The Clinician in the Psychiatric Diagnostic Process PDF
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The Clinician in the Psychiatric Diagnostic Process Massimo Biondi Angelo Picardi Mauro Pallagrosi Laura Fonzi Editors 123 The Clinician in the Psychiatric Diagnostic Process Massimo Biondi • Angelo Picardi Mauro Pallagrosi • Laura Fonzi Editors The Clinician in the Psychiatric Diagnostic Process Editors Massimo Biondi Angelo Picardi Department of Human Neurosciences Centre for Behavioural Sciences and Sapienza University of Rome Mental Health Rome, Italy Italian National Institute of Health Rome, Italy Mauro Pallagrosi Community Service for Prevention and Laura Fonzi Early Intervention in Mental Health National Institute of Training Rome 1 Local Health Unit Italian Psychoanalytic Society Rome, Italy Rome, Italy ISBN 978-3-030-90430-2 ISBN 978-3-030-90431-9 (eBook) https://doi.org/10.1007/978-3-030-90431-9 © Springer Nature Switzerland AG 2022 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Foreword Several years ago, as a junior doctor I had just joined the Maudsley Hospital in London to be trained to become a psychiatrist. We were a group of young clinicians, having an induction on mental state and risk assessment, and at one point our tutor said to us “sometimes you are sitting with a patient, and you will have a subjective feeling, which you will find difficult to relate back to their words or categorise, but you should pay attention to that, and not ignore it just because it is not explicit in the words of that person.” I have never forgotten that day and that advice, which just brought to us what many psychopathologists had extensively written about, and which has continued to resonate in my clinical practice even now as a senior consul- tant. It is thus with great pleasure that I see in this book an entire, sophisticated body of work able to capture the essence, implications, and full potential of the clinician’s subjective experience in the diagnosis and treatment of mental health problems. To fully appreciate the contemporary relevance of this work, it would be helpful to take a step back, and look at the use, right or wrong, we have been making of diagnostic manuals. On one side, these manuals have allowed us to speak a “com- mon language” in the diagnosis of mental disorders, with great advantages in having a more reliable and comparable way to study mental disorders, across countries and across cultures. Still, these manuals have not left space to the role of intersubjectiv- ity or of the clinician’s subjective experience, in fact, rather the opposite. Generations of clinicians have been trained, and entire services evaluated on the basis of either DSM or ICD diagnostic criteria, with little space to the development of other clini- cal skills, or to the understanding of the complexity of mental health problems and their diagnosis, management, treatment, and outcomes. Furthermore, the distinct nosological categories of diagnostic manuals have not found the same discrete cor- respondence in the neurobiology of such categories. If anything, genetics, biology, neuroimaging, or cognitive sciences have shown us that the areas of overlap are so many that distinct neuropathological processes or biomarkers for separate diagnos- tic categories are yet to be identified. Some of the limitations imposed by these symptom-based diagnostic systems were the push for the creation of the RDOC framework, which has aimed to offer an integration of multiple levels of informa- tion (from genomics and circuits to behavior and self-report) to allow the evaluation of dimensions of functioning spanning the full range of human behavior, of which mental illnesses could be seen as extremes. v vi Foreword While both diagnostic manuals or RDOC constructs could, to an extent, help research investigations, they cannot help exploit the potential that the consideration and evaluation of the intersubjective experience offers to our understanding of men- tal illness and psychopathology. As Jaspers argued after all, human communities, in contrast to animal communities, are “mediated through a relation to something other: through a relation to commonly known purposes in the world, through a rela- tion to truth, through a relation to God (transcendence)” (Jaspers K: Vernunft und Existenz, ed 4. München/Zürich, Piper, 1935/1987; p. 59), and like him we should recognize the impact that intersubjectivity has for us as human beings. The time is thus ripe for the body of work presented in this book. Starting from a historical perspective of the contribution that many psychopathologists have made to our understanding of the role that the intersubjective clinician–patient interaction can play in the diagnostic process, moving to a critical appraisal of how to approach the diagnostic and semi-structured interview, with a discussion of the implications of first-second- and third-person relations. The chapters then run from the knowl- edge that can be derived from the understanding of the other, to the potential that an appraisal of intersubjectivity has in informing the therapeutic relationship and pro- cesses. A central key part of the book is devoted to how neuroscience can help us understand the basis for the intersubjective experience, and how it is actually pos- sible to obtain a reliable psychometric assessment of the multidimensional profile of the psychiatrist’s lived experience during the interview, which can then be validated back to specific psychopathological characteristics. Although much has been written about the quantification of the intersubjective experience in psychiatry, here we find in fact presented in detail the validation and clinical application of a psychometric instrument (the “Assessment of Clinician’s Subjective Experience (ACSE)” scale), which investigates clinicians’ feelings, thoughts, and perceptions related to the clinical encounter in a measurable and quantifiable way. This represents an excellent endeavor in capturing the reliability of the intersubjective experience, on which clinicians themselves can reflect and from which they can then draw to learn about the ongoing relationship, such that the experience derived from the clinical encounter truly informs the diagnostic and therapeutic process, from the very initial phase. As a clinician and a researcher, I cannot but be incredibly attracted by the state- ment of Fonzi and colleagues in this book (Chap. 8) that “the data collected so far seem solid enough to claim that the clinician’s subjective experience, far from being an individual volatile and idiosyncratic reaction, should be seen as an intrin- sic, meaningful and exploitable part of the psychiatric assessment.” This shows us that we can not only learn at the individual level, but we can also use this experi- ence to understand more about the psychopathology that is presented to us and about the possible neurobiological underpinnings of such presentation and interaction. Reading this book and learning about the role of intersubjective experience in psychiatry should not be limited to a niche of passionate phenomenologists, but Foreword vii instead used as a precious resource to raise more questions, and attract the attention of educators and trainees, as well as of those already trained, and at the same time be a source of inspiration for those interested in studying the neuroscientific basis of the human experience. Paola Dazzan July 2021 Institute of Psychiatry, Psychology and Neuroscience King’s College London London, UK Preface It was the year 2008 when the four of us, a small group of researchers of different ages, with diverse clinical experiences and professional lives, teamed up to reflect on the role of the clinician’s subjectivity in the process of psychiatric assessment and therapeutic intervention. While some of us were more involved in clinical work and others in research, we all shared a deep interest in the rich psychopathological literature about the psychiatrist’s ability to “feel” the patient. We were puzzled by the degree to which the concepts in this literature, which we found useful in our clinical work, were largely neglected by the mainstream scientific discourse. At that time, we were all collaborating with the psychiatric department of the Sapienza University of Rome, where interest in phenomenological psychopathology dated back to the days of the direction of Giancarlo Reda, who in the 1970s had spread Minkowski’s thinking through the wards of the psychiatric clinic. Since then, it has always been a major concern, in the department, to teach classical psychopathology to young psychiatrists and to promote the development of a sharp clinical eye. Possibly, our group drew strength from the fact that we were at different stages of our careers and that our professional interests ranged from clinical psychiatry to psy- chotherapy, research, and teaching. At any rate, given that we all shared a deep interest both in the clinical diagnostic process and in scientific research, we felt we could try to pursue the aim of approaching the heritage of the classical authors from a new, empiri- cal perspective, from which this body of scholarship could command greater attention. After all, during those very years, new empirical instruments, such as the Examination of Anomalous Self-Experience (EASE), began to spread across aca- demic and clinical settings. These new instruments encouraged novel approaches to clinical assessment and a reappraisal of the “old-fashioned” phenomenological and psychopathological concepts. However, when we started our reflection, we faced the reality of a world where mainstream psychiatry ignored the clinician’s subjectivity altogether, while a small professional niche deeply rooted in the phenomenological tradition believed in the diagnostic value of the clinician’s feelings despite the absence of solid empirical support for this notion. It was, after all, impossible to provide such support, given the lack of validated measures of the psychiatrist’s subjective experience during the clinical assessment. In order to have any hope of being able to substantially contribute to the field, it was necessary, as daunting as such a task appeared, to attempt to develop and ix x Preface validate a measure of the clinician’s subjective experience. Such an instrument would be necessary to test whether the great phenomenological psychopathologists of the twentieth century were on a reasonably valid path. In this book, we provide a detailed overview of the theoretical background, the meth- odology, the findings, and the future perspectives of our decade-long work along this line of research. The common thread of the book is the role of the clinician’s subjective experience in clinical diagnosis, including its theoretical and practical implications. The diversity of views on the subject is also illustrated, through the lens of a number of con- temporary scholars in phenomenology, psychopathology, and psychotherapy. In Chap. 1, we present an overview of the classical authors, who more than other leaders in psychiatry have dealt with the significance of feelings, empathy, and intu- ition in diagnostic reasoning, thus building the foundations for the current reflection. In Chaps. 2 through 5, a philosophical and clinical outline of the fundamental nature of the processes involved in the psychiatric encounter is drawn, with a focus on the modes of human knowing and psychopathological understanding. Chapter 6 explores the question of whether neuroscience can help, and how, in the development of a better conceptual understanding of the explicit and implicit processes related to intersubjective dynamics. In Chaps. 7 and 8, we describe in detail the development and research applica- tions of the Assessment of Clinician’s Subjective Experience (ACSE) self-report questionnaire, while Chap. 9 illustrates a different empirical approach to the con- cept of Praecox Feeling and its use in the diagnosis of schizophrenia. In Chaps. 10 and 11, the psychotherapeutic perspective is highlighted and dis- cussed, starting with the classical and contemporary psychoanalytic view and end- ing with viewpoints from the field of cognitive therapy. Finally, Chaps. 12 and 13 offer a deep and thoughtful look at the most profound sense of mental illness, which—as a fundamentally human experience—requires human comprehension as well as human care. This comprehensive overview should allow the reader to become familiar with both the theoretical and practical aspects of studying the clinician’s subjective emo- tions and perception during the diagnostic process, and how this experience can be used to gain insight into the patient’s condition. Indeed, we hope that our readers, be them students, residents, trainees, experienced clinicians, or researchers, will be intrigued by the possibility of regaining their own centrality as irreplaceable and scientifically valid instruments of knowing. We deeply thank Claudia S. Copeland, PhD, for her masterful help in editing the chapters. We also express our gratitude to Prof. Paola Dazzan for kindly writing an inspiring foreword to this book. Rome, Italy Massimo Biondi Rome, Italy Angelo Picardi Rome, Italy Mauro Pallagrosi Rome, Italy Laura Fonzi Contents 1 The Clinician’s Subjective Feeling in Psychiatric Diagnosis: A Historical Excursus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Matteo Buonarroti, Laura Fonzi, and Mauro Pallagrosi 2 The Psychiatric Assessment: First Person, Second Person, and Third Person Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Thomas Fuchs and Eugenio Dalpane 3 A Cookbook Recipe for the Clinical and Phenomenologically Informed, Semi-structured Diagnostic Interview . . . . . . . . . . . . . . . . . 37 Mads Gram Henriksen, Lennart Bertil Jansson, and Julie Nordgaard 4 T he Distinction Between Second-Person and Third-Person Relations and Its Relevance for the Psychiatric Diagnostic Interview . . . . 51 Felipe León, Maja Zandersen, Patricia Meindl, and Dan Zahavi 5 Understanding Other Persons. A Guide for the Perplexed . . . . . . . . . . 71 Giovanni Stanghellini 6 Intersubjectivity and Neuroscience in the Diagnostic Process . . . . . . . 81 Massimiliano Aragona 7 Origin and Development of the Assessment of Clinician’s Subjective Experience (ACSE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Mauro Pallagrosi, Angelo Picardi, Laura Fonzi, and Massimo Biondi 8 Evidence Supporting a Role for the Intersubjective Dimension in the Clinical Encounter: Empirical Findings from ACSE Research . . . . . . . . . . . . . . . . . . . . . . . 115 Laura Fonzi, Mauro Pallagrosi, Angelo Picardi, and Massimo Biondi 9 Clinical Judgment of Schizophrenia: Praecox Feeling and the Bizarreness of Contact—Open Controversies . . . . . . . . . . . . . 135 Marcin Moskalewicz and Tudi Gozé 10 The Diagnostic Use of Countertransference in Psychodynamic Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Annalisa Tanzilli and Vittorio Lingiardi xi
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