As professional voice users, teachers are particularly at risk of abusing their voices and developing voice disorders during their career. In spite of this, attention paid to voice care in the initial training and further professional development of teachers is unevenly spread and insufficient. This article describes a questionnaire survey of 171 trainee teachers at the end of their Postgraduate Certificate in Education year that included the Voice Handicap Index . The survey aimed to identify the (...) prevalence and types of voice problems experienced by students during their teaching practice and to relate these to previous history and to the area of the curriculum they were teaching. The analysis suggests that over a third of trainees suffer from voice difficulties on teaching practice and that one student in 12 was classified as having a moderate handicap as defined by the VHI. Trends of symptoms particular to individual curricular areas appear to be a fruitful area for further study. (shrink)

Hearing Voices and Other Unusual Experiences examines the long-recognized and striking similarities between features of mental disorders and features of religions. Robert McCauley and George Graham emphasize underlying cognitive continuities between familiar features of religiosity, of mental disorders, and of everyday thinking and action. They contend that much religious thought and behavior can be explained in terms of the cultural activation of humans' natural cognitive systems, which address matters that are essential to human survival: hazard precautions, agency detection, language processing, (...) and theory of mind. Those systems produce responses to cultural stimuli that may mimic features of cognition and conduct associated with mental disorders, but are sometimes coded as "religious" depending on the context. Their approach promises to shed light on both mental abnormalities and religiosity. (shrink)

A Notional Level of Cognitive Distortions in Depression: Does It Exist? A Voice for Interdisciplinarity in Studying Cognitive Functioning of Individuals with Depressive Disorders This aritcle raises the problem of cognitive depressive distortions observed at the notional level. It relates to recent neuropsychological, psychological, and linguistic studies, taking an interdisciplinary theoretical perspective, and illustrating the advantages of interdisciplinarity in modern psycholinguistic projects. It shows that, generally, the notional level has been neglected in psychopathological and psychological research on depressive functioning. (...) The problem is described with reference to linguistic and psycholinguistic theories linking language with cognition. Particular emphasis is devoted to theories and methods of metaphorical processing analysis which, taking into account the similarities between cognitive functions engaged in understanding metaphors, and those disordered as a result of depression, seem to be an adequate frame to study the problem. The text ends with a proposal of an interdisciplinary research project dedicated to the study of metaphorical conceptualizations of some notions created by people suffering from depression. (shrink)

This study compares 20 subjects, in each of three different settings, with serious psychotic disorder who hear voices, and compares their voice-hearing experience. We find that while there is much that is similar, there are notable differences in the kinds of voices that people seem to experience. In a California sample, people were more likely to describe their voices as intrusive unreal thoughts; in the South Indian sample, they were more likely to describe them as providing useful guidance; (...) and in our West African sample, they were more likely to describe them as morally good and causally powerful. What we think we may be observing is that people who fall ill with serious psychotic disorder pay selective attention to a constant stream of many different auditory and quasi-auditory events because of different “cultural invitations”—variations in ways of thinking about minds, persons, spirits and so forth. Such a process is consistent with processes described in the cognitive psychology and psychiatric anthropology literature, but not yet described or understood with respect to cultural variations in auditory hallucinations. We call this process “social kindling.”. (shrink)

Humans' voice offers the widest variety of motor phenomena of any human activity. However, its clinical evaluation in people with movement disorders such as Parkinson's disease lags behind current knowledge on advanced analytical automatic speech processing methodology. Here, we use deep learning-based speech processing to differentially analyze voice recordings in 14 people with PD before and after dopaminergic medication using personalized Convolutional Recurrent Neural Networks and Phone Attribute Codebooks. p-CRNN yields an accuracy of 82.35% in the binary classification (...) of ON and OFF motor states at a sensitivity/specificity of 0.86/0.78. The PAC-based approach's accuracy was slightly lower with 73.08% at a sensitivity/specificity of 0.69/0.77, but this method offers easier interpretation and understanding of the computational biomarkers. Both p-CRNN and PAC provide a differentiated view and novel insights into the distinctive components of the speech of persons with PD. Both methods detect voice qualities that are amenable to dopaminergic treatment, including active phonetic and prosodic features. Our findings may pave the way for quantitative measurements of speech in persons with PD. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Eating Disorders and Mimetic Desire René Girard Stanford University Among younger women, eating disorders are reaching epidemic proportions. The most widespread and spectacular at this moment is the most recently identified, the so-called bulimia nervosa, characterized by binge eating followed by "purging," sometimes through laxatives or diuretics, more often through self-induced vomiting. Some researchers claim that, in American colleges, at least one third of the female student population is (...) involved to some degree. (Since nine out of ten sufferers are women I will use feminine pronouns in this paper but some undergraduates at Stanford tell me that the epidemic is spreading to male students.) G.M.F. Russell, the first researcher who focused on the specific aspects ofmodern bulimia, is usually presented as the discoverer of a new illness. The title ofhis 1979 publication contradicts this view: "Bulimia Nervosa: An Ominous Variant ofAnorexiaNervosa." And, indeed, all the symptoms he describes had been mentioned before in connection with anorexia (see Bruch). The insurance companies and the medical profession like only welldefined illnesses, and so does the public. We all try to distance ourselves from pathological contamination by giving it a name. Eating disorders are often discussed as ifthey were new varieties ofmeasles or oftyphoid fever. Why distrust the distinction between two illnesses with symptoms as radically opposed as those of anorexia and bulimia? Because we live in a world where eating too much and not eating enough are opposite but inseparable ways ofcoping with the slenderness imperative that dominates 2 René Girard our collective imaginations. Most of us oscillate all our lives between attenuated forms ofthese two pathologies. The man in the street understands perfectly a truth that most specialists prefer not to confront. Our eating disorders are caused by our compulsive desire to lose weight. Most books on the subject acknowledge the universal calorie phobia but somewhat absent-mindedly, as if it could not be the major cause ofa serious illness. How could a fundamentally healthy desire become the cause ofpathological behavior, even ofdeath? Many people would be healthier, no doubt, ifthey ate less. In view of this fact, it is not illogical to suppose that, in anorexia, there must be some motivation other than this healthy desire, some unconscious drive, no doubt, that generates abnormal behavior. By turning anorexia and bulimia into two separate pathologies, the classificators make it easier for us to lose sight of their common basis. The bankruptcy of modern theories The search for hidden motivations is the alpha and omega, ofcourse, of our modern culture. Our number one principle is that no human phenomenon is really what it seems to be. A satisfactory interpretation must rely on one of the hermeneutics of suspicion that have become popular in the nineteenth and twentieth century, or on several ofthese, on a cocktail of soupçon: psychoanalysis, Marxism, feminism, etc. We automatically assume that social phenomena have little if anything to do with what is obvious in them, in this case the rejection offood. In anorexia, psychoanalysts usually diagnose "a refusal of normal sexuality," due to the patient's excessive desire "to please her father," etc. These explanations are still invoked in books being written right now but the voice is growing fainter. Around this sort of thing the smell of mustiness is overpowering. Even in Lacan's own land, the old arrogance is gone. Early in my life, I had an opportunity to observe that the eating practices ofyoung women have nothing to do with a desire to please their fathers. Just before World War II, a pretty cousin of mine was dieting furiously and her father, my uncle, was storming about helplessly, trying to get her to eat more. Fathers, as a rule, are not pleased to see their daughters starve themselves. This particular father was also a physician, at a time when the medical profession had not yet caught the disease it was already trying to cure. Eating Disorders andMimetic Desire3 This uncle was our family doctor and, as such, had great prestige in my eyes, at least until that day. I had not yet read Freud but my later skepticism regarding his conception offatherhood may well originate in this incident. I immediately... (shrink)

Patients with psychotic disorders experience a range of reality distortions. These often include auditory-verbal hallucinations, and thought insertion to a lesser degree; however, their mechanisms and relationships between each other remain largely elusive. Here we attempt to establish a integrative model drawing from the phenomenology of both AVHs and TI and argue that they in fact can be seen as ‘spectra’ of experiences with varying degrees of agency and ownership, with ‘silent and internal own thoughts’ on one extreme and ‘fully (...) external and clearly audible voices’ in the absence of a speaker on the other. We believe a spectral model will add emphasis to the continuity of experience and help to better understand how one type of psychotic symptom may interact with another, and put forward the argument that the experience of TI itself is not sufficient to classify as a delusion. In addition we aim to discuss some of the conceptual issues surrounding AVHs and TI with first-person accounts and current philosophical and neuropsychological theories in mind. We propose that the mechanisms behind AVHs and TI are more complex than source-monitoring deficits; indeed, to understand such phenomena one must appreciate that their very ‘existence’ and ‘reality’ as experienced by the individual have much deeper implications and meaning, both philosophically and clinically. (shrink)

Borderline personality disorder (BPD) is characterized by severe disturbances in a subject’s sense of identity. Persons with BPD suffer from recurrent feelings of emptiness, a lack of self-feeling, and painful incoherence, especially regarding their own desires, how they see and feel about others, their life goals, or the roles to which they commit themselves. Over the past decade or so, clinical psychologists, psychotherapists, and psychiatrists have turned to philosophical conceptions of selfhood to better understand the borderline-specific ruptures in the (...) sense of identity, which are frequently associated with severe affective instability and turbulence in interpersonal relationships. Fuchs (2007) has suggested that these disturbances in self-experience can best be described and explained by using notions—widely discussed in philosophy and psychology—ofnarrativityandnarrative identity. On such a narrative view, key features of BPD present significant modifications of proto-narrative structures and inhibit the development of a narrative identity, resulting in a disturbed sense of identity. Although the role of narrativity in BPD has been acknowledged by many researchers, some have voiced dissatisfaction with what they take to be limitations of a narrativistic understanding of the disorders of identity characterizing BPD, and have proposed alternative, allegedly non-narrativistic, accounts. In this paper, we critically examine an example of the latter, viz. Gold and Kyratsous’ (2017) account ofthe person as an intrapersonal team reasoner. We defend a narrativistic understanding of BPD identity disorder against their objections. To this end, we propose a broader, and more finely-differentiated, concept of narrativity. On this account, four aspects of narrativity are distinguished, the disordering of which can affect those with BPD. As it turns out, our account implies that even Gold and Kyratsous—in order to ground their approach—must either make use of these aspects or propose an as-yet unarticulated alternative. This casts doubt upon whether their approach is non-narrativistic after all. (shrink)

Popular interest in the topic of food has exploded in the past decade. Due in part to books by Michael Pollan, Barbara Kingsolver, and Eric Schlosser and films such as Food, Inc., Super Size Me, and Forks over Knives, people are starting to think critically about where their food originates, how it is processed, and how their consumption choices affect the environment, nonhuman animals, and other people. At the same time, there is rising concern about the dangers of obesity. Although (...) the voices raising these concerns are by no means monolithic, one of the most common solutions offered to various food-related issues is the suggestion that people educate themselves and make.. (shrink)

al treatment of episodic substance intoxicated states with or without self-inflicted injuries. Patients later can develop comorbid medical illnesses associated with nonadherence of treatment or iatrogenic conditions, both of which result in complex end-of-life-care decisions. Institutional familiarity of repeat patients often leaves healthcare providers feeling responsible for the patient despite having little influence over the patients' ultimate behavioral outcomes. This article describes a patient with chronic alcohol abuse, treatment noncompliance, severe personality disorder, recurrent suicidal ideation, self-injurious behavior, alcoholic cirrhosis, (...) and suicide attempt resulting in multisystem injuries leading to an ethical conflict regarding end-of-life care.... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Mental Disorder and Religious ExperienceThe Need for a Humble, Pragmatic PluralismWarren Kinghorn, MD (bio)Mohammed Abouelleil Rashed follows Charles Taylor’s argument that in the “therapeutic turn” of modernity, “certain human struggles, questions, issues, difficulties, problems are moved from a moral/spiritual to a therapeutic register,... from a hermeneutic of sin, evil or spiritual misdirection, to one of sickness” (Taylor, 2007, pp. 619–620). While the project of construing mental disorder (...) in naturalistic, non-religious terms carries the risk of subsuming “the rest of life” into the realm of the medical, it is nonetheless needed in order “to protect a region of illness and incapacity from the reach and excesses of the hermeneutic disciplines with their tendency to over-interpretation, and from cultural traditions, including religious discourse, that can implicate the person in narratives of evil, sin, faithlessness, spiritual misdirection, and moral deviance.” Rashed notes, however, that this medical narrative is challenged not only by religious communities but also by various forms of identity-based activism including the Mad Pride and Neurodiversity movements. He argues that strict illness/purpose, deficit/value, mechanism/meaning dichotomies have become “unstable” and encourages scholars to focus their attention on resolving the apparently contradictory realities that people sometimes demand and require medical forms of care while investing significance in the sociocultural and existential context of their distress and refusing reductionistic constructions of their distress as illness.I agree wholeheartedly with Rashed’s conclusion that clinicians and scholars must move beyond a strict mechanism/meaning dichotomy with respect to unwanted and/or disvalued experience and behavior, and must remain open to the social and contextual interpretations that particular cultural communities—including religious communities—offer. But as a psychiatrist who is also [End Page 215] a Christian theological ethicist, I suggest that this sensible conclusion can be reached more straightforwardly by adopting a more flexible approach to “religious experience” and by abandoning the assumptions that mental disorder is “a fully areligious type of suffering” and that religious experience and mental disorder are “fundamentally separate apprehensions of our experience.”Although Rashed never defines religious experience, he posits a distinction between “psychological distress or anomalous experience that has a religious origin, content, or end (purpose)” and “psychological distress or anomalous experience that has no religious origin, content, or end (purpose).” He then helpfully describes how Islamic tradition narrates psychological suffering as deviation from fitrah and as God’s trial, arguing that in Islamic perspective “mental disorder cannot be disentangled from the person’s religious situation and from the religious origin, content, or end (purpose) of his distress.” I make no claim about Rashed’s interpretation of Islam, but would observe that many voices within Christian tradition resist both the equation of psychological suffering with wrongdoing and the assertion that God is the direct cause of psychological suffering (see, for example, John Paul II, 1984). Suffering may instead have to do with being sinned against (as in the case of war, assault, or oppression), or the experience of living in a fallen world that God will one day make right. When the psalmist cries, “Save me, O God, for the waters have come up to my neck” (Psalm 69:1, NRSVue), many Christians observe that it is the psalmist’s enemies, not God, who are the proximate cause of the psalmist’s distress. That is to say, Christian tradition allows for a broad range of interpretations about the cause of distress, including distress resulting from injury, physical illness, and oppression. Christians are encouraged to regard all of their lives as in some way related to God as the creator, sustainer, and orienting end of life—and so in that sense all experience is “religious” in nature. But at least for Christians this does not preclude more naturalistic or sociological interpretations of distress and suffering.Rashed is right that a “fully areligious type of suffering” with “no religious origin, content, or end (purpose)” can only be invoked from a secular standpoint—if “secularity” is taken in Charles Taylor’s first sense of “public spaces... [that] have been allegedly emptied of God, or of any reference to ultimate reality” (Taylor, 2007, p. 2). This is not because... (shrink)

This study juxtaposes Simone Weil's exposition of God's invitation to know and love the good through the divine signature of beauty stamped on the order of the world and Flannery O'Connor's depiction of a society whose oppressive order allows some characters to oppose outright a divine order or to live under the illusion that the divine invitation is irrelevant because they, in their egoism and materialist values, are the centre of the universe. An examination of O'Connor's and Weil's ideas on (...) order and beauty, grace and decreation, within the disorders of their contexts, reveals both writers' skills in pointing prophetically through disorder to divine order, thus, disclosing bridges of revelation. (shrink)

Disorders of the self figure prominently in psychotic experiences. Subjects de­scribe that “alien” thoughts are inserted in their mind by foreign powers, can sometimes hear their thoughts aloud or describe complex voices interacting with each other. Such experiences can be conceptualized in the framework of a Philosophical Anthropology, which suggests that human experience is characterized by centric and excentric positionality: subjects experience their environment centered around their enlived body and at the same time can reflect upon their place in a (...) shared lifeworld from an excentric point of view. Pre-reflective self awareness has been suggested to ensure that subjects can identify their own thoughts or actions as belonging to themselves, even when they reflect upon them from an excentric point of view. This pre-reflective self awareness appears to be impaired during psychotic experiences, when subjects no longer identify thoughts in their own stream of consciousness as belonging to themselves and instead attribute them to an outside agent. Among several potential causes, it is suggested that such impairments can be due to discrimi­natory or traumatic experiences, which affect the enlived (centric) position of a person and make her feel encircled and deeply threatened by aversive powers. As a consequence, the afflicted individual may fundamentally distance herself from her current centric position in a hostile environment, at the price of experiencing her own thoughts or actions as alien. Philosophical Anthropology may thus help to explain how social exclusion, discrimination and traumatization can promote psychotic experiences and why social support is of primary importance for any treatment of psychosis. (shrink)

Personal positions and voices of a patient diagnosed with borderline personality disorder and the therapist during long-term psychotherapy were studied aiming to find differences in the patterns formed in these aspects of subjectivity according to the level of elaboration of the change episodes achieved by the patient. This case study considered a stage of qualitative analysis where change episodes of the patient were traced through the Change Episodes Model. Later, through the Model of Analysis of Discursive Positioning in Psychotherapy, (...) the voices and personal positions of the patient and her therapist were identified in each of the change episodes. In the stage of quantitative analysis, dynamic patterns in the voices and personal positions were established, accounting for hypothetical attractors using the Space State Grid technique in each of the three different levels of subjective elaboration that constitute the change episodes. The results established differentiated dynamic patterns in the change episodes, coherent with the patient’s change process, and formation of propositive/reflective specific patterns as the patient evolved in the three different levels of subjective elaboration. The above suggests that a subjective transformation process is displayed, and this is manifested in the different voices and personal positions that emerged as the change episodes evolve. The identified dynamic patterns can be considered nonlinear and emergent subjective exchanges between the patient and the therapist throughout the psychotherapy. (shrink)

Socio-emotional impairments are key symptoms of Autism Spectrum Disorders. This work proposes to analyze the neuronal activity related to the discrimination of emotional prosodies in autistic children as follows. Firstly, a database for single words uttered in Mexican Spanish by males, females, and children will be created. Then, optimal acoustic features for emotion characterization will be extracted, followed of a cubic kernel function Support Vector Machine in order to validate the speech corpus. As a result, human-specific acoustic properties of emotional (...) voice signals will be identified. Secondly, those identified acoustic properties will be modified to synthesize the recorded human emotional voices. Thirdly, both human and synthesized utterances will be used to study the electroencephalographic correlate of affective prosody processing in typically developed and autistic children. Finally, and on the basis of the outcomes, synthesized voice-enhanced environments will be created to develop an intervention based on social-robot and Social StoryTM for autistic children to improve affective prosodies discrimination. This protocol has been registered at BioMed Central under the following number: ISRCTN18117434. (shrink)

From a phenomenological viewpoint, shame and guilt may be regarded as emotions which have incorporated the gaze and the voice of the other, respectively. The spontaneous and unreflected performance of the primordial bodily self has suffered a rupture: In shame or guilt we are rejected, separated from the others, and thrown back on ourselves. This reflective turn of spontaneous experience is connected with an alienation of primordial bodiliness that may be described as a "corporealization": The lived-body is changed into (...) the objective, corporeal body or "body-for-others." The polarity of "bodiliness" and "corporeality" may further a phenomenological understanding of several mental disorders connected with shame and guilt. This is shown by the examples of body dysmorphic disorder and melancholic depression. (shrink)

Many philosophers and psychologists have sought to explain experiences of auditory verbal hallucinations and “inserted thoughts” in schizophrenia in terms of a failure on the part of patients to appropriately monitor their own inner speech. These self-monitoring accounts have recently been challenged by some who argue that AVHs are better explained in terms of the spontaneous activation of auditory-verbal representations. This paper defends two kinds of self-monitoring approach against the spontaneous activation account. The defense requires first making some important clarifications (...) concerning what is at issue in the dispute between the two forms of theory. A popular but problematic self-monitoring theory is then contrasted with two more plausible conceptions of what the relevant self-monitoring deficits involve. The first appeals to deficits in the neural mechanisms that normally filter or attenuate sensory signals that are the result of one’s own actions. The second, less familiar, form of self-monitoring approach draws an important analogy between Wernicke’s aphasia and AVHs in schizophrenia. This style of self-monitoring theory pursues possible connections among AVHs, inserted thoughts, and the disorganized speech characteristic formal thought disorder. (shrink)

The voices and visions experienced by Emanuel Swedenborg remain a topic of much debate. The present article offers a reconsideration of these experiences in relation to changes in psychiatric practice. First, the phenomenology of Swedenborg's experiences is reviewed through an examination of his writings. The varying conceptualizations of these experiences by Swedenborg and his contemporaries, and by psychiatrists of later generations, are examined. We show how attempts by 19th- and 20th-century psychiatrists to explain Swedenborg's condition as the result of either (...) schizophrenia or epilepsy are unable to account for his experiences. We then demonstrate that the re-emergence of the 19th-century concept of `hallucinations in the sane' offers an alternative way to understand Swedenborg's experiences outside typical discourses of mental illness. Finally we argue that Swedenborg's experiences should be understood as exemplifying phenomena which we term `hallucinations without mental disorder', and investigate how conceiving of Swedenborg in this way can inform future research into the experience and clinical significance of hallucinations. (shrink)

ObjectivesTo identify and analyse ethical considerations raised when individuals with body dysmorphic disorder consult for non-surgical cosmetic procedures.MethodsEthical analysis was conducted addressing the issues of best interests and capacity to consent for non-surgical cosmetic procedures in individuals with BDD. Analysis was informed by the findings of semistructured interviews with non-surgical cosmetic practitioners and mental health professionals.FindingsNon-surgical cosmetic interventions were viewed not to be in the best interests of individuals with BDD, as they fail to address core psychological issues, result (...) in dissatisfaction post-procedure, and risk harm. Referral to mental health services was advocated, however numerous obstacles to this were perceived. The issue of capacity to consent to non-surgical cosmetic procedures raised questions regarding whether standard capacity assessment is sensitive to the manner in which BDD may influence decision-making processes. In addition, concerns were voiced that decisions made by individuals with BDD in this context may be judged foolish, and thus wrongly equated with lack of capacity.Discussion/conclusionsEthical analysis, informed by the available evidence base, suggests that it is generally not in the best interests of individuals with BDD to undergo non-surgical cosmetic intervention, and referral to mental health services is indicated. Analysis of capacity draws parallels between BDD and anorexia nervosa, as decision-making capacity in both conditions can be impaired by pathological values derived from the disorder. Means of differentiating clinical assessment of pathological values from inappropriate value judgements are advocated, in order to safeguard against the latter encroaching into capacity assessment. (shrink)

Background Deep brain stimulation is approved for treating refractory obsessive-compulsive disorder in adults under the US Food and Drug Administration Humanitarian Device Exemption, and studies have shown its efficacy in reducing symptom severity and improving quality of life. While similar deep brain stimulation treatment is available for pediatric patients with dystonia, it is not yet available for pediatric patients with obsessive-compulsive disorder, although soon could be. The prospect of growing indications for pediatric deep brain stimulation raises several ethical (...) concerns relating to bodily integrity, the ability to offer informed assent, and the role pediatric patients play in the decision-making process. Objective The aim of this study is to solicit and assess the views of stakeholders (children, parents, clinicians) on pediatric assent, autonomy, and bodily integrity in the context of potential pediatric deep brain stimulation for obsessive-compulsive disorder. Methods Semi-structured interviews were conducted with pediatric obsessive-compulsive disorder patients ( n = 21), caregivers of pediatric obsessive-compulsive disorder patients aged 14–18 ( n = 19), and clinicians with experience treating refractory obsessive-compulsive disorder ( n = 25). Interviews were transcribed and coded in MAXQDA 2018 and 2020 software and processed for thematic content analysis to isolate and compare specific themes. Results A majority of respondents (74%, 48/65) across all three stakeholder groups voiced that the decision-making process should be collaborative and involve everyone (clinicians: 84% or 21/25, caregivers 71% or 15/21, and patients 63% or 12/19). We identified a split between respondents’ views on who should have the final say in the event of disagreement (38% or 25/65 favored the patient versus 35% or 23/65 favoring caregivers). A split between respondents also emerged concerning the maturity relevant for deep brain stimulation decision-making, with 45% (29/65) favoring developmental maturity (age/physiological development) and 45% (29/65) favoring decisional maturity (capacity to understand and weigh information). A majority of clinicians indicated that they would not move forward with deep brain stimulation without securing patient assent (80% or 20/25), with some stating the only exception is if patient quality of life was very poor and/or they lacked insight. Both caregivers and patients expressed a significant respect for the patient's right to bodily integrity, with 67% of caregivers (14/21) and 68% of patients (13/19) justifying patient involvement in decision-making specifically with reference to infringements of bodily integrity. Conclusion Our findings demonstrate that despite broad agreement across stakeholders that the decision-making process for pediatric deep brain stimulation for obsessive-compulsive disorder should be collaborative and somehow involve pediatric patients, there is disagreement about what this process entails and what factors determine patient involvement in the process. However, there is agreement that children have a right to bodily and brain integrity, which should only be infringed upon in rare circumstances. (shrink)

There is a long-standing failure to create an ethical culture around substance use disorders (SUDs) or dependence that actively supports people’s recovery efforts. Issues which impede the development of prorecovery environments are complex, but include the far-reaching effects of the social stigma that surrounds SUDs; and the failure to harness relational and social support that allows debates to transcend blaming individual substance users. As part of efforts to create prorecovery environments, it is important to acknowledge that bioethics debate on SUDs (...) is narrow in scope, prioritising topics related to its traditional interests in individual autonomy and novel technologies. As a result, it has not played a significant role in helping to transform the ethical cultures in which substance use recovery takes place. For example, it largely neglects the ethical challenges of developing an empathic, person-centred approach to substance use problems that listens and responds to the voices of clients. It has also participated little in efforts to develop a positive response to reducing the toxic effects of stigma. Indeed, some contributions from the field fan stigma, rather than alleviate it. The aim of this paper is to seed broader ethical debate, in academic literature and lay/professional communities, on how societies should respond to SUDs: steering a course between the critical, but narrow approach of bioethics and the empowerment discourse of evidence-based treatments. (shrink)

Stephens and Grahamset themselves an apparently modest task, to understand why people who experience alien voices and inserted thoughts do not believe that they themselves are the source of these experiences. However, it soon becomes clear that there are many connected issues here. In eight short chapters, they address the phenomenology and ontology of consciousness, the phenomenology of alien voices, inserted thoughts, obsessive-compulsive thoughts and feelings, and other cases of unusual experience often associated with psychopathology, including brief discussion of multiple (...) personality disorder. They survey some of the main empirical explanations of the phenomenology, set out the shortcomings of these theories, and end by proposing their own schematic account. (shrink)

Drawing upon core phenomenological contributions of the last decades, the present paper provides an integrated description of the development of auditory hallucinations in schizophrenia. Specifically, these contributions are the transitional sequences of development of psychotic symptoms of schizophrenia as envisioned by Klosterkötter and rooted in the basic symptoms approach, Conrad’s Gestalt-analysis of developing psychosis, and Sass and Parnas’ self-disturbance approach. Klosterkötter’s contribution provides a general descriptive psychopathological approach to the transitional sequence of the development of auditory hallucinations. The key concepts (...) in Conrad’s proposal are discussed, as their role is central as driving forces of the process from non-psychotic symptoms to overt hallucinations. Finally, Parnas and Sass link psychiatry to philosophy and psychology, and provide an in-depth and thorough description of these phenomena in their work on schizophrenia as a disorder of consciousness and self-experience with hyper-reflexivity and diminished self-affection as key aspects. (shrink)

Speech is a primary means of human communication and one of the most basic features of human conduct. Voice is an important part of its subsystems. A speech disorder is a condition that affects the ability of a person to speak normally, which occasionally results in voice impairment with psychological and emotional consequences. Early detection of voice problems is a crucial factor. Computer-based procedures are less costly and easier to administer for such purposes than traditional methods. (...) This study highlights the following issues: recent studies, methods of voice pathology detection, machine learning and deep learning (DL) methods used in data classification, main datasets utilized, and the role of Internet of things (IoT) systems employed in voice pathology diagnosis. Moreover, this study presents different applications, open challenges, and recommendations for future directions of IoT systems and artificial intelligence (AI) approaches in the voice pathology diagnosis. Finally, this study highlights some limitations of voice pathology datasets in comparison with the role of IoT in the healthcare sector, which shows the urgent need to provide efficient approaches and easy and ideal medical diagnostic procedures and treatments of disease identification for doctors and patients. This review covered voice pathology taxonomy, detection techniques, open challenges, limitations, and recommendations for future directions to provide a clear background for doctors and patients. Standard databases, including the Massachusetts Eye and Ear Infirmary, Saarbruecken Voice Database, and the Arabic Voice Pathology Database, were used in most articles reviewed in this article. The classes, features, and main purpose for voice pathology identification are also highlighted. This study focuses on the extraction of voice pathology features, especially speech analysis, extends feature vectors comprising static and dynamic features, and converts these extended feature vectors into solid vectors before passing them to the recognizer. (shrink)

BackgroundDespite consensus about the importance of implementing shared decision-making (SDM) in clinical practice, this ideal is inconsistently enacted today. Evidence shows that SDM practices differ in the degree of involvement of patients or family members, or in the amount of medical information disclosed to patients in order to “share” meaningfully in treatment decisions. Little is known on which representations and moral justifications physicians hold when realizing SDM. This study explored physicians’ experiences of SDM in the management of paediatric patients with (...) prolonged disorders of consciousness (PDOC). Specifically, we focused on physicians’ SDM approaches, representations, and ethical justifications for engaging in SDM.MethodsWe used a qualitative approach to explore the SDM experiences of 13 ICU physicians, paediatricians, and neurologists based in Switzerland who have been or were involved in the care of paediatric patients living with PDOC. A semi-structured interview format was used and interviews were audio-recorded and transcribed. Data were analysed through thematic analysis.ResultsWe found that participants followed three main decision-making approaches: the “brakes” approach, characterized by maximized family’s decisional freedom, though conditional to physician’s judgment regarding the medical appropriateness of a treatment; the “orchestra director” approach, characterized by a multi-step decision-making process led by the main physician aimed at eliciting the voices of the care team members and of the family; and the “sunbeams” approach, characterized by a process oriented to reach consensus with family members through dialogue, where the virtues of the physician are key to guide the process. We also found that participants differed in the moral justifications sustaining each approach, citing the duty to respect parental autonomy, to invest in an ethics of care, and to employ physicians’ virtues to guide the decision-making process.ConclusionOur results show that physicians come to perform SDM in different ways, with several representations, and distinct ethical justifications. SDM training among health care providers should clarify the ductility of SDM and the several ethical motivations underpinning it, rather than insisting on the principle of respect for patient’s autonomy as its only moral foundation. (shrink)

Background Transcranial direct current stimulation (tDCS) is a brain stimulation technique currently being researched as an alternative or complimentary treatment for various neurological disorders. There is little knowledge about experiences of the participants of tDCS clinical research, especially from pediatric studies. Methods An interview study with typically developing minors (n = 19, mean age 13,66 years) participating in a tDCS study, and their parents (n = 18) was conducted to explore their views and experiences and inform the ethical analysis. Results (...) Children (10–13 years old) and adolescents (14–18 years old) reported good experiences with the stimulation. Next to financial incentives, main motives to participate in the study were curiosity and the possibility to help develop treatments for children affected by neurological disorders. They could also see a potential of using tDCS in a non-medical setting, especially regarding the provision of equal opportunity, e.g. in education. Parents also presented a positive attitude towards tDCS and their children participation in the basic research study. Nevertheless, their understanding of tDCS was rather poor. Even though many of them understood the techniques, they often did not see the link between the (current) lack of side effects and an absence of longitudinal studies. Parents were also cautious about using tDCS for non-medical/enhancement purposes. Conclusions The study findings show a need for more transparent information about the state of the art of tDCS, its function and what it might be able to offer, especially considering the good acceptability of tDCS. (shrink)

The life of Saint Teresa of Jesus, the most famous mystic of sixteenth-century Spain, was characterized by recurrent visions and states of ecstasy. In this paper, we examine social components related to Teresa’s personal crises and the historical conditions of her times, factors that must be taken into account to understand these unusual forms of experience and behavior. Many of these factors (e.g., increasing individualism and reflexivity) are precursors of the condition of modern times. Indeed, certain parallels can be observed (...) between Saint Teresa and certain present-day psychopathological disorders. The analogy should not, however, be carried too far. Religion played a particularly crucial role in Teresa’s cultural context; as a result, it would be misleading to view her mystical experiences as resulting from a mental disorder. (shrink)

Compelling voices charge that the theological notion of “sacrifice” valorizes suffering and fosters a culture of violence by the claim that Christ’s death on the Cross paid for human sins. Beneath the ‘sacred’ violence of sacrifice, René Girard discerns a concealed scapegoat-murder driven by a distortion of human desire that itself must lead to human self-annihilation. I here ask: can one speak safely of sacrifice; and can human beings somehow cease to practice the sacrifice that must otherwise destroy them? Drawing (...) on Gregory the Great (ca. 540–604), I propose an understanding of sacrifice that both distinguishes Christian sacrifice from sacred violence and accounts for how to overcome the roots of the sacred violence identified by Girard. I make four claims: First, Girard recognizes two kinds of sacrifice—one, the scapegoat murder, overcomes community rivalries by unanimous imitation of an accuser, shifting blame onto a third party who is collectively murdered; the other sort of sacrifice practices renunciation and forgiveness in imitation of God. These I respectively designate the “Satanic” (Girard’s term) and the “theomimetic” (mine). Second, I analyze the intrinsic instability that keeps the Satanic from sustaining the societal order and unity that it promises. Third, by a constructive reading of Gregory the Great, I posit that satanic sacrifice overlooks and indeed exacerbates the root of human covetousness—a failure to love. Fourth, Gregory’s teaching on the imitation of Christ enables us to expand on Girard’s account of the theo¬mimetic sacrifice of renunciation, to clarify how this latter might not only oppose but also systematically subvert the Satanic by healing the disorder out of which mimetic rivalry and scapegoating first take their rise. (shrink)

How are we to make sense of madness and psychosis? For most of us the words conjure up images from television and newspapers of seemingly random, meaningless violence. It is something to be feared, something to be left to the experts. But is madness best thought of as a medical condition? Psychiatrists and the drug industry maintain that psychoses are brain disorders amenable to treatment with drugs, but is this actually so? There is no convincing evidence that the brain is (...) disordered in psychosis, yet governments across the world are investing huge sums of money on mental health services that take for granted the idea that psychosis is an illness to be treated with medication. Although some people who use mental health services find medication helpful, many do not, and resist the idea that their experiences are symptoms of illnesses like schizophrenia. Consequently they are forced into having treatment against their wishes. So, how do we make sense of this situation? Postpsychiatry addresses these questions. It involves an attempt to rethink some of the fundamental assumptions of mental health work, showing how recent developments in philosophy and ethics can help us to clarify some of the dilemmas and conflicts around different understandings of madness. Throughout, the authors examine the conflicting ways in which politicians, academics, and mental health professionals appear to understand madness, and contrast this with voices and experiences that are usually excluded - those of the people who use mental health services. They then examine the power of psychiatry to shape how we understand ourselves and our emotions, before considering some of the basic limitations of psychiatry as science to make madness meaningful. In the final section of the book they draw on evidence from service users and survivors, the humanities and anthropology, to point out a new direction for mental health practice. This new direction emphasises the importance of cultural contexts in understanding madness, placing ethics before technology in responding to madness, and minimising 'therapeutic' coercion. (shrink)

The VOICES study involved at least one radical move in the decades-old debates about attention deficit hyperactivity disorder diagnosis and stimulant drug treatments: to systematically investigate young people's perspectives and experiences so that these could be included as evidence in social, ethical and policy deliberations about the benefits and risks of these interventions. The findings reported in this article were both surprising and unsurprising to us as researchers. We were surprised at the consistency of children's positive responses to stimulant (...) medication, and at the robustness of the experience of increased capacity for moral agency with medication. We were unsurprised at the insights many young people have into their own behaviours and that of others.I am hopeful that the perspectives of children reported in this article will inspire a fresh public conversation about the ethics of stimulant drug treatments, as well as further research with children. In order to believe that children's perspectives add something new and valuable to the social discourse, one must first view children as capable of reliably reporting their own experiences as part of a well-designed research study. It seems that Steven Rose does …. (shrink)

Increasingly, voices in the growing neurodiversity movement are alleging that individuals who are neurologically divergent, such as those with conditions related to bipolar disorder, autism, schizophrenia, and depression, must struggle for their civil rights. This movement therefore raises questions of interest to scholars in the humanities and social sciences, as well as to concerned members of the general public. These questions have to do with such matters as the accessibility of knowledge about mental health; autonomy and community within the (...) realm of the mentally ill; and accommodation in civil society and its institutions. The contributors to Ethics and Neurodiversity explore these questions, and the traditional philosophical questions related to them. The authors pay special attention to the need to examine the policies and practices of institutions, such as higher education, social support, and healthcare. (shrink)

Anxiety disorders are one of the most prevalent mental disorders globally, and 63% of those diagnoses are of women. Although widely acknowledged across health disciplines and news and social media outlets, the majority of attention has left assumptions underlying women's anxiety in the twenty-first century unquestioned. Drawing on my own experiences of anxiety, I will the explore both concept and diagnosis in the Western world. Reflecting on my own experiences through a critical feminist lens, I will investigate the construction of (...) anxiety as mental disorder in the context of neoliberal late-stage capitalism, heteropatriarchy, and biomedical psychiatry. Tracing the postpositivistic foundations of anxiety, as well as the historical and ongoing medicalization and pathologization of women, I will critically consider the sociopolitical implications of constructing anxiety as biomedical disorder. Assumptions underlying mental health will be explored within the context of the construction, experience, and operationalization of gender and the way gender intersects with diverse positionalities, power, knowledge, and neoliberal governance. Weaving the voices of women poets with the biomedical language of disorder, this critical-realist inquiry will explore my anxiety as it relates to the epidemic levels of anxiety among other women, and the late-stage capitalist world within which anxiety flourishes. (shrink)

The ongoing debate within neuroethics concerning the degree to which neuromodulation such as deep brain stimulation (DBS) changes the personality, identity, and agency (PIA) of patients has paid relatively little attention to the perspectives of prospective patients. Even less attention has been given to pediatric populations. To understand patients’ views about identity changes due to DBS in obsessive-compulsive disorder (OCD), the authors conducted and analyzed semistructured interviews with adolescent patients with OCD and their parents/caregivers. Patients were asked about projected (...) impacts to PIA generally due to DBS. All patient respondents and half of caregivers reported that DBS would impact patient self-identity in significant ways. For example, many patients expressed how DBS could positively impact identity by allowing them to explore their identities free from OCD. Others voiced concerns that DBS-related resolution of OCD might negatively impact patient agency and authenticity. Half of patients expressed that DBS may positively facilitate social access through relieving symptoms, while half indicated that DBS could increase social stigma. These views give insights into how to approach decision-making and informed consent if DBS for OCD becomes available for adolescents. They also offer insights into adolescent experiences of disability identity and “normalcy” in the context of OCD. (shrink)

Stroke and other neurological disorders have an effect on mobility which has a significant impact on independence and quality of life. The core rehabilitation requirements for patients with lower limb motor dysfunction are gait training, restand, and mobility. In this work, we introduce a newly developed multifunctional wheelchair that we call “ReChair” and evaluated its performance preliminarily. ReChair seamlessly integrates the mobility, gait training, and multiposture transformation. ReChair driving and multiposture transformation are done using the voice, button, and mobile (...) terminal control. This work describes the functional requirements, mechanical structure, and control system and the overall evaluation of ReChair including the kinematic simulation of the multiposture transformation and passive lower limb rehabilitation training to quantitatively verify the motion capability of ReChair, the voice control system evaluation that shows how the voice recognition system is suitable for home environment, the sensorless speed detection test results that indicate how the wheel speeds measured by sensorless method are appropriate for travelling control, and the passive and balance training test results that show how the lower limb rehabilitation training in daily life by ReChair is convenient. Finally, the experimental results show that ReChair meets the patients’ requirements and has practical significance. It is cost-effective, easy to use, and supports multiple control modes to adapt to different rehabilitation phases. (shrink)

IntroductionFrontline healthcare workers have faced significant plight during the ongoing Coronavirus disease 2019 pandemic. Studies have shown their vulnerabilities to depression, anxiety disorders, post-traumatic stress, and insomnia. In a developing country like India, with a rising caseload, resource limitations, and stigma, the adversities faced by the physicians are more significant. We attempted to hear their “voices” to understand their adversities and conceptualize their resilience framework.MethodsA qualitative approach was used with a constructivist paradigm. After an initial pilot, a socio-demographically heterogeneous population (...) of 172 physicians working in COVID-designated centers were purposively sampled from all over India. Following in-depth virtual interviews using a pre-formed semi-structured guide, the data was transcribed and translated verbatim. The interview was focused on their challenges, needs, and processes of coping and support. Charmaz’s grounded theory was used for analysis supplemented by NVivo 10 software.ResultsFear of infection, uncertainty, stigma, guilt, and social isolation emerged as the main challenges. Simultaneously, their “unmet needs” were flexible work policies, administrative measures for better medical protection, the sensitivity of media toward the image of HCW, effective risk communication for their health, and finally, social inclusion. Their resilience “framework” emerged as a process while navigating these adversities and consisted of three facets: forming a “resilient identity,” managing the resilience, and working through the socio-occupational distress. The role of mental well-being, social network, peer support, problem negotiation, and self-care emerged as the key coping strategies.ConclusionThe study findings support the global call for better psychosocial health and quality of life of the frontline HCWs. Their “unheard voices” explored in the study can anchor subsequent resilience-enhancing interventions and policies. Guidelines focusing on the psychological wellbeing of frontline HCWs need to be grounded in their unmet needs and lived experiences. (shrink)

Medicine maintains a distinction between the medical symptom -- the patient''ssubjective experience and expression, and the privileged medical sign -- the objective findings observable by the doctor. Although the distinction is not consistently applied, it becomes clearly visible in the undefined, medically unexplained disorders of women patients. Potential impacts of genderized interaction on the interpretation of medical signs are addressed by re-reading the diagnostic process as a matter of social construction, where diagnosis results from human interpretation within a sociopolitical context. (...) The discussion is illustrated by a case story and empirical evidence of the gendering in the doctor-patient relationship. The theoretical analysis is supported by semiotic perspectives of bodily signs, feminist theory on experience, and Foucault''sideas about medical perception and gaze, and concludes that a medical diagnosis is seldom a biological fact, but the outcome of a process where biological, cultural and social elements are interwoven. Further deconstruction of the chain of signs from a feminist perspective, assigning validity to the voice of the woman patient, might broaden the understanding of women''shealth, illness and disease. (shrink)

This book uses insights from disability studies to understand in a deeper way the ethical implications that genetic technologies pose for Christian thought. Theologians have been debating genetic engineering for decades, but what has been missing from many theological debates is a deep concern for persons with genetic disabilities. In this ambitious and stimulating book, Devan Stahl argues that engagement with metaphysics and a theology of nature is crucial for Christians to evaluate both genetic science and the moral use of (...) genetic technologies, such as human genetic engineering, gene therapy, genetic screenings, preimplantation genetic diagnosis, and gene editing. Using theological notions of creation ex nihilo and natural law alongside insights from disability studies, the book seeks to recast the debate concerning genetic well-being. Following the work of Stanley Hauerwas, Stahl proposes the church as the locus for reimagining disability in a way that will significantly influence the debates concerning genetic therapies. Stahl's project in "genethics" proceeds with an acute awareness of her own liberal Protestant tradition's early embrace of the eugenics movement in the name of scientific and medical advancement, and it constructively engages the Catholic tradition's metaphysical approach to questions in bioethics to surpass limitations to Protestant thinking on natural law. Christianity has all too frequently been complicit in excluding, degrading, and marginalizing people with disabilities, but the new Christian metaphysics developed here by way of disability perspectives provides normative, theological guidance on the use of genetic technologies today. As Stahl shows in her study, only by heeding the voices of people with disabilities can Christians remain faithful to the call to find Christ in "the least of these" and from there draw close to God. This book will be of interest to scholars in Christian ethics, bioethics, moral theology, and practical theology. (shrink)

The article concentrates on answering the main question to be addressed, as stated in its title: which psychology(ies) serves us best? In order to achieve this goal, we pursue possible answers in history of psychology of religion and its interdisciplinary relationships with its sister disciplines, anthropology of religion and religious studies, resulting with sketching a typology of the main attitudes towards conceptualising psycho-cultural interface, prevalent among psychologists: the Universalist, the Absolutist and the Relativist stances. Next chosen examples from the field (...) of applied psychology are presented, as the role of the cultural factor within the history of Diagnostic and Statistical Manual of Mental Disorders’ ( DSM) development is discussed alongside presenting research on the phenomenon of ‘hearing voices’, in order to show the marked way for the future – the importance of including the cultural factor in psychological research on religion. (shrink)

Progress in genetic and reproductive technology now offers us the possibility of choosing what kinds of children we do and don't have. Should we welcome this power, or should we fear its implications? There is no ethical question more urgent than this: we may be at a turning-point in the history of humanity. The renowned moral philosopher and best-selling author Jonathan Glover shows us how we might try to answer this question, and other provoking and disturbing questions to which it (...) leads. Surely parents owe it to their children to give them the best life they can? Increasingly we are able to reduce the number of babies born with disabilities and disorders. But there is a powerful new challenge to conventional thinking about the desirability of doing so: this comes from the voices of those who have these conditions. They call into question the very definition of disability. How do we justify trying to avoid bringing people like them into being? In 2002 a deaf couple used sperm donated by a friend with hereditary deafness to have a deaf baby: they took the view that deafness is not a disability, but a difference. Starting with the issues raised by this case, Jonathan Glover examines the emotive idea of 'eugenics', and the ethics of attempting to enhance people, for non-medical reasons, by means of genetic choices. Should parents be free, not only to have children free from disabilities, but to choose, for instance, the colour of their eyes or hair? This is no longer a distant prospect, but an existing power which we cannot wish away. What impact will such interventions have, both on the individuals concerned and on society as a whole? Should we try to make general improvements to the genetic make-up of human beings? Is there a central core of human nature with which we must not interfere? This beautifully clear book is written for anyone who cares about the rights and wrongs of parents' choices for their children, anyone who is concerned about our human future. Glover handles these uncomfortable questions in a controversial but always humane and sympathetic manner. (shrink)

Since the 1990s, educators and social commentators have raised alarms regarding the moral character of successive generations of Americans. A consistent concern within those calls for alarm directs attention to teaching ethics in secondary education. A pedagogy of accompaniment recognizes the timeliness for objective and subjective approaches to learning social ethics, transcending the either/or of subject-object, content-skill educational conflicts as well as the disordered distractions of a performance-merit based assessment of learning. In secondary education, the praxis of accompaniment through social (...) ethical discernment creates an occasion wherein students hear and take seriously for the first time their moral voices and imagine their social ethical horizons. (shrink)

This essay argues that making a diagnosis in medicine is essentially a hermeneutic enterprise, one in which interpretation skills play a major part in understanding a disease. The clinical encounter is an event comprised of two voices; one is the voice of science which is grounded in empiricism, the other is that of human experience, which is grounded in story-telling and the interpretation of those stories.Using two voices, one from the Diagnostic and Statistical Manual of Mental Disorders-III-Revised, which describes (...) alcohol abuse and alcohol dependence, and the other, that of Claire, a character in Edward Albee's play, A Delicate Balance, who is conversing with her brother-in-law, Tobias, I apply principles from Hans-Georg Gadamer's hermeneutics to the clinical diagnostic process. The essay will demonstrate that we overlook an enormous amount of information about alcoholism by an overreliance on objective data and that our hope for understanding alcoholics is in listening to their voices, and sharing the interpretation of their experiences with them. (shrink)

People have shared funds of sense that operate in every aspect of their lives. These complex sensibilities constitute a range of often contradictory dispositions and attunements that we can describe as sensible disorders. Further, sensibilities are available for multiple differential determinations from which the ability for self-reflection and intervention derives. 'Democratic space' is an appropriate name for the region of sensibilities. Rather than naming a grounding identity, 'democratic space' names a region without imperative, voice, or intention. Nothing that happens (...) defines the region of determination. The paper describes a sense of democratic space that is distinguishable from other senses and points to dispositional and political aspects of that sense. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Notes on Psychodramatic Treatment of a Person with SchizophreniaJonathan D. Moreno, PhD (bio)I have enjoyed reflecting on Mr. Chapy’s account of work in psychodrama with a patient with schizophrenia.Although at one time many years ago I was interested in phenomenological psychiatry, and especially the writings of Ludwig Binswanger and Medard Boss, I am not an authority on dasein-analysis, so I have nothing to add to the discussion. I should (...) say, however, that my father had little interest in this approach, which was far too abstract for his taste. He proceeded from the standpoint of the theater, of action and enactment. He believed that the drama itself provided the insight.For the purposes of this response, I take it as a given that the patient in question has been accurately diagnosed, although in the description of the scene with his father he does not exhibit the usual symptoms, such as auditory hallucinations. People with schizophrenia often find it difficult to manage the voices they are hearing without substantial preparation for a psychodrama. According to psychodramatic method, one way to prepare them is to externalize the voices, allowing a different therapist to take the role of each one as the protagonist instructs them how to play that role. Chair may be set up so that each “voice,” personified by an auxiliary ego, can sit in each chair in an array. This preparation may require a number of sessions. If the scene is to be enacted with a significant other, like the father in this instance, the patient may not be able to warm up to a direct encounter, especially with all the different voices competing for his internal attention. So he may be directed to observe each voice in the encounter with his father, preferably played by a therapist of his choosing and trained for the role, usually by giving the father-player certain lines so that they can learn something about the father and the way he addresses his son.Or consider the patient whose illness manifests itself as delusions, often of a megalomaniac character. They may be a messiah, for example, or the rightful heir of a royal line whose identity is being suppressed by governmental forces. The patient might be invited to choose key therapists to play the roles of key members of their circle, [End Page 225] enacting critical scenes like the sermon on the mount or speeches to their oppressed followers. In this way the patient’s “act hunger” may be to some degree satiated and have a calming effect on their anxiety and irritation with the frustrating world around them that refuses to accept their “authentic” identity and belief system.In these ways, psychodrama therapy can take advantage of one of the remarkable advantages of this method for such patients, who are generally recalcitrant to talk therapy alone and for whom medication is at best modestly effective. Still, these disorders are among the most challenging for psychotherapists. Although the process of treating them may open up insights into the nature of the human mind, as Chapy has pursued in this paper, we await the neuroscience that can affect the kind of long-term remission they and their families so desperately wish. [End Page 226]Jonathan D. MorenoUniversity of Pennsylvania morenojd@pennmedicine.upenn.eduJonathan D. Moreno Jonathan D. Moreno is a philosopher and historian who specializes in the intersection of bioethics, culture, science, and national security, and has published seminal works on the history, sociology and politics of biology and medicine. He is an elected member of the National Academy of Medicine.submitted on January 27, 2023Accepted on January 30, 2023Copyright © 2023 Johns Hopkins University Press... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Why the Phenomenology Remains FoundationalRobert Harland (bio)Keywordspsychology, cognitive-behavioral therapy (CBT), phenomenology, psychiatry, depressionDemian Whiting in his paper criticizes an exclusively cognitive approach to the treatment of emotional problems. There is no doubt that the cognitive model of the mind has been recently in the ascendancy and therapies based on it are to be found in almost every subspecialty of psychiatry. Cognitive-behavioral therapy (CBT) in particular is "discovered" as being (...) effective in everything from posttraumatic stress disorder to psychosis. The heartland of the approach is and remains anxiety and depression, the two most common emotional states that psychiatrists and psychologists are asked to deal with. As Dr. Whiting describes, leaving aside the behavioral aspects, the basic principle is about eliciting and challenging distorted cognitions. Cognitive theory suggests that distorted cognitions are the cause of, the substance of, and the maintaining factors in most if not all depression and anxiety.The author accepts that in certain cases distorted cognitions lead to an experience that is represented contra to reality. He suggests that in certain circumstances a cognitive therapist could help a patient to reappraise the world they find themselves in and by gathering evidence with the therapist, to challenge these distortions. So in depression, a patient sees themselves as worthless and their therapist suggests they gather evidence that helps them form a more balanced perspective. The cognition "I am worthless" is shown empirically to be a distortion. Whiting argues, correctly in my opinion, for the limitation of this approach. In doing so he argues against a growing psychological hegemony, one that sees itself as developing evidence-based practice that should be applied (on the back of national guidelines) to many presentations before or exclusively of others such as medication or alternative psychotherapeutic approaches.Whatever the outcome in the clinic, as opposed to the randomized controlled trials, many clinicians and health care managers are attracted to CBT because of its pragmatic, short-term, problem- and consumer-orientated nature. It has an approach tailored for most disorders and therefore fits very well within the organization of modern mental health services. With this background, nonclinical readers may more readily appreciate the potential target of Dr. Whiting's critique.Whiting suggests three examples where eliciting cognitions can at best be seen as secondary [End Page 247] to the problem in hand: First, where a drug (e.g., alcohol) or state (e.g., tiredness) directly causes an emotion; second, where an emotion causes a mistaken understanding of a situation; and third, where the representation is accurate but the response defective (e.g., the pedophile in his article, or more routinely a person particularly sensitive to anxiety). The phenomenology, before the prism of analysis, is that in all three cases the patients find themselves in an emotional state where any putative cognitive etiology is at best post hoc and at worst tautological. Furthermore, as the author states, in the cases where accurate representations elicit the wrong kinds of emotions, the question why cannot be answered by referring back to the person's representations.To answer the question of why someone is particularly sensitive to anxiety or gets aroused by children, Dr. Whiting points to several possibilities that all impact on treatment: First, the influence of noncognitive desires and emotions; second, physical contamination; third, an idiosyncratic or abnormal constitution; and fourth, a defective emotional acculturation. In all these cases, suggesting that the patient's problems will be resolved through altering eliciting cognitions seems illogical.The paper then preempts two criticisms from the cognitive approach. The first again rightly expands that, if a higher order evaluative level is proposed, this in no way answers a noncognitive critique. Either the higher level of evaluation is simply an unnecessary (or unpredictable) cognitive confirmation of a negative (or positive) representation, or the evaluation is a cognitive foil for an emotional reaction that is simply not cognitive; when someone says they are worthless they are merely giving voice to their depressed emotional state. Second, that retreating to a position where the cognitive approach is used to challenge distorted representations that are secondary to, and yet maintain, an inappropriate emotion may have a role, but does not mean that... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Hermeneutics, Neuroscience and PsychiatryMichael T. H. Wong, MBBS, MD, MA, MDiv, PhD, FRCPsych, FRANZCP, FHKAM (bio)Hermeneutic practice in mental health has been a theme in Philosophy, Psychiatry, & Psychology (PPP) since its very beginnings. In this essay I argue that hermeneutics, the theory and practice of interpretation, promotes therapeutic interaction between mental health professionals, patients and their family.Why does this patient present in such a way at this particular (...) point in time? The distressing symptoms are there. The changes in behavior are obvious. Impairments of functions are hurting. A mental illness clearly runs in the family. There were early losses of loved ones, physical abuse at home, bullying by peers and self-medication with drugs and alcohol. Three in four adults with a mental illness first experienced that before they turned 24. The brain goes through major reorganization during adolescence and early adulthood. If synaptic pruning went wrong, psychoses emerged. When stresses activated the hypothalamic–pituitary–adrenal axis the elevated cortisol level impacted the size and function of the hippocampus and amygdala in the genetically vulnerable; anxiety, depression, bipolar, and personality disorders developed. The patient needs a voice/language to describe all these experiences and events and the psychiatrist needs a discourse to make sense of them.Eisenberg laments the swings between "brainlessness" and "mindlessness" in psychiatry. Engel argues for a "biopsychosocial" discourse. The major challenge for psychiatry is how to organize clinical information of different nature (categories, dimensions, narratives; i.e., objective vs. subjective, personal vs. interpersonal) into a coherent and comprehensible account for us all. Mental illnesses are not only neuropsychiatric spectrum disorders but also dysfunctions of social relationship and environmental/ecological adaptation. Psychiatry as a clinical neuroscience per se lacks the semantics to address the rich interactions between the physical, psychological, social, cultural, and spiritual in the illness experience of our patients. Explanation in the diagnostic formulation (objective scientific discourse on cause and effect) and understanding in the patient narrative (subjective ordinary everyday discourse on significance and meaning) are irreducible to each other (Wong, 2018). They instead interact with one another to achieve an integrative formulation, not through merging different discourses into a single assertion/monologue but via the dialectic/dialogue of "explaining more in order to understand better," as Ricoeur puts it, and between "the whole and the parts," as Schleiermacher highlights.This "therapeutic hermeneutic circle" of "explanation vs understanding" and "the whole vs the parts" includes symptoms behavior function and life events. It correlates between bio-psychosociocultural-spiritual dimensions/perspectives and does not reduce them to any particular/single [End Page 13] stance. The whole integrates the parts and the parts enrich the whole. It explains but does not explain away. It understands through an articulation of meaning and significance. This discourse is a multilayered (bio-psycho-social-cultural-spiritual) personal narrative that formulates diagnosis and care in a correlative (linking different voices/discourses) and non-reductive (no particular voice/discourse is prejudiced against) manner that is comprehensible to us all (Wong, 2021).PPP will be an excellent forum for discussing clinical hermeneutics in the future. In this digital era of social media and virtual reality, hermeneutics has the never-ending task to tackle the unprecedented challenges to meaning illness and health posed by polarizing discourses.Michael T. H. Wong Michael T.H. Wong, MBBS, MD, MA, MDiv, PhD, FRCPsych, FRANZCP, FHKAM, is Hon Clinical Professor, Department of Psychiatry, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, HKSAR, China. Michael is Chair, Section of Philosophy & Humanities in Psychiatry, World Psychiatric Association. He is an Organizational Partner & International Lead with The Collaborating Centre for Values-Based Practice in Health and Social Care, St Catherine's College Oxford. He is Advisor to the Chinese Health Foundation of Australia.ReferencesWong M. T. H. (2018). Ricoeur and the third discourse of the person: From philosophy and neuroscience to psychiatry and theology. London: Lexington Books. Google ScholarWong, M. T. H. (2021). Values, meanings, hermeneutics and mental health. In Stoyanov, D., Fulford, K. M. W. F., Stanghellini, G., Van Staden, W., & Wong, M. TH. (Eds.), International perspectives in values-based mental health practice: Case studies and commentaries (pp. 341–349... (shrink)

This article is situated within the framework of schema therapy and offers a comprehensive and clinically useful list of schema modes that have been identified as being relevant to conceptualizing complex psychological problems, such as those posed by personality disorders, and, in particular, the way that those problems are perpetuated. Drawing on the schema therapy literature, as well as other literature including that of cognitive behavior therapy and metacognitive therapy, over eighty modes are identified altogether, categorized under the widely accepted (...) broad headings of Healthy Adult, Child modes, Parent modes and coping modes which are, in turn, divided into Surrender, Detached/Avoidant, and Overcompensator. An additional category is included: Repetitive Unproductive Thinking. This draws attention to the recognition by metacognitive therapists that such covert behaviors play a significant role in amplifying distress and perpetuating a range of psychological problems and symptoms. In addition to the modes themselves, several concepts are defined that are directly relevant to working with modes in practice. These include: default modes, blended modes, mode suites and mode sequences. Attention is also drawn to the way in which Child modes may be hidden “backstage” behind coping modes, and to the dyadic relationship between Child modes and Parent modes. Also relevant to practice are: the recognition that Critic voices may have different sources and this has implications for treatment, the concept of complex modes in which several submodes work together, and the fact that in imagery work and image of a child may not represent a Vulnerable Child, but a Coping Child. The modes and mode processes described are directly relevant to clinical practice and, in addition to being grounded in the literature, have grown out of and proved to be of practical use in conceptualizing my own cases, and in supervising the cases of other clinicians working within the schema therapy framework. (shrink)

Considering the highly complex structure of quantum chaos and the nonstationary characteristics of speech signals, this paper proposes a quantum chaotic encryption and quantum particle swarm extraction method based on an underdetermined model. The proposed method first uses quantum chaos to encrypt the speech signal and then uses the local mean decomposition method to construct a virtual receiving array and convert the underdetermined model to a positive definite model. Finally, the signal is extracted using the Levi flight strategy based on (...) kurtosis and the quantum particle swarm optimization optimized by the greedy algorithm. The bit error rate and similarity coefficient of the voice signal are extracted by testing the source voice signal SA1, SA2, and SI943 under different SNR, and the similarity coefficient, uncertainty, and disorder of the observed signal and the source voice signal SA1, SA2, and SI943 verify the effectiveness of the proposed speech signal extraction method and the security of quantum chaos used in speech signal encryption. (shrink)