Too similar, too different? The paradoxical dualism of psychiatric stigma

Challenges to psychiatric stigma fall between a rock and a hard place. Decreasing one prejudice may inadvertently increase another. Emphasising similarities between mental illness and ‘ordinary’ experience to escape the fear-related prejudices associated with the imagined ‘otherness’ of persons with mental illness risks conclusions that mental illness indicates moral weakness and the loss of any benefits of a medical model. An emphasis on illness and difference from normal experience risks a response of fear of the alien. Thus, a ‘likeness-based’ and ‘unlikeness-based’ conception of psychiatric stigma can lead to prejudices stemming from paradoxically opposing assumptions about mental illness. This may create a troubling impasse for anti-stigma campaigns

“Shock tactics”, ethics, and fear. An academic and personal perspective on the case against ECT.

Despite extensive evidence for its effectiveness, ECT remains the subject of fierce opposition from those contesting its benefits and claiming extreme harms. Alongside some reflections on my experiences of this treatment, I examine the case against ECT, and find that it appears to rest primarily on unsubstantiated claims about major ethical violations, rather than clinical factors such as effectiveness and risk

Manic Temporality

Time-consciousness has long been a focus of research in phenomenology and phenomenological psychology. We advance and extend this tradition of research by focusing on the character of temporal experience under conditions of mania. Symptom scales and diagnostic criteria for mania are peppered with temporally inflected language: increased rate of speech, racing thoughts, flight of ideas, hyperactivity. But what is the underlying structure of temporal experience in manic episodes? We tackle this question using a strategically hybrid approach. We recover and reconstruct three hypotheses regarding manic temporality that were advanced and modelled by two pioneers of clinical phenomenology: Eugène Minkowski (1885-1972) and Ludwig Binswanger (1881-1966). We then test, critique, and refine these hypotheses using heterophenomenological methods in an interview-based study of persons with a history of bipolar and a current diagnosis of acute mania. Our conclusions support a central hypothesis due to Minkowski and Binswanger, viz., that disturbance in the formal structure of temporal experience is a core feature of mania. We argue that a suitably refined variant of Binswanger’s model of disturbance in manic protention helps to explain a striking pattern of impaired insight and impaired reasoning in manic episodes

Self-binding directives in psychiatric practice: a systematic review of reasons

Self-binding directives (SBDs) are an ethically controversial type of advance decision making involving advance requests for involuntary treatment. This study systematically reviewed the academic literature on psychiatric SBDs to elucidate reasons for and against their use in psychiatric practice. Full-text articles were thematically analysed within the international, interdisciplinary authorship team to produce a hierarchy of reasons. We found 50 eligible articles. Reasons for SBD use were promoting service user autonomy, promoting wellbeing and reducing harm, improving relationships, justifying coercion, stakeholder support, and reducing coercion. Reasons against SBD use were diminishing service user autonomy, unmanageable implementation problems, difficulties with assessing mental capacity, challenging personal identity, legislative issues, and causing harm. A secondary finding was a clarified concept of capacity-sensitive SBDs. Future pilot implementation projects that operationalise the clarified definition of capacity-sensitive SBDs with safeguards around informed consent, capacity assessment, support for drafting, and independent review are required

Misevaluating the Future: Affective Disorder and Decision-Making Capacity for Treatment-A Temporal Understanding

Background: Within psychiatric practice and policy there is considerable controversy surrounding the nature and assessment of impairments of decision-making capacity (DMC) for treatment in persons diagnosed with affective disorders. We identify the problems of "cognitive bias" and "outcome bias" in assessment of DMC for treatment in affective disorder and aim to help resolve these problems with an analysis of how time is experienced in depression and mania. Sampling and Methods: We conducted purposeful sampling and a qualitative phenomenological analysis of interview data on patients with depression and mania, exploring temporal experience and decision-making regarding treatment. Results: In both severe depression and mania there is a distinctive experience of the future. Two consequences can follow: a loss of evaluative differentiation concerning future outcomes and, relatedly, inductive failure. This temporal inability can compromise an individual's ability to appreciate or "use or weigh" treatment information. Conclusions: The decision-making abilities required for self-determination involve an ability to evaluate alternative future outcomes. Our results show that, within severe depression or mania, anticipation of future outcomes is inflexibly fixed at one end of the value spectrum. We therefore propose a temporal model of decision-making abilities, which could be used to improve assessment of DMC in affective disorder