certain dysfunctional style. In its turn this dysfunctional style is self-presented as a meaningful myth of "Great Love", "Eternal Love", "Tragic Love" etc. So the viceous circle is formed. Females are inclined to experience traumatic love much more than males.
Psychotherapeutic technique to deal with this personal mythology is offered (on a videotape).

Seminar "Ethics in psychiatry: the social context"

- The importance of the concept of relational agency in psychiatric care

M. Verkerk

Faculty of Philosophy, Erasmus University Rotterdam

The principle of respect for autonomy of persons in terms of respect for the right of self-determination has been the dominant value in caring relationships and has been expressed in several medical laws for the last fifteen years in the Netherlands. The Law on Contract of Medical Treatment (WGBO) in 1995 and the Law on Special Admission of Psychiatric Hospitals (Wet bopz) in 1994 are two important examples of such medical law. The WGBO defines patients rights in professional health-care situations, such as the right of informed consent and the right to refuse medical treatment. The Wet bopz defines the legal position of the psychiatric patient who faces possible coercive institutionalisation. In contrast to the past, coercive institutionalisation and coercive treatment is no longer justified for paternalistic reasons. The right of self-determination overrules considerations of protecting the well-being of patients. Coercive interventions are legally and morally justified, only in cases of severe risk or danger to society and patient. Nowadays a discussion has been started about the dominance of the right of self-determination, particularly in the context of psychiatric health care. It seems that current care practices cannot answer sufficiently to the needs of patients, precisely because of the dominant value of non-interference and self-determination. Sometimes, patients are left to themselves in respect for these values, whereas at the same time they do need help for flourishing and viable relationships. For this reason, 'self-binding' contracts or 'compassionate interference' are introduced as forms of good psychiatric care. For the justification of these forms of good care , other justifying reasons than the right of self-determination and autonomy as non-interference are put forward. Values such as trust and commitment are also important values in good caring. In this paper I want to develop a more relational model of agency, in which interventions in care can be shown to be in the interest of patients, that is, they can be seen as interventions for attaining relational autonomy, instead of threatening autonomy and in which values such as trust and connectedness do get a place in caring relationships..

- The interpersonal mind and the ownership of feeling

A.J. Korner

Department of Psychological Medicine, University of Sydney at Nepean Hospital, Australia

Heidegger's conception of being a "person-in-the-world" and of being "thrown into" a complex environment are taken as a starting point for a model of mind that is irreducibly interpersonal in nature. Mind cannot be separated from environment and therefore cannot be equated to brain, which can be conceived of as separate from environment. Nor, however, can mind be separated from brain.

Psychoanalytic and psychological literature have problems in trying to formulate biological understanding of psychological processes when focus is maintained on internal mechanisms. Although it is possible to talk in terms of "having a mind of one's own", this statement includes an irreducible environmental component. In contrast, feelings arise within the individual person. Feelings, a product of the interaction of the person-in-the-world, are more truly identifiable as existing only within individuals.

It is therefore proposed that a rational approach to the study of the biology of psychological processes would be advanced by considering the bodily / mental feelings that arise out of interactions with the environment as a "basic" unit for examination in research. Of particular importance in this regard will be the feelings that arise out of interpersonal interaction.

- The phenomenological approach to social competence: a critique of the normative model of social dysfunction in schizophrenia

M. Ballerini, G. Stanghellini

In the DSM-IV, the concept of social dysfunction is a fundamental diagnostic feature of schizophrenia. Social dysfunction in schizophrenia has been considered the consequence of the disease process (i.e. defict state, as in the classical kraepelinian model), social stigma (chronicity as a social artifact) or a specific domain of psychopathology (e.g. in the model of J.S. Strauss) .
Disability model considers social dysfunction a multi-factorial epiphenomenon of the disease process - social dysfunction is viewed as an impairment of role-taking functions. Social adjustment is considered the ability to perform social roles as it is expected by others. Social roles are considered the interface between individuals and social expectancies. This approach, whose background is Parsons's structural-functionalism, is labeled as the normative model: social behaviour must be guided by acquisition and fulfillment of the roles and the rules taken for granted in one's social environment.
The phenomenological approach assumes that the dysfunction of social relationships is the core feature of schizophrenia and holds that the vulnerability to schizophrenic is a disorder of inter-subjectivity. Social competence, i.e. the ability to constitute intersubjectivity, is not just a consequence of one's knowledge of social rules and one's ability to perform social skills, but of the capacity to attune with common sense, i.e. the meaning attribution practices of one's social environment (e.g. the account-practices as in model of Garfinkel)

- Ethics for psychiatrists derived from virtue theory

A. Fraser

Waitemata Mental Health Services and Department of Psychiatry, School of Medicine, Auckland, New Zealand

Traditional medical ethics were based on professional characteristics and ideals. Trends in philosophical thought have moved from Aristotelian conceptions towards a debate between Kantianism and utilitarianism. The growth of consumerism in the later part of the twentieth century reinforced the rejection of professional elitism, and a growth in universalist principles in the codes of ethics for professionals, often at the expense of the specifics. The author contends that this ignores the value which comes from the recognition that being a professional involves having a certain identity or character; being a person of a particular sort.
Psychiatrists must meet challenges to what they do and how they do it from within the medical profession, from other professions and from the public at large. Specific mental health legislation sets psychiatry apart from the rest of medicine, and exposes patients and staff to intense scrutiny. Mental health legislation contains a tension between legally requiring reluctant patients to accept treatment in their best interests and treatment or detention for the benefit of others. As a result, psychiatrists are often subject to criticism, inquiry and sanction. Rule based codes of ethics promote sanction while seemingly providing little help in prevention of unethical behaviour.
This paper presents an argument for virtue theory as the basis of a code of ethics which will assist in preventing unethical behaviour. Such a code would recognise and promote the professional character of the psychiatrist within the unique nature of the doctor patient relationship in psychiatry, including the impact on that relationship of the psychiatrist's wider obligations to family and society. Adoption of such a code would have implications for acceptance into training.

- Re-assessment of social cohesion in a situation of exogenous threat

P. Mannoni, C. Bonardi

A number of daily life situations are characterized by the presence of danger, in the more or less direct and imaginative environment of subject people. This danger can be substantialized in different ways : it can appear as of comparatively little account with a relatively moderate intensity but it can also take the shape of dangerous exogenous factors bearing a high degree of emotional stress. In the first case, subjects people usually resort to run away or to install defensive means, which corresponds to an adpatative, in most cases satisfactory strategy (classic fight or flight).
But the second case gives matter to a new scientific investigation. as a matter of fact people faced with a situation of induced threat may become in a critical condition, more especially as the possible answers are made questionable due to the nature itself of the stressors and/or of their strengh, so that they overthrow the normal adaptative ability of said subject people. We could establish that a socio-cognitive disorganization of their performance was induced, and that subject people were forced, socially speaking, to fix choices in circumstances of group facing dangerous situations. It is noticed that the commonly admitted definition of moral rules is beeing called into question by those choices and that a self centered attitude is preferred to a solidarity ruled behaviour, resulting in severe disruptions in social integration, thus showing its frailty, and in a general disorganization of social cohesion, torn by those individualistic behaviours, bringing u^p again, in fine, the problem of the real nature of social cohesion. considering the significance of this matter we have been led to work out for five years a number of experimental situations liable to investigate a new paradigm of social psychapathology, threat situations and the various adjustment strategies, in terms of coping, developped by individuals people tanken up with such situations. A number of results were obtained (and communicated) in this area.

Seminar "Empirical methods and psychiatric ethics"

- What have you been told about the disease? Information about illness among dementia patients

M. Marzanski MD, M. Phil, MA, MRCPsych

Coventry Health Care NHS Trust

30 patients with dementia had been asked what they thought was wrong with them, what they were told about the disease and by whom, and what they wished to know about their illness. Analysis of their answers has shown that the quality of received information was poor and many patients had no opportunity to discuss their illness with anybody. Despite that almost half of the participants in the study had adequate insight and majority declared that they would like to know more about their predicaments. The results have been discussed in the context of current psychiatric practice in the UK and views of patients' relatives on telling dementia sufferers their diagnosis. Ambivalent attitudes among clinicians and carers seem to reflect different values in medical practice and various beliefs regarding dementia itself.

- Structured interview for competency and incompetency assessment testing and ranking inventory (SICIATRI): inter-rater agreement, factor structure, and ethics of informed consent

T. Kitamura, F. Kitamura, H. Higuchi, A. Tomoda, N. Kijima, M. Kato, M. Mimura, K. Matsubara, T. Hayakawa, H. Koishikawa, K. Tsukada

Department of Sociocultural Environmental Research, National Institute of Mental Health, Japan

Patients' right to autonomous decision-making can be embodied only when their competency is measured with a reliable and valid instrument. The Structured Interview for Competency and Incompetency Assessment Testing and Ranking Inventory (SICIATRI) is a product of such an effort of ours. The SICIATRI is a semi-structured interview guide applicable to many clinical situations. Using the SICIATRI for 103 newly admitted inpatients (23 medical and 80 psychiatric), we confirmed the inter-rater agreement of the interview items. A factor analysis of the SICIATRI yielded three factors interpretable as reflecting "insight and evidencing a choice", "awareness of legal rights", and "understanding of treatment". The score for these three SICIATRI subscales were differentially linked to patients' diagnosis, legal status, demographic features, and disclosure of medical and legal information by the attending physician. Information disclosed by the attending physician prior to the SICIATRI interview was crucial for patients with schizophrenia. Thus, in a two-way analysis of variance, they performed more poorly for "insight and evidencing a choice" when they were not informed of the fact that they had a right to decide and when they were not asked to decide, in comparison with patients with other diagnoses. Ethical issues will be discussed in terms of the use of competency testing prior to informed consent.

- The Ethical, Legal and Social Problems Arising from Changes in Psychiatric Classification as a Result of the New Technologies in Brain Research

J.M. Vile, K.W.M. Fulford, M.D. Beer

Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, Kent, UK

In this report we integrate the techniques of history, philosophy and sociology to examine the ethical, legal and social consequences of the changes in psychiatric classification which are likely to result from developments in brain imaging, genetics and psychopharmacology (collectively the "New Technologies" in brain research).
1) We made a brief historical survey of systems of classification in psychiatry from the Ancient Greeks to the present day. From this we suggest that different systems of classification of mental disorders can usefully be viewed as varying along three axes, i) symptom-aetiology ii) psychological-organic iii) treatment-control.
2) We then used philosophical techniques to analyse how the results of the New Technologies will result in changes along each of these axes i) towards aetiologically based classification systems, ii) towards organic models of mental functioning and disorder and iii) towards the view that psychiatry has a social control role.
3) It is these changes in turn which will generate ethical, social and legal consequences.
We discuss the social and ethical consequences in relation to:
. Personality disorders - there will be a blurring of the boundary with mental illness
. The scope and appropriate boundaries of psychiatry - severity may be an appropriate basis for determining the remit of psychiatry
. Screening for psychiatric disorders - will require classification systems easily understood by the public
. Stigma - the effects of different classifications on stigma requires research
. Addictive behaviours - the New Technologies will encourage the 'medical model' of addictive behaviours
We discuss the legal consequences in relation to:
. Legal responsibility - there will be pressure to use results of the New Technologies to determine legal responsibility
. Involuntary treatment - there will be increasing pressure to 'treat' socially undesirable states against the person's will
We make thirteen specific recommendations aimed at investigating these developments clarifying their effects, and ensuring that any necessary regulation is put in place.

- Interpersonal processes - a new anthropology

R. McClelland

School of Medicine, Queen's University, Belfast

'We are fascinated by all forms of rivalry, by so-called love, by fighting, by violence, by chaos. These are all aspects of the mimesis of desire which is all around us and in us.' [1].
This paper introduces a new anthropology developed by Roel Kaptein and Rene Girand [2] and examines its relevance for mental health. It considers a paradigm shift from the usual emphasis on the centrality of personal autonomy. For the new anthropology relationships are fundamental for well being and indeed for existence. For all living forms existence is only possible when we have a place. For the rest of the animal kingdom dominance patterns provided that place. For emerging human kind because of the strength of rivalry the dominance pattern failed. Culture with its scapegoat mechanism, its rituals, rites and prohibitions, provided a solution. The solution was never perfect and again it failed. The winner in the rivalries got their place. The losers eventually fall ill. In the mimetic model, all therapy has the task to bring the loser out of her/his position, out of the results of rivalry which made them ill.

[1] 1 Kaptien R. Freedom in Relationships. Queen's University , Belfast. 1993.
[2] 2 Girand R. Things hidden since the foundation of the world. Athlone Press, London, 1987.

1Which is not to claim that we need or are able to abandon our so called moral sentiments.
2'Responisbility' is understood in terms of the so called normative competence view of responsibility as it is endorsed by, for instance,Wallace, R. J. (1994). Responsibility and the Moral Sentiments. Harvard University Press. and Wolf, S. (1990). Freedom within Reason. New York: Oxford University Press.
*Who believe that the urge to justify our practices of responsibility is completely out of place because we cannot abandon them.
#Who believe our practices of responsibility are justified because freedom and/or responsbility is compatible with determinism.