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A Theory of Feelings Anger and Forgiveness"My Madness Saved Me"10 Good Questions about Life and Death12 Modern Philosophers50 Reasons People Give for Believing in a GodA Cabinet of Philosophical CuriositiesA Case for IronyA Companion to BioethicsA Companion to Buddhist PhilosophyA Companion to FoucaultA Companion to GenethicsA Companion to GenethicsA Companion to HumeA Companion to KantA Companion to Phenomenology and ExistentialismA Companion to PragmatismA Companion to the Philosophy of ActionA Companion to the Philosophy of BiologyA Companion to the Philosophy of LiteratureA Conceptual History of PsychologyA Critique of Naturalistic Philosophies of MindA Cursing Brain?A Delicate BalanceA Farewell to AlmsA Frightening LoveA Future for PresentismA Guide to the Good LifeA History of PsychiatryA History of the MindA Life Worth LivingA Manual of Experimental PhilosophyA Map of the MindA Metaphysics of PsychopathologyA Mind So RareA Natural History of Human MoralityA Natural History of Human ThinkingA Natural History of VisionA Parliament of MindsA Philosopher Looks at The Sense of HumorA Philosophical DiseaseA Philosophy of BoredomA Philosophy of Cinematic ArtA Philosophy of CultureA Philosophy of EmptinessA Philosophy of FearA Philosophy of PainA Physicalist ManifestoA Place for ConsciousnessA Question of TrustA Research Agenda for DSM-VA Revolution of the MindA Sentimentalist Theory of the MindA Stroll With William JamesA Tear is an Intellectual ThingA Theory of FreedomA Thousand MachinesA Universe of ConsciousnessA Very Bad WizardA Virtue EpistemologyA World Full of GodsA World Without ValuesAbout FaceAbout the Beginning of the Hermeneutics of the SelfAction and ResponsibilityAction in ContextAction Theory, Rationality and CompulsionAction, Contemplation, and HappinessAction, Emotion and WillAdam SmithAdaptive DynamicsAddictionAddictionAddiction and ResponsibilityAddiction Is a ChoiceAdvances in Identity Theory and ResearchAftermathAfterwarAgainst AdaptationAgainst AutonomyAgainst BioethicsAgainst HappinessAgainst HealthAgency and ActionAgency and AnswerabilityAgency and EmbodimentAgency and ResponsibilityAgency, Freedom, and Moral ResponsibilityAl-JununAlain BadiouAlain BadiouAlasdair MacIntyreAlien Landscapes?Altered EgosAn Anthology of Psychiatric EthicsAn Ethics for TodayAn Intellectual History of CannibalismAn Interpretation of DesireAn Introduction to EthicsAn Introduction to Kant's Moral Philosophy An Introduction to Philosophy of EducationAn Introduction to the Philosophy of MindAn Introduction to the Philosophy of MindAn Introduction to the Philosophy of PsychologyAn Introductory Philosophy of MedicineAn Odd Kind of FameAnalytic FreudAnalytic Philosophy in AmericaAncient AngerAncient Models of MindAncient Philosophy of the SelfAngerAnimal LessonsAnimal MindsAnimals Like UsAnnihilationAnother PlanetAnswers for AristotleAnti-ExternalismAnti-Individualism and KnowledgeAntigone’s ClaimAntipsychiatryAre We Hardwired?Are Women Human?Arguing about DisabilityArguing About Human NatureAristotle and the Philosophy of FriendshipAristotle on Practical WisdomAristotle's ChildrenAristotle's Ethics and Moral ResponsibilityAristotle, Emotions, and EducationArt & MoralityArt After Conceptual ArtArt in Three DimensionsArt, Self and KnowledgeArtificial ConsciousnessArtificial HappinessAspects of PsychologismAsylum to ActionAtonement and ForgivenessAttention is Cognitive UnisonAutobiography as PhilosophyAutonomyAutonomy and Mental DisorderAutonomy and the Challenges to LiberalismBabies by DesignBackslidingBadiouBadiou's DeleuzeBadiou, Balibar, Ranciere: Rethinking EmancipationBare Facts And Naked TruthsBasic Desert, Reactive Attitudes and Free WillBattlestar Galactica and PhilosophyBeautyBecoming a SubjectBecoming HumanBehavingBehavioral Genetics in the Postgenomic EraBeing AmoralBeing HumanBeing Mentally Ill: A Sociological Theory Being No OneBeing Realistic about ReasonsBeing ReducedBeing YourselfBelief's Own EthicsBending Over BackwardsBerlin Childhood around 1900Bernard WilliamsBertrand RussellBetter than BothBetter Than WellBetween Two WorldsBeyond HealthBeyond Hegel and NietzscheBeyond KuhnBeyond LossBeyond Moral JudgmentBeyond PostmodernismBeyond ReductionBeyond the DSM StoryBioethicsBioethics and the BrainBioethics in the ClinicBiological Complexity and Integrative PluralismBiology Is TechnologyBiosBipolar ExpeditionsBlackwell Companion to the Philosophy of EducationBlindsight & The Nature of ConsciousnessBlues - Philosophy for EveryoneBlushBob Dylan and PhilosophyBody ConsciousnessBody Image And Body SchemaBody ImagesBody LanguageBody MattersBody WorkBody-Subjects and Disordered MindsBoundBoundaries of the MindBoyleBrain Evolution and CognitionBrain FictionBrain, Mind, and Human Behavior in Contemporary Cognitive ScienceBrain-WiseBrainchildrenBrains, Buddhas, and BelievingBrainstormingBrave New WorldsBreakdown of WillBrief Child Therapy Homework PlannerBrief Inquiry into the Meaning of Sin and FaithBrief Therapy Homework PlannerBritain on the CouchBrute RationalityBuffy the Vampire Slayer and PhilosophyBut Is It Art?Camus and SartreCartesian LinguisticsCartographies of the MindCarving Nature at Its JointsCase Studies in Biomedical Research EthicsCassandra's DaughterCato's TearsCausation and CounterfactualsCauses, Laws, and Free WillChanging Conceptions of the Child from the Renaissance to Post-ModernityChanging the SubjectChaosophyCharacter and Moral Psychology Character as Moral FictionCharles DarwinCherishmentChildhood and the Philosophy of EducationChildrenChildren, Families, and Health Care Decision MakingChoices and ConflictChoosing Not to ChooseChristmas - Philosophy for EveryoneCinema, Philosophy, BergmanCinematic MythmakingCity and Soul in Plato's RepublicClassifying MadnessClear and Queer ThinkingClinical EthicsClinical Psychiatry in Imperial GermanyCodependent ForevermoreCoffee - Philosophy for EveryoneCognition and the BrainCognition of Value in Aristotle's EthicsCognition Through Understanding: Self-Knowledge, Interlocution, Reasoning, ReflectionCognitive BiologyCognitive FictionsCognitive Neuroscience of EmotionCognitive Systems and the Extended MindCognitive Systems and the Extended Mind Cognitive Theories of Mental IllnessCoherence in Thought and ActionCollected Papers, Volume 1Collected Papers, Volume 2College SexComedy IncarnateCommitmentCommunicative Action and Rational ChoiceCompetence, Condemnation, and CommitmentConcealment And ExposureConceptual Analysis and Philosophical NaturalismConceptual Art and PaintingConceptual Issues in Evolutionary BiologyConfessionsConfucianismConnected, or What It Means to Live in the Network SocietyConquest of AbundanceConscience and ConvenienceConsciousnessConsciousnessConsciousnessConsciousness ConsciousnessConsciousness and Its Place in NatureConsciousness and LanguageConsciousness and Mental LifeConsciousness and MindConsciousness and the NovelConsciousness and the SelfConsciousness EmergingConsciousness EvolvingConsciousness ExplainedConsciousness in ActionConsciousness RecoveredConsciousness RevisitedConsciousness, Color, and ContentConsole and ClassifyConstructing the WorldConstructive AnalysisContemporary Debates In Applied EthicsContemporary Debates in Moral TheoryContemporary Debates in Philosophy of BiologyContemporary Debates in Philosophy of MindContemporary Debates in Political PhilosophyContemporary Debates in Social PhilosophyContemporary Perspectives on Natural LawContested Knowledge: Social Theory TodayContesting PsychiatryContext and the AttitudesContinental Philosophy of ScienceControlControlling Our DestiniesConversations About Psychology and Sexual OrientationCopernicus, Darwin and FreudCrazy for YouCreating a Life of Meaning and CompassionCreating ConsilienceCreating HysteriaCreating Mental IllnessCreating Scientific ConceptsCreating the American JunkieCreation, Rationality and AutonomyCreatures Like Us?Crime and CulpabilityCrime, Punishment, and Mental IllnessCrimes of ReasonCritical New Perspectives on Attention Deficit/Hyperactivity DisorderCritical PsychiatryCritical PsychologyCritical ResistanceCritical Thinking About PsychologyCritical VisionsCross and KhoraCruel CompassionCTRL [SPACE]Cultural Psychology of the SelfCultural Theory: An IntroductionCulture and Psychiatric DiagnosisCulture and Subjective Well-BeingCulture of DeathCultures of NeurastheniaCurious EmotionsCurrent Controversies in Experimental PhilosophyCustom and Reason in HumeCustomers and Patrons of the Mad-TradeCutting God in Half - And Putting the Pieces Together AgainCylons in AmericaDamaged IdentitiesDamasio's Error and Descartes' TruthDangerous EmotionsDaniel DennettDaniel DennettDark AgesDarwin and DesignDarwin's Dangerous IdeaDarwin's LegacyDarwin, God and the Meaning of LifeDarwinian PsychiatryDarwinian ReductionismDarwinizing CultureDating: Philosophy for EveryoneDeathDeathDeath and CharacterDeath and CompassionDeath and the AfterlifeDebating DesignDebating HumanismDecision Making, Personhood and DementiaDecomposing the WillDeconstructing PsychotherapyDeconstruction and DemocracyDeeper Than DarwinDeeper than ReasonDefending Science - within ReasonDefining Psychopathology in the 21st CenturyDegrees of BeliefDelusion and Self-DeceptionDelusions and Other Irrational BeliefsDelusions and the Madness of the MassesDementiaDemons, Dreamers, and MadmenDennett and Ricoeur on the Narrative SelfDennett’s PhilosophyDepression Is a ChoiceDepression, Emotion and the SelfDepthDerrida, Deleuze, PsychoanalysisDescartesDescartes and the Passionate MindDescartes' CogitoDescartes's Changing MindDescartes's Concept of MindDescribing Inner Experience?Descriptions and PrescriptionsDesembodied Spirits and Deanimated Bodies Desert Islands and Other Texts (1953-1974)Desire and AffectDesire, Practical Reason, and the GoodDiagnosing the Diagnostic and Statistical Manual of Mental DisordersDialectics of the SelfDid My Neurons Make Me Do It?Difference and IdentityDigital SoulDimensional Models of Personality DisordersDisability, Difference, DiscriminationDisjunctivismDisorders of VolitionDisorientation and Moral LifeDispatches from the Freud WarsDisrupted LivesDistractionDisturbed ConsciousnessDivided Minds and Successive SelvesDo Apes Read Minds?Do Fish Feel Pain?Do We Still Need Doctors?Does Consciousness Cause Behavior?Does the Woman Exist?Doing without ConceptsDon't Believe Everything You ThinkDonald DavidsonDonald Davidson on Truth, Meaning, and the MentalDoubting Darwin?Dreaming and Other Involuntary MentationDSM-IV SourcebookDSM-IV SourcebookDSM-IV-TR CasebookDworkin and His CriticsDying to KnowDynamics in ActionDysthymia and the Spectrum of Chronic DepressionsEccentricsEducational MetamorphosesEffective IntentionsElbow Room: The Varieties of Free Will Worth WantingEmbodied Minds in ActionEmbodied RhetoricsEmbodied Selves and Divided MindsEmbryos under the MicroscopeEmergencies in Mental Health PracticeEmerging Conceptual, Ethical and Policy Issues in BionanotechnologyEmotionEmotion and ConsciousnessEmotion and PsycheEmotion ExperienceEmotion RegulationEmotion, Evolution, And RationalityEmotional IntelligenceEmotional ReasonEmotional ReasonEmotional TruthEmotions in Humans and ArtifactsEmotions in the Moral LifeEmotions in the Moral LifeEmpathyEmpathy and AgencyEmpathy and Moral DevelopmentEmpathy and MoralityEmpathy in the Context of PhilosophyEmpirical Ethics in PsychiatryEnchanted LoomsEngaging BuddhismEngineering the Human GermlineEnjoymentEnvyEpicureanismEpistemic LuckEpistemologyEpistemology and EmotionsEpistemology and the Psychology of Human JudgmentEros and the GoodErotic MoralityEssays in Social NeuroscienceEssays in the Metaphysics of Mind Essays on Derek Parfit's On What MattersEssays on Free Will and Moral ResponsibilityEssays on Nonconceptual ContentEssays on Philosophical CounselingEssays on Reference, Language, and MindEssays on the Concept of Mind in Early-Modern PhilosophyEssential Sources in the Scientific Study of ConsciousnessEsssential Philosophy of PsychiatryEternal Sunshine of the Spotless MindEthical Conflicts in PsychologyEthical Issues in Forensic Mental Health ResearchEthical Issues in Human CloningEthical TheoryEthicsEthicsEthics and the A PrioriEthics and the Metaphysics of MedicineEthics and Values in PsychotherapyEthics Done RightEthics ExpertiseEthics in Plain EnglishEthics in PracticeEthics in Psychiatric ResearchEthics of PsychiatryEthics without OntologyEuropean Review of Philosophy. Vol. 5Everyday IrrationalityEvil in Modern ThoughtEvolutionEvolution and the Human MindEvolution's RainbowEvolutionary Origins of MoralityEvolutionary PsychologyExamined LifeExamined LivesExistential AmericaExistentialismExistentialism and Romantic LoveExperimental PhilosophyExperimental PhilosophyExperimental PhilosophyExperimental Philosophy, Rationalism, and NaturalismExperiments in EthicsExplaining ConsciousnessExplaining the BrainExplaining the Computational MindExplanatory PluralismExploding the Gene MythExploring HappinessExploring the SelfExpression and the InnerExpressions of JudgmentFaces of IntentionFact and ValueFact and Value in EmotionFacts, Values, and NormsFads and Fallacies in the Social SciencesFaith and Wisdom in ScienceFatherhoodFear of KnowledgeFearless SpeechFeeling Pain and Being in PainFeelings and EmotionsFeelings of BeingFellow-Feeling and the Moral LifeFeminism and Its DiscontentsFeminism and Philosophy of ScienceFeminist Ethics and Social and Political PhilosophyFeminist Interpretations of Rene DescartesFeminist TheoryField Notes from ElsewhereFinding Consciousness in the BrainFingerprints of GodFlesh in the Age of ReasonFolk Psychological NarrativesFolk Psychology Re-AssessedForces of HabitForgivenessForgiveness and LoveForgiveness and RetributionFoucault 2.0Foucault and PhilosophyFoucault NowFoucault, Psychology and the Analytics of PowerFoundational Issues in Human Brain MappingFoundations of Ethical Practice, Research, and Teaching in PsychologyFour Views on Free WillFree WillFree WillFree WillFree WillFree Will and Action ExplanationFree Will and LuckFree Will And Moral ResponsibilityFree Will as an Open Scientific ProblemFree Will, Agency, and Meaning in LifeFree: Why Science Hasn't Disproved Free WillFreedomFreedom and DeterminismFreedom And NeurobiologyFreedom and ResponsibiltyFreedom and ValueFreedom EvolvesFreedom RegainedFreedom vs. InterventionFreedom, Fame, Lying, and BetrayalFreudFreud and the Question of PseudoscienceFreud As PhilosopherFreud's AnswerFreud, the Reluctant PhilosopherFriedrich NietzscheFrom Chance to ChoiceFrom Clinic to ClassroomFrom Complexity to LifeFrom Enlightenment to ReceptivityFrom Knowledge to Wisdom: A Revolution for Science and the HumanitiesFrom Morality to Mental HealthFrom Passions to EmotionsFrom Philosophy to PsychotherapyFrontiers of ConsciousnessFrontiers of JusticeFurnishing the MindGalileo in PittsburghGenderGender and Mental HealthGender in the MirrorGender TroubleGenesGenes, Women, EqualityGenetic Nature/CultureGenetic ProspectsGenetic ProspectsGenetic SecretsGenocide's AftermathGenomes and What to Make of ThemGerman Idealism and the JewGerman PhilosophyGetting HookedGilles DeleuzeGlobal PhilosophyGluttonyGod and Phenomenal ConsciousnessGoffman's LegacyGoing Amiss in Experimental ResearchGoodness & AdviceGrassroots SpiritualityGrave MattersGrave MattersGreedGreek Models of Mind and SelfGut ReactionsHabilitation, Health, and AgencyHabits of MindHallucinationHandbook of BioethicsHandbook of EmotionsHappinessHappinessHappinessHappinessHappiness and EducationHappiness and the Good LifeHappiness Is OverratedHappiness, Death, and the Remainder of LifeHard LuckHarmful ThoughtsHaving the World in ViewHealing PsychiatryHealing the Soul in the Age of the BrainHealth, Illness and DiseaseHealth, Science, and Ordinary LanguageHegelHeidegger and a Metaphysics of FeelingHeidegger, Metaphysics and the Univocity of BeingHermann von Helmholtz's MechanismHermeneutics As PoliticsHeterophobiaHeterosyncraciesHeuristics and BiasesHeuristics and the LawHidden ResourcesHidden SelvesHiding from HumanityHigh Art LiteHistorical OntologyHistory of Psychiatry and Medical PsychologyHistory, Historicity And ScienceHobbesHomosexualitiesHope and Dread in PsychoanalysisHot ThoughtHow Can I Be Trusted?How Can the Human Mind Occur in the Physical Universe?How Children Learn the Meanings of WordsHow Could Conscious Experiences Affect Brains?How Do We Know Who We Are?How Emotions WorkHow Emotions WorkHow History Made the MindHow Images ThinkHow is Nature Possible?How Propaganda WorksHow Science WorksHow Scientific Practices MatterHow Scientists Explain DiseaseHow The Body Shapes The MindHow the Body Shapes the Way We ThinkHow the Mind Explains BehaviorHow the Mind Uses the BrainHow to Make Opportunity EqualHow to Solve the Mind-Body Problemhow to stop timeHow to Think More About SexHow We HopeHow We ReasonHuman CloningHuman Development, Language and the Future of MankindHuman EnhancementHuman Evolution, Reproduction, and MoralityHuman GoodnessHuman Identity and BioethicsHuman NatureHuman NatureHuman Nature and the Limits of ScienceHuman-Built WorldHumanismHumanism, What's That?HumanityHumans, Animals, MachinesHumeHumeHume on Motivation and VirtueHusserlHystoriesI of the VortexI Was WrongIdeas that MatterIdentifying the MindIdentity and Agency in Cultural WorldsIgnorance and ImaginationIllnessImagination and Its PathologiesImagination and the Meaningful BrainImagining NumbersImmortal RemainsImproving Nature?In Defense of an Evolutionary Concept of HealthIn Defense of SentimentalityIn Love With LifeIn Praise of Athletic BeautyIn Praise of the WhipIn Pursuit of HappinessIn Search of HappinessIn the Name of GodIn the Name of IdentityIn the Space of ReasonsIn Two MindsIncompatibilism's AllureIndividual Differences in Conscious ExperienceInfinity and PerspectiveInformation ArtsInformed Consent in Medical ResearchIngmar Bergman, Cinematic PhilosopherInhuman ThoughtsInner PresenceInsanityIntegrating Psychotherapy and PharmacotherapyIntegrity and the Fragile SelfIntelligent VirtueIntentionIntentionality, Deliberation and AutonomyIntentions and IntentionalityIntentions and IntentionalityInterpreting MindsInterpreting NietzscheIntroducing Greek PhilosophyIntrospection and ConsciousnessIntrospection VindicatedIntuition, Imagination, and Philosophical MethodologyIntuitionismInvestigating the Psychological WorldIrrationalityIrrationalityIs Academic Feminism Dead?Is It Me or My Meds?Is Long-Term Therapy Unethical?Is Oedipus Online?Is Science Neurotic?Is Science Value Free?Is the Visual World a Grand Illusion?Is There a Duty to Die?Issues in Philosophical CounselingJacques LacanJacques RancièreJacques RanciereJean-Paul SartreJohn McDowellJohn SearleJohn Searle's Ideas About Social RealityJohn Stuart MillJohn Stuart Mill and the Writing of CharacterJoint AttentionJokesJonathan EdwardsJudging and UnderstandingJustice for ChildrenJustice in RobesJustice, Luck, and KnowledgeKantKant and MiltonKant and the Fate of AutonomyKant and the Limits of AutonomyKant and the Role of Pleasure in Moral ActionKant on Freedom, Law, and HappinessKant on Moral AutonomyKant's Anatomy of EvilKant's Anatomy of the Intelligent MindKant's Theory of VirtueKarl JaspersKarl PopperKey Concepts in PhilosophyKierkegaardKierkegaard as PhenomenologistKierkegaard's Concept of DespairKinds of MindsKinds, Things, and StuffKnowing, Knowledge and BeliefsKnowledge MonopoliesKnowledge, Belief, and CharacterKnowledge, Possibility, and ConsciousnessLacanLack of CharacterLack of CharacterLanguageLanguage in ContextLanguage, Consciousness, CultureLanguage, Culture, and MindLanguage, Vision, and MusicLaw and the BrainLaw, Liberty, and PsychiatryLaws, Mind, and Free WillLeaving YouLectures on the History of Political PhilosophyLevelling the Playing FieldLiberal Education in a Knowledge SocietyLiberatory PsychiatryLife and ActionLife at the Texas State Lunatic Asylum, 1857-1997Life Is Not a Game of PerfectLife of the MindLife's FormLife, Death, & MeaningLife, Death, and Meaning: Key Philosophical Readings on the Big Questions Life, Liberty, and the Pursuit of UtilityLife, Sex, and IdeasLight in the Dark RoomLike a Splinter in Your MindLiving and Dying WellLiving NarrativeLiving Outside Mental IllnessLiving with DarwinLiving With One’s PastLockeLocke LockeLogic and the Art of Memory Loneliness in Philosophy, Psychology, and LiteratureLooking for SpinozaLooking for The StrangerLost SoulsLOT 2LoveLoveLove's ConfusionsLove's VisionLove, Friendship, and the SelfLove, Sex & TragedyLuckyLudwig WittgensteinLustLyingMachine ConsciousnessMad for FoucaultMad TravelersMade with WordsMadness And Death In PhilosophyMadness and DemocracyMadness at HomeMadness Is CivilizationMaking Natural KnowledgeMaking Sense of EvolutionMaking Sense of Freedom and ResponsibilityMaking the DSM-5Making the Social WorldMaking TruthMale Female EmailMan, Beast, and ZombieMandated Reporting of Suspected Child AbuseManiaManic Depression and CreativityMapping the Edges and the In-betweenMapping the Future of BiologyMarcus AureliusMaster PassionsMatters of the MindMe++Meaning and Moral OrderMeaning and Value in a Secular AgeMeaning in LifeMeaning in Life and Why It MattersMeaning, Basic Self-Knowledge, and MindMeasuring HappinessMeasuring PsychopathologyMedia MadnessMedical Enhancement and PosthumanityMedicine and Philosophy in Classical AntiquityMedicine of the PersonMedicine, Mental Health, Religion, Science and Well-BeingMelancholy And the Care of the SoulMelancholy and the Otherness of GodMementoMemory and NarrativeMental ActionsMental CausationMental Causation and OntologyMental HealthMental Health At The CrossroadsMental Health Policy in BritainMerit, Meaning, and Human BondageMerleau-PontyMerleau-Ponty and the Possibilities of PhilosophyMetacognition and Theory of MindMetacreationMetaethical SubjectivismMetaethicsMetal and FleshMetaphors of MemoryMetapoliticsMethods in MindMichel FoucaultMill's UtilitarianismMindMindMind and ConsciousnessMind and CosmosMind and MechanismMind GamesMind in a Physical WorldMind in Everyday Life and Cognitive ScienceMind in LifeMind TimeMind's LandscapeMind, Brain and the Elusive SoulMind, Brain, and Free WillMind, Reason and ImaginationMinding MindsMindreadersMindreading AnimalsMinds and PersonsMinds, Brains, and LawMinds, Ethics, and ConditionalsMindshapingMindsightMindworldsMirror, MirrorMixed FeelingsMockingbird YearsModels of the SelfModern Social ImaginariesModern Theories of JusticeModernity and SubjectivityModernity and TechnologyMoody Minds DistemperedMoral DimensionsMoral FailureMoral ImaginationMoral LiteracyMoral MachinesMoral ParticularismMoral PsychologyMoral Psychology and Human AgencyMoral Psychology, Volume 1Moral Psychology, Volume 2Moral Psychology, Volume 3Moral Psychology: Volume IVMoral RepairMoral Responsibility and Alternative PossibilitiesMoral TribesMoral Value and Human DiversityMorality and Self-InterestMorality in a Natural WorldMorality, Moral Luck and ResponsibilityMotherhoodMotive and RightnessMoving Beyond Prozac, DSM, and the New PsychiatryMultiple Analogies in Science and PhilosophyMultiple Identities & False MemoriesMusic, Madness, and the Unworking of LanguageMy Brain Made Me Do ItMy Double UnveiledMy WayNarrativeNarrative and IdentityNarrative MedicineNarrative PsychiatryNarrative Theory and the Cognitive SciencesNatural Ethical FactsNatural Kinds and Conceptual ChangeNatural MindsNatural-Born CybogsNaturalism and the First-Person PerspectiveNaturalism and the Human ConditionNaturalism in the Philosophy of HealthNaturalism in the Philosophy of HealthNaturalized BioethicsNaturalizing the MindNatureNature and NarrativeNear Death ExperienceNeither Bad nor MadNeither Victim nor SurvivorNeuro-Philosophy and the Healthy MindNeuroethicsNeuroethicsNeurological Foundations of Cognitive Neuroscience Neurophilosophy at WorkNeurophilosophy of Free WillNeuropoliticsNeuropsychoanalysis in PracticeNeuroscience and PhilosophyNew Essays on the Explanation of ActionNew Philosophy for a New MediaNew Versions of VictimsNew Waves in Philosophy of ActionNietzscheNietzsche and Buddhist PhilosophyNietzsche on Ethics and PoliticsNietzsche's TherapyNietzsche, Culture and EducationNietzsche: The Man and His PhilosophyNihil UnboundNoir AnxietyNormative EthicsNormativityNorms of NatureNotebooks 1951-1959Notes Toward a Performative Theory of AssemblyNothing So AbsurdOblivionOn AnxietyOn ApologyOn Being AuthenticOn Being AuthenticOn BeliefOn BullshitOn DelusionOn DesireOn EmotionsOn HashishOn Human RightsOn Loving Our EnemiesOn Nature and LanguageOn PersonalityOn ReflectionOn Romantic LoveOn the EmotionsOn the Freud WatchOn the Government of the LivingOn the Human ConditionOn the InternetOn the Meaning of LifeOn the Philosophy of LawOn the Pragmatics of CommunicationOn the Punitive SocietyOn TruthOn Virtue EthicsOn What MattersOn What We Owe to Each OtherOne Hundred DaysOnflowOnly a Promise of HappinessOntology of ConsciousnessOpen MindedOpen Your EyesOrgans without BodiesOther MindsOur Last Great IllusionOur Own MindsOur Posthuman FutureOur StoriesOut of Its MindOut of Our HeadsOxford Guide to the MindOxford Handbook of Psychiatric EthicsOxford Textbook of Philosophy of PsychiatryPanic DisorderPanpsychism in the WestPartialityPassionate EnginesPassionate EnginesPathologies of BeliefPathologies of ReasonPatient Autonomy and the Ethics of ResponsibilityPC, M.D.Perceiving the WorldPerception & CognitionPerception and Basic BeliefsPerception, Hallucination, and IllusionPerceptual ExperiencePerfecting VirtuePerplexities of ConsciousnessPersistencePersonal AutonomyPersonal Autonomy in SocietyPersonal IdentityPersonal Identity and EthicsPersonal Identity and Fractured SelvesPersonhood and Health CarePersonsPersons and BodiesPersons, Humanity, and the Definition of DeathPersons, Souls and DeathPerspectives on ImitationPerspectives on PragmatismPessimismPhenomenal Concepts and Phenomenal KnowledgePhenomenal ConsciousnessPhenomenal IntentionalityPhenomenology and ExistentialismPhenomenology and Philosophy of MindPhilosophersPhilosophers on MusicPhilosophers without GodsPhilosophical CounselingPhilosophical Counselling and the UnconsciousPhilosophical DevicesPhilosophical Foundations of NeurosciencePhilosophical History and the Problem of ConsciousnessPhilosophical Issues in PsychiatryPhilosophical Issues in PsychiatryPhilosophical Issues in Psychiatry IIPhilosophical MethodologyPhilosophical MidwiferyPhilosophical Myths of the FallPhilosophical Perspectives on DepictionPhilosophical Perspectives on Technology and PsychiatryPhilosophical PracticePhilosophical Reflections on DisabilityPhilosophizing About Sex Philosophizing the EverydayPhilosophy and HappinessPhilosophy and LivingPhilosophy and PsychiatryPhilosophy and PsychotherapyPhilosophy and Science FictionPhilosophy and the EmotionsPhilosophy and the EmotionsPhilosophy and the Interpretation of Pop CulturePhilosophy and the Moving ImagePhilosophy and the NeurosciencesPhilosophy and This Actual WorldPhilosophy As FictionPhilosophy BitesPhilosophy Bites BackPhilosophy for Counselling and PsychotherapyPhilosophy for LifePhilosophy in a New CenturyPhilosophy in an Age of SciencePhilosophy in Children's LiteraturePhilosophy of ActionPhilosophy of ActionPhilosophy of BiologyPhilosophy of BiologyPhilosophy of BiologyPhilosophy of BiologyPhilosophy of BodyPhilosophy of Film and Motion PicturesPhilosophy of LovePhilosophy of Love, Sex, and MarriagePhilosophy of MindPhilosophy of Mind and CognitionPhilosophy of Personal Identity and Multiple PersonalityPhilosophy of PsychologyPhilosophy of Public HealthPhilosophy of SciencePhilosophy of SciencePhilosophy of Technology: The Technological ConditionPhilosophy of the Social SciencesPhilosophy on TapPhilosophy PracticePhilosophy the Day after TomorrowPhilosophy's Role in Counseling and PsychotherapyPhilosophy, Neuroscience and ConsciousnessPhilosophy, Politics, DemocracyPhotography and PhilosophyPhysical RealizationPhysicalism and Its DiscontentsPhysicalism and Mental CausationPhysicalism, or Something Near EnoughPhysician-Assisted DyingPillar of SaltPin-up GrrrlsPlatoPlatoPlato, Not Prozac!Platonic Ethics, Old and NewPluralistic CasuistryPolarities of ExperiencesPolitical EmotionsPopper, Objectivity and the Growth of KnowledgePornPorn StudiesPornography, Sex, and FeminismPortrait of the Psychiatrist as a Young ManPostcolonial DisordersPostpsychiatryPosttraumatic Stress DisorderPower and the SelfPower SplitPractical Autonomy and BioethicsPractical ConflictsPractical Identity and Narrative AgencyPractical PhilosophyPractical RulesPractical Tortoise RaisingPractically ProfoundPracticing Feminist Ethics in PsychologyPragmatic BioethicsPragmatismPragmatism, Old And NewPraise and BlamePredicative MindsPreferences and Well-BeingPrescriptions for the MindPresocraticsPrimary and Secondary QualitiesPrimates and PhilosophersPrivacyPrivileged AccessProblems in MindProblems of RationalityProzac As a Way of LifeProzac BacklashProzac on the CouchPsyche and SomaPsychiatric Aspects of Justification, Excuse and Mitigation in Anglo-American Criminal Law Psychiatric Cultures ComparedPsychiatric Diagnosis and ClassificationPsychiatric EthicsPsychiatric PowerPsychiatric SlaveryPsychiatry and Philosophy of SciencePsychiatry and ReligionPsychiatry as a Human SciencePsychiatry as Cognitive NeurosciencePsychiatry in SocietyPsychiatry in the New MilleniumPsychiatry in the Scientific ImagePsychiatry, Psychoanalysis, And The New Biology Of MindPsycho-Physical Dualism TodayPsychoanalysis and Narrative MedicinePsychoanalysis and the Philosophy of SciencePsychological Concepts and Biological PsychiatryPsychology and PhilosophyPsychology and the Question of AgencyPsychology's Interpretive TurnPsychology, Psychotherapy, Psychoanalysis, and the Politics of Human RelationshipsPsychotherapy and ConfidentialityPsychotherapy As PraxisPublic PhilosophyPunishmentPure ImmanencePurple HazePursuing MeaningQuality of Life and Human DifferenceQueer PhilosophyQuestions for FreudQuestions for FreudQuine and Davidson on Language, Thought and RealityRaceRace in Contemporary MedicineRadiant CoolRadical AlterityRadical ExternalismRadical HopeRational and Social AgencyRational CausationRational Choice in an Uncertain WorldRationality + Consciousness = Free WillRationality and FreedomRationality and the Reflective MindRationality in ActionRawls, Dewey, and ConstructivismRe-creating MedicineRe-EmergenceRe-Engineering Philosophy for Limited BeingsReading AutobiographyReading Bernard WilliamsReading SartreReadings in the Philosophy of TechnologyReal MaterialismReal Natures and Familiar ObjectsReal ScienceRealism in ActionReason & EmancipationReason in ActionReason in PhilosophyReason's GriefReasonably ViciousReasoning About Rational AgentsReasoning in Biological DiscoveriesReasons from WithinReasons without RationalismReclaiming CognitionReclaiming the SoulReconceiving SchizophreniaReconstructing Reason and RepresentationReconstructing the Cognitive WorldRecreative MindsRediscovering EmotionRediscovering EmpathyReference and ExistenceReference and the Rational MindReflections On How We LiveReframing Disease ContextuallyRefusing CareRegulating SexReinventing the SoulRelativism and Human RightsRelativism and the Foundations of PhilosophyRelativism and the Foundations of PhilosophyReliable ReasoningReligion without GodRelying on OthersRemembering HomeResponsibility and PunishmentResponsibility and PunishmentResponsibility from the MarginsRestraining RageRethinking ExpertiseRethinking IntrospectionRethinking Mental Health and DisorderRethinking RapeRethinking the DSMRethinking the Sociology of Mental HealthRethinking the Western Understanding of the SelfReturn to ReasonRevolt, She SaidRichard RortyRichard RortyRichard RortyRichard RortyRichard RortyRichard Rorty's New PragmatismRightsRights, Democracy, and Fulfillment in the Era of Identity PoliticsRise And Fall of Soul And SelfRitalin NationRobert NozickRousseauRousseau and the Dilemmas of Modernity Routledge Philosophy Guidebook to Derrida on DeconstructionRules, Reason, and Self-KnowledgeSaints, Scholars, and Schizophrenics: Mental 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Psychiatry in the New MilleniumReview - Psychiatry in the New Millenium
by Sidney Weissman, Melvin Sabshin, and Harold Eist (editors)
American Psychiatric Press, 1999
Review by Christian Perring, Ph.D.
Dec 7th 2001 (Volume 5, Issue 49)

This collection of articles is put together by psychiatrists at the heart of the establishment of American Psychiatry.  Weissman is at Loyola University Stritch School of Medicine, Sabshin is Medical Director Emeritus of the APA, and Eist is a past president of the APA.  It features articles by notable psychiatrists such as Glen Gabbard, Steven Hyman (director of NIMH), Donald Klein, and Harold Pincus.  So this is as close to a definitive statement about the current and future state of psychiatry as we are likely to get from those at the head of the profession. 

According to the editors, the book is aimed at practicing psychiatrists; the introduction says it is designed to provide “the conceptual tools that will enable him or her to assess and use psychiatry’s vast professional literature base” and also provide “a basis on which to effectively assess the presentations at scientific meetings.” (xxiii).  However, this stated aim seems to sell the book short, since it does more than this.  It gives us an opportunity to assess at least some aspects of psychiatry as it is currently understood, and to contemplate the future role of psychiatry in our society. 

There are twenty chapters grouped into four sections: the first is in two parts, “The Impact of Changing Conceptual, Organizational, and Philosophical Issues and on the Shape of Psychiatry,” and “The Impact of Research Findings on the Shape of Psychiatry,” then The Practice of Psychiatry, The Psychiatric Workforce and Its Education, and finally, The Future.

Joseph Coyle writes on “The Neuroscience Revolution and Psychiatry.”  He sets out come of the advances in out understanding of how mental disorder affects the brain, and some of the discoveries in genetics and molecular psychology.  He expresses hope that our expanded knowledge will lead great advances in treatment through medication, but he also emphasizes the dangers of reductionist attitudes.  He emphasizes that environment and psychotherapy can have measurable effects of people’s emotional lives and their brains.  He also stresses that psychiatric training needs to broad enough to enable psychiatrists to be leaders, and that we need to reverse the current trend of managed care putting the least qualified mental health professionals in charge of mental health care.  The chapter contains a great deal of interesting scientific information, presented in a technical manner that will be intimidating to people who are not familiar with the notation and terminology. 

Weissman’s chapter on psychoanalysis is lightweight.  He defends ten major psychoanalytic concepts by responding to critiques of psychoanalysis.  He says that there are two main reasons why psychoanalysis has been held in disrepute recently.  First, people think that recent advances in neuroscience have undermined it because psychoanalytic thinking is dualist.  Second, philosophers and others have criticized psychoanalysis for failing to meet the criteria of good science.  Weissman’s response it to point out that psychoanalysis is compatible with monism about the mind, and that Freud himself was a monist.  Furthermore, he points out that neuroscience has not provided anything like an explanation of the nature of experience.  He also says that although it is true that psychoanalysis is not as scientific as Newton’s theory of motion, this is not a significant criticism.  He points out, citing Duhem and Quine, that confirmation or falsification is never a simple relation between a single observation and a theory.  He then goes on to discuss familiar concepts of consciousness, the dynamic unconscious, repression, defense mechanisms, models of the psychic apparatus, drives, identification, empathy, and Kohut’s concept of selfobject, giving a few examples to illustrate these concepts. 

This defense of psychoanalysis and in particular his criticism of Adolf Grűnbaum (whose name he consistently misspells throughout the paper) are weak.  Grűnbaum is well aware of the work of Duhem and Quine, and his criticism of Freud rests on a particular argument of Freud’s, which he calls the “Tally argument.”  Weissman says nothing to give the reader any reason to think that psychoanalysis has a good evidential base or is worth taking seriously.  His assertion that people object to psychoanalysis because it is dualistic may be true, but this objection is not one that is taken seriously by any of the informed parties to the debate over psychoanalysis, since it is well known that Freud’s project was ultimately based on the hope that the mind could be understood in terms of brain function and that psychoanalytic theory be vindicated by out understanding of the brain.  Insofar as modern neuroscience is a threat to psychoanalysis, it is because it shows little sign of actually vindicating Freudian models of the mind. 

In the paragraphs setting out psychoanalytic concepts, Weissman seems to take himself as showing their usefulness in relation to his examples.  Of course, his discussion here is so brief that it could not possibly do anything more than hint at a defense of psychoanalysis, and he does not even acknowledge that there may be competing explanations of the phenomena he mentions.  These limitations of space is of course inevitable given the place of the paper in the book – a defense of psychoanalysis would really require a book – but it’s striking that Weissman does not refer to one other work that defends psychoanalysis from its critics.  Not only does Weissman fail to defend psychoanalysis here from anything but the most superficial criticisms, but also his paper exemplifies the shoddy state of thinking about psychoanalysis in psychiatry today.

Joseph A. Flaherty and Boris M. Astrachan write chapter 3 on social psychiatry.  This outlines how social issues and sociological discussion impact on psychiatry.  It includes epidemiology, substance use and abuse, violence, aggression and trauma, and breakdown of family bonds.  The simple message is that sociological issues are relevant to psychiatry.  The chapter contains no controversial claims.

Sidney Weissman writes on psychiatric diagnosis.  He explains how DSM-IV came to be as it is, and how we could improve our classification scheme.  The discussion is a little idiosyncratic.  It does not engage with other major discussions of psychiatric diagnosis.  Daniel Offer’s chapter on “Normality and the Boundaries of Psychiatry” is also eccentric.  This builds on previous work of Offer and Sabshin, and makes the basic point that psychiatrists are better at identifying abnormality than normality.  Studying normal coping methods and ways of living can be helpful to psychiatric practice.

Lois Flaherty’s “The Evolution of Psychiatric Subspecialities” ends this section of papers.  She points out that psychiatry has fewer subspecialities than other areas of medicine, and she suggests this may be due to the psychoanalytic ideal that practitioners should be able to master all psychopathology.  But given the modern pressures of clinical practice, it is inevitable that there will be increasing specialization, and the psychoanalytic idea is now less commonly shared.  Child psychiatry and geriatric psychiatry are the major specialities, but she also discusses clinical neurophysiology, forensic psychiatry, and other subfields, and the effect of increasing specialization on the whole field.  She provides a competent survey of issues.

In Chapter 7, Steven Hyman explains “The Role of Genetics and Molecular Biology in Research on Mental Illness.”  This is basically the information one would also find in a psychiatric textbook.  It is rather technical and only readers with a strong background in biology will be able to follow the details.  There’s very little discussion of the future of any of the wider implications of current research for the future of psychiatry. The chapter deals with a large topic, and so it’s inevitable that it cannot deal with all aspects of the issue, but given the theme of the book, it is still disappointing that the chapter does not venture into more speculation. 

Another chapter of great potential interest is “Functional Brain Imaging: Future Prospects for Clinical Practice,” by Joseph Callicott and Daniel Weinberger.  Neuroimaging has been one of the greatest areas of growth in modern psychiatry and there are often tantalizing announcements of new advances in the field.  The authors start by noting how few clinical applications have resulted from research so far.  The most common application is n the identification of structural pathology.  But the authors note that the structural abnormalities associated with the major mental illnesses are likely to be subtle, and they stress the difficulties of acquiring useful data when scanning people with major mental illnesses.  Given these concerns, they ask whether clinical functional neuroimaging is feasible.  They give a brief but technical summary of recent scientific progress in the field.  The upshot of the summary is that brain imaging cannot yet provide a diagnosis of a patient, but the authors remain optimistic that it will soon produce clinically useful results. New technology is developing that is less invasive, nonradioactive, and which can provide more fine-grained images.

The next section deals with the practice of psychiatry.  First to come under scrutiny is the use of practice guidelines, by John McIntyre, Deborah Zarin and Harold Pincus.  They assert that the APA (American Psychiatric Association) has “developed a rigorous process for the development of practice guidelines.”  (143).  The aim is to assist clinicians and patients in clinical decision-making.  These standards and options provided are not meant to be inviolable rules, but the authors say that exceptions to the recommendations “should be rare and require considerable justification.”  (143). 

            According to the authors, there are at least four reasons for the explosion in the development of practice guidelines in a wide range of professions. 

  1. There has been an exponential growth in our knowledge base, and so it is very difficult to stay abreast of the latest developments, and it is hard to integrate all the data available. 
  2. Health care costs have risen dramatically, and it has become necessary to contain expenditure.  Guidelines help to do this.
  3. National guidelines help to minimize regional variation on treatment approaches.
  4. The availability of guidelines helps patients and potential patients to be more involved in the decision-making process.

Recently in the health care profession, there has been more need for standardized guidelines, and the AMA has provided a series of principles to be followed in the development of guidelines.  The Institute of Medicine identified eight desiderata for guidelines: validity, reproducibility, clinical applicability, clinical flexibility, clarity, multidisciplinary process, scheduled review, and documentation.  (146)

There is also resistance to the use of guidelines.  Some have complained that they lead to a ‘cookbook’ approach to dealing with patients, and that they will limit innovations, as well as increasing professional liability exposure.  The authors suggest that guidelines should acknowledge their limitations, especially with regard to evidence, and this will leave room open for innovation. They also note that APA guidelines emphasize that they are not intended to serve as a standard of medical care, and that they do not ensure a successful outcome of treatment. They also say it is unclear what impact guidelines have on professional practice. 

The authors move on to setting out the APA guidelines for developing guidelines.  The eight stages are:

  • Topic selection,
  • Work group appointment,
  • Evidence definition,
  • Draft development,
  • Review process,
  • Dissemination and implementation,
  • Evaluation, and
  • Revision.

These are very much what one would expect.  The guidelines have the following format:

I.                    Executive Summary (with different recommendation weighted with its level of clinical confidence; substantial, moderate, or on the basis of individual circumstances)

II.                 Disease Definition, Epidemiology, and Natural History (which uses DSM-IV)

III.               Treatment Principles and Alternatives (three broad categories: psychiatric management, psychosocial interventions, and somatic interventions)

IV.              Formulation and Implementation of a Treatment Plan

V.                 Clinical Features Influencing Treatment

VI.              Research Directions

VII.            Individuals and Organizations That Submitted Comments

VIII.         References

Again, these are very much as one would expect.  The authors note that the development of guidelines has helped to identify gaps in psychiatric knowledge.  The APA is taking steps to fill those gaps.  It has formed the APA practice research network (PRN) to increase the communication between researchers and clinicians.  By 2000, it will have over 1000 APA members. 

Glen Gabbard writes an impressive chapter on “The Psychiatrist as Psychotherapist.”  He cites a wide range of data that demonstrate that psychotherapy is effective even with disorders identified as “disorders of the brain” such as schizophrenia and manic depression.  He emphasizes that it is important that psychiatrists continue to perform psychotherapy.  He expresses concern about the trend towards psychiatrists becoming merely dispensers of pills while other people with fewer qualifications do therapy.  He argues that not only does it improve the quality of treatment when it is one and the same person providing psychological and biological treatments, but also this approach can in the long term be the most cost-effective.  One of the major reasons for relapse of people with serious mental illnesses is that they stop taking their medication, and when psychiatrists are psychotherapists, patients tend to keep on taking their medication more than in other treatment circumstances.  While it may save money in the short term to get non-psychiatrists to do psychotherapy, this often turns out to be a false economy.  Of course, it seems likely that Gabbard’s warnings will go unheeded; managed care continues to divide treatment between different specialists, and most of the signs point toward psychiatrists having only one function, to prescribe medication.

            Maybe it is worth lamenting the fact that Gabbard has nothing to report on recent research on new forms of psychotherapy.  He takes it as given that we know the range of forms of psychotherapy that might be available, and while he acknowledges that some may be more appropriate for some kinds of disorders, Gabbard does not focus much on the differences between different kinds of psychotherapy.  One gets the impression that psychiatric research now has no interest in the idea of making psychotherapy better and improving its techniques. 

            The trend away from psychiatric psychotherapists might not alarm the author of the next chapter, Alan Schatzberg, who writes on “Psychopharmacology in the New Millennium.”  He surveys some of the medications that have come into use recently.  These are mostly approved for use as antidepressants, although they are used in a wide range of mental disorders.  The discussion is somewhat technical, depending on many terms from neuroscience, so it may be beyond the understanding of non-specialists.  He does discuss some of the new directions of research on psychopharmacology, but one can’t help keeping in mind that much of the research currently performed is confidential, since it is funded by corporations planning to make a profit from their research. 

            It is good that more attention is being paid to the efficacy of psychiatric medication with special populations, such as women and racial minorities.  It is a little disappointing that he did not mention the use of medication on children, even though such use of medication has increased significantly in recent decades and looks set to continue this upward trend.  Schatzberg emphasizes that the psychopharmacologist of the future will have to have even broader knowledge than before, but this is compatible with retaining an understanding of the whole person and a humanistic approach to mental disorders.  It is not clear, however, what steps the profession is taking to ensure that future researchers on brain processes do not lose sight of the persons who experience mental illnesses.

            Especially interesting is the division of labor between psychotherapy and medication in the treatment of mental disorders, and this is taken up by Mark Levy in “A Clinical Model for Selecting Psychotherapy or Pharmacotherapy.”  There have been some theoretical arguments that they are incompatible with each other, but no empirical evidence backs up such a view.  Indeed, evidence suggests that for many mental disorders, a combination of talk therapy and medication is most effective.  This still leaves us to explain why this is, and what kind of contribution to health each treatment modality makes.  Levy surveys various answers to this question, and also suggests some problems with those answers.  Some have argued, in a “two-track model,” that medication and psychotherapy treat different aspects of a mental disorder, but there’s little evidence to support this as a general thesis.  There are methodological problems too: it can be hard to separate out the effects of the two, since there are psychodynamic issues even in the interaction between a patient and the psychopharmacologist, and the medication can alter the course of psychotherapy.  The alternative to the two-track model is a unified model using an integrated approach, and Levy finds this has many advantages.  He points out that there is an important parallel in the discussion of the comparative benefits of different kinds of psychotherapy, and this leads him to a fascinating discussion of technical eclecticism versus theoretical integration.  He sets our various proposals about how to unify different approaches, and goes into detail in presenting a conceptual model for anticipatory anxiety.  His positive proposal is somewhat provisional and certainly it has elements that some will find problematic, but it merits investigation.  Even if his specific proposals do not win universal agreement, his discussion makes a strong case that these issues are at the center of the future of psychiatric theorizing.  Levy’s brief descriptions of some patients help to bring this point home. 

            In chapter 13, Donald Klein goes into related issues, explaining some of the technical details of trying to measure the effectiveness of psychotherapy compared with pharmacotherapy.  He emphasizes the difficulty of getting reliable data, because of the problem of creating a true pill placebo group.  He says that using studies of people on a wait list as a control group leads to positively biased estimates of efficacy.  He insists that a pill placebo case management control group is necessary in comparing pharmacotherapy with psychotherapy, and suggests that studies that have been performed without such a control group were a waste of time and money.  He is also skeptical about the value of meta-analyses of previous studies.  A 1990 study by Robinson et al. “demonstrated that the investigator’s alligiance may play an overriding role in determining differential treatment outcomes because partialling for allegiance removes any difference in effectiveness between studies.” (p. 227).  He concludes that it is difficult to prove the effectiveness of psychotherapy over placebo or to show any significant differences in different forms of psychotherapy.  Klein’s conclusion is that more careful work needs to be done in measuring the effectiveness of treatment.

The next two chapters have a good deal of overlap, although they have differences in approach.  Steven Sharfstein’s “Less Is More: Financing Mental Health Care for the New Century” details some of the major changes in the in the structuring of psychiatric treatment over the last century, and especially the rise in managed care companies.  His approach is to give a rather sweeping survey of major trends, and he gives only two references, one being the 1952 DSM, and the other being a 1983 APA report on “Madness and Government.”  In striking contrast, Jeremy Lazarus, discussing “Ethical Conduct of the Psychiatrist,” gives three pages of references; he focuses on how the rise in managed care introduces new ethical issues for psychiatrists.  Sharfstein suggests that a major issue is the fact that health insurance does not treat major mental illness and major physical illnesses equally, and lifetime limits on compensation tend to be much less for psychiatric treatment.  He also points out that often outpatient care, day hospital, and residential alternatives for major mental illness is more cost-effective than inpatient care.  For some reason he does not explain, he voices extreme optimism about the future of psychiatric care, saying that the remedicalization of psychiatry will lead to greater integration of mental health care with the rest of medicine, and this will ensure that there will be no more discrimination against the mentally ill.  The challenge for the future is to ensure that mental health care is regulated in an ethical manner, with humane treatment for the seriously ill.  Given that allocation of funds for different forms of health care is inevitable, which is to say that we cannot avoid rationing treatment, Sharfstein points out that the standard methods of cost containment and profit making – “risk selection, denial of care, and the dumping of the most seriously ill,” (247) – need the oversight of government to avoid the problematic policies this mentality can lead to.  He suggests that the APA needs work as an advocate in order to ensure the future excellence of psychiatric treatment. 

Lazarus takes up this point, writing, “The principal ethical question is how health care professionals either balance or integrate their responsibilities as patient advocates and members of society.” (252).  He echoes many of the Sharfstein’s concerns concerning managed care and his predictions about the integration of psychiatry with the rest of medicine.  There are potential ethical problems in the cost containment of managed care and the use of financial incentive for physicians to curtail the care they provide.  He says in the future there may be more ethical issues in the use of technology such as brain scans for diagnostic and treatment purposes, and also as we become increasingly able to use genetic engineering to influence people’s susceptibility to mental illness and to enhance their desirable character traits.  Other examples where psychiatrists may become involved in social issues include the treatment of prisoners condemned to death and of sexually violent predators – the primary problem here is the conflict between the responsibility to the patient and the responsibility to society. 

Psychiatric research on new treatments will continue to pose important ethical questions.  Other perennial issues include the question of when it is unethical for psychiatrists to have romantic or sexual relationships with patients or past-patients.  The question of how to deal with boundaries of the profession need continued attention.  As psychiatry becomes more ruled by the principles of commerce, there is a danger that ethical issues may be left aside, but obviously this is not an ethically allowable outcome.    Lazarus ends with a list of eleven guidelines for psychiatric ethics, which although verging on the platitudinous, are nevertheless important to keep in mind.

The next two chapters, dealing with the psychiatric workforce, focus on the role of immigrant physicians.  James H. Scully explains predictions that there will be a surplus of physicians in the near future, and how ways to deal with this surplus may affect psychiatry.  Some have suggested that the best plan is to reduce the number of immigrant students allowed to enter medical school.  This gives cause for concern in psychiatry, however, because international medical graduates (IMGs) because the psychiatric profession relies heavily on IMGs.  Richard Balon, Rodrigo Muñoz and Nyapati Rao take a stronger stance, pointing out not only how immigrants to the USA have contributed to psychiatric thought and research, but also that, “Poor, severely mentally ill, and minority patients have been and will continue to be treated predominantly by IMGs,” (298) and state categorically that “the United States cannot afford to reduce the number of IMGs in psychiatry.” 

Carolyn Robinowitz surveys the future of psychiatric education.  Her message is that the changes in psychiatry directly affect the knowledge and skills that future psychiatrists will need.  She predicts that the changes in the educational experience will be major, although it is hard to know exactly what they will be.  Certainly neuroscience will be an increasingly important part of psychiatry, but it will still be necessary to use a variety of treatments apart from medication.  It is likely that there will be less training in hospital settings.  Computers and the Internet will have a large effect on how psychiatrists in training get their information and how their abilities are measured.  Maybe the most significant point that Robinowitz makes concerns the level of job-satisfaction of psychiatrists.  She says that many middle-aged and older teachers are dissatisfied, and they communicate this to medical students, making psychiatry a less attractive choice for many students.  This will mean that there will be increased reliance on international medical graduates.  It is important to continue to put energy into faculty development and retention as well as recruitment if psychiatry is to be a vital field.

The book ends with two chapters on the future of psychiatry.  They recap much of the information and many of the ideas of previous chapters.  Steven Mirin engages in “Predictions About the Financing and Delivery of Care.”  He says that mental health care costs have risen for individual services, and the use of these services has also increased.  Managed care organizations (MCOs) have become more prevalent, and they have introduced policies to deal with these rising costs.  This has had significant impact on clinicians, hospitals, and patients, and it will continue to do so.  It is likely that hospitals will have a reduced role in the provision of mental health care, and many hospitals will have to fight for their survival.  Furthermore, psychotherapists and providers of other psychosocial treatments will have to fight against financial pressures to reduce their availability to patients. 

One of the distinctive ideas mentioned by Melvin Sahshin is the role of theory in psychiatry.  He suggests that psychiatry will move away from its current atheoretical tendency to a more theoretical approach grounded in evidence, as the evidence becomes available and it becomes more feasible to formulate testable hypotheses.  He also suggests that there will be a gradual reduction in the stigma associated with mental illness. 

In sum, Psychiatry in the New Millennium provides a broad overview from a mainstream perspective of the current state of psychiatry.  Naturally, some chapters are more thoughtful or careful than others, and there are some differences of opinion between authors, especially concerning the effectiveness of psychotherapy and the role of psychiatrists in providing psychotherapy.  There is a fair amount of overlap of information in different chapters, and the editors could have done more to divide up the topics between different authors, maybe reducing the size of the book a little.  Nevertheless, most of the chapters provide useful surveys of their topics, and I recommend this book to those looking for an inside look at the primary concerns of the leaders of American psychiatry.

© 2001 Christian Perring. First Serial Rights.

Christian Perring, Ph.D., is Chair of the Philosophy Department at Dowling College, Long Island. He is editor of Metapsychology Online Review. His main research is on philosophical issues in psychiatry. He is especially interested in exploring how philosophers can play a greater role in public life. He is available to give talks on many philosophical or controversial issues in mental health.


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