Thursday, 30 January 2020

What is Therapeutic Necessity?


Introduction

In Herczegfalvy v Austria the European Court of Human Rights ruled that imposed psychiatric treatment without consent did not breach Article 3 of the European Convention of Human Rights (freedom from torture and inhuman or degrading treatment) in situations of medical or therapeutic necessity (Bartlett, 2011: p. 525). In order to grant this warrant to override the usual ethical position of respecting patient autonomy it is necessary to define what medical or therapeutic necessity is. Bartlett, a legal expert, suggested therapeutic necessity should involve “treating the underlying disorder or improving outcomes” in situations of severity (Bartlett, 2011: p. 525) whilst expressing scepticism about psychiatric treatments.
I will argue that Bartlett’s criteria are unnecessarily restrictive as to what a therapeutic objective is (for example can include reducing distress), is overly pessimistic about psychiatric treatment effectiveness, that necessity involves the clinician weighing up several factors and that safeguards exist to oversee clinical decision-making.

1.    Why is Therapeutic Necessity Important?


“A characteristic feature of mental health legislation … is the provision which is made for waiving, in certain cases, that respect for patients’ autonomy, their right not to be treated without their explicit consent, … regarded as a requirement in most fields of medicine.” (Mathews, 2000: p.59)
Psychiatric detention and treatment without consent may be regarded by some as breaching Articles 3 (freedom for torture and inhuman/ degrading treatment),  5 (liberty and security of the person) and 8 (respect for private and family life) of the European Convention of Human Rights (Bartlett, 2012:  352). On the specific issue of enforced treatment without consent the case of Herczegfalvy v Austria is “key” in establishing under which circumstances Article 3 has not been breached (Bartlett, 2011).

“The established principles of medicine are admittedly in principle decisive
in such cases; as a general rule, a measure which is a therapeutic
necessity cannot be regarded as inhuman or degrading. The Court must
nevertheless satisfy itself that the medical necessity has been convincingly
shown to exist.” (Bartlett, 2012: p.365)


Specific advice has been given firstly for necessity (Article 18) and what constitutes therapeutic (Article 19).

The Recommendation of the Committee of Ministers to Member States concerning the protection of the human rights and dignity of persons with mental disorder, Rec(2004)10,.. sets out different criteria for involuntary treatment and involuntary detention. The substantive recommendations concerning involuntary treatment are as follows: Article 18 – Criteria for involuntary treatment A person may be subject to involuntary treatment only if all the following conditions are met: i. the person has a mental disorder; ii. the person’s condition represents a significant risk of serious harm to his or her health or to other persons; iii. no less intrusive means of providing appropriate care are available; iv. the opinion of the person concerned has been taken into consideration. Article 19 – Principles concerning involuntary treatment 1. Involuntary treatment should: i. address specific clinical signs and symptoms; ii. be proportionate to the person’s state of health; iii. form part of a written treatment plan; iv. be documented; v. where appropriate, aim to enable the use of treatment acceptable to the person as soon as possible.” (Bartlett, 2012: p.374)
Legal justification for enforced psychiatric treatment without consent relies on the condition of therapeutic necessity and split into two further conditions – what is therapeutic intervention and what is necessity. 


2. What is Bartlett’s definition of Therapeutic Necessity?


Bartlett, a legal academic, defines therapeutic (as opposed to therapeutically necessary) as “treatments {which} may appropriately be prescribed which are not therapeutically necessary. Treatments which attack the symptoms of a disorder but not the underlying disease are an obvious example” (Bartlett, 2011: p. 533) as well as “treating the underlying disorder or improving outcomes” (Bartlett, 2011: p. 531). The Code of Practice of the Mental Health Act (1983) requires that appropriate treatment “must be treatment which is for the purpose of alleviating or preventing a worsening of the patient’s mental disorder or its symptoms or manifestations” (Bartlett, 2011: p.533). Whereas Bartlett does not regard lessening symptoms as part of therapeutic necessity – only those treatments that target “underlying disease” or improve outcomes (but not outcomes such as improving symptoms). Bartlett further distinguishes between therapeutic appropriateness and therapeutic necessity with only the latter justifying compulsion (Bartlett, 2011: p.534). To discuss this distinction further:
“that an appropriate treatment is available should not mean that a State should… force people to undergo that treatment.  ‘Medical necessity’ as intended by the Court presumably does not mean that without such treatment the patient will suffer death or serious physical injury, since, at least as regards the neuroleptic medication, it is not obvious that this would have been the result in Herczegfalvy.  The degree to which treatment can be enforced in order to safeguard others in society is likely to prove a controversial point” (Bartlett, 2012 p.366).
Bartlett sets further requirements for therapeutic necessity:
 “likelihood of given result… achieve long-term and sustainable change in … underlying disorder…some sort of substantive threshold of degree of benefit… {when} stabilization of a condition that would otherwise worsen may sometimes be all that is realistic, it is possible… that treatments that will reliably achieve this end might …meet… therapeutic necessity test; but the outcomes of treatment over non-treatment must presumably be real, significant and manifest” (Bartlett, 2011: p. 534).
“Is the degree of likelihood of success relevant–that is, even to prevent death, can it be said that a highly intrusive and painful treatment with a low probability of success is ‘medically necessary’? These and many other questions are left unanswered by the standard articulated… While the treating physician may be best placed to make an initial evaluation of the situation.. he or she is too close to the situation for the process to end with him or her…the State’s right to impose treatment raises a variety of political, legal and social issues as well as medical ones. This is not a purely medical matter, and the process must allow for an independent review of the decision” (Bartlett, 2012: p.367).
Bartlett’s own conclusions on psychiatric treatment are that they do not meet his ideal of knowing based on the patient’s own history of a treatment that has a high degree of success with few adverse effects but that in practice
 “serious mental illness involve a considerable amount of trial and error by clinicians in individual cases…results of this process can be mixed: sometimes, drug combinations are found which largely alleviate the disorder with minimal adverse effects; sometimes drug treatments have minimal beneficial effects, following considerable unpleasant adverse effects. In these circumstances, knowledge of probable outcomes in the specific case may be low, and the above standard would not allow compulsory treatment to be used” (Bartlett, 2011: p. 534)
Further,
“reasonable certainty of diagnosis, therapeutically necessary treatment, and outcome should be required before involuntary treatment is contemplated. If such certainty is absent, it is difficult to see that a human rights infringement is ‘balanced’ by a corresponding benefit (if indeed such a balancing is the correct approach), since the benefit is speculative. The requirement that a therapeutic necessity must be ‘convincingly shown to exist’, as required by Herczegfalvy, suggests a medical consensus on the appropriate treatment in the patient’s case, and disagreements between medical professionals are thus particularly problematic” (Bartlett, 2011: p.535).

Summarising Bartlett’s view is the difference between a treatment being appropriate (such as being indicated for a condition) or available and therapeutic necessity. He does not outline what the grounds for necessity are but does seem to acknowledge it is not necessarily life or death severity but even preventing harm to others is potentially controversial (Bartlett, 2012 p.366). Bartlett expects that to meet therapeutic necessity threshold to justify compulsion that proposed treatments should have a known high probability of affecting the underlying causes of disorder and achieving a substantial clinical benefit (Bartlett, 2011: p. 534). Taking into account the realities of clinical practice in psychiatry as well as adverse effects in treatment Bartlett doubts that psychiatric treatments would meet this threshold (Bartlett, 2011: p. 534 and p. 535) and that independent review of treatment plans by clinicians is necessary when compulsion is used (Bartlett, 2012 p.367).

3. Problems with Bartlett’s interpretation of Therapeutic Necessity

There are several problems with Bartlett’s positions – medical treatment in all of medicine does not necessarily have to address the underlying causes of a disorder to be regarded as therapeutic, psychiatric treatments overlap in effectiveness with many general medical treatments regarded as effective, in general medicine as well as psychiatry treatment often involves uncertainty of outcome, adverse effects are common to all types of medical treatment not just psychiatric treatment, his views on what is necessity may be regarded as overly restrictive to clinicians and finally his values seem to be against psychiatric treatment which may have informed his criteria for therapeutic necessity. I shall start with discussions of what is regarded as therapeutic in medicine before moving onto necessity.
Critical psychiatrists offer two models of prescribing goals – one a “disease-centred model” where medication reverses hypothesised mechanisms of disease producing symptoms -similar to Bartlett’s definition of therapeutic - or a “drug-centred model” where a drug is regarded as always harmful and producing many effects of which some may be regarded by the patient as beneficial such as blunting of painful emotions (Yeomans et al, 2015) – which would not meet Bartlett’s criteria. A more sophisticated view of therapeutic interventions in psychiatry has three potential goals: “alleviation of symptoms without affecting the disease course; prevention of progression, but not curative …; and curative or preventive …” (Lieberman et al, 2019: p.794
Sackett - the prime mover behind the “Evidence Based Medicine movement” - along with his co-authors outlined a list of objectives of treatments (Sackett et al, 1991: p. 189) which are relevant to discussions of therapeutic intentions in general medicine as whole as well as psychiatry in particular. Cure as an objective should be applied to circumstances such as a reversal of disease process but in layman terms often refers to situations where the symptoms are eliminated or a disease mechanism is compensated for (such as insulin to replace the body’s own insulin or benzodiazepines are used to greatly reduce the symptoms of alcohol withdrawal). Prevent recurrence refers to situations where treatment is aimed at preventing a return of the medical condition (or maintenance antipsychotics in schizophrenia) and can be expanded to preventing a first occurrence of a condition (such as vaccination to prevent infections) (Huda, 2019: p.80). Limiting deterioration are where interventions are given to prevent further problems such as the use of plasters and surgical fixation to prevent displacement of fractures or skills training to prevent loss of psychosocial functioning in severe mental illness. Many medical conditions are treated to prevent known complications associated with the condition such as the use of antihypertensives in high blood pressure to prevent cardiovascular disease. Relieving distress or symptoms is an important therapeutic goal as it is often distress or other unpleasant experiences labelled as symptoms that bring people to seek out medical help. Examples include painkillers for pain or antidepressants in depression.
These therapeutic goals regarded as legitimate in medicine as a whole and applied to psychiatry in particular are clearly broader than the narrow definition of Bartlett of affecting the underlying cause of the disorder. It should also be noted at this point that treatments used in general medicine do not always affect the underlying cause of the disorder either (Huda, 2019: p.291-292). Although outcomes such as preventing suicide and homicide may be accepted as outcomes by Bartlett they are thankfully relatively infrequent so it is difficult to have studies large enough to demonstrate proven benefit in achieving these outcomes. This should not be used as a reason to rule out psychiatric treatment unless that is one’s intention a priori as other treatment goals are regarded as legitimate in medicine.
In terms of establishing “substantive threshold of degree of benefit”(Bartlett, 2011: p.534) for psychiatric treatments, there is an overlap in effectiveness between medication used in psychiatry and general medicine in achieving therapeutic objectives (Leucht et al, 2012 and Leucht et al, 2015). What is the threshold in establishing substantial benefit? The psychiatric treatment with the largest effectiveness magnitude is electroconvulsive therapy (Huda, 2019: p.284) so if a threshold for substantial benefit is set that excludes antidepressants, antipsychotics and mood stabilisers then the only treatment option left under Bartlett’s criteria for enforced treatment would be electroconvulsive therapy – surely a drastic conclusion and potentially harmful when the excluded treatments may be more appropriate choices for the particular patient.

Bartlett’s point about trial and error in deciding treatments also applies in general medicine given the overlap in effectiveness with psychiatric and general medical treatments. There is often no absolute certainty about treatment in general medicine either. Number Needed to Treat (NNT) is a metric used in the medical literature: it indicates how many people need to be treated with the specified treatment before one person achieves the target significant clinical benefit compared to those given placebo or other control treatment. The NNT for psychiatric treatments overlaps with those of treatments regarded as effective in general medicine (Huda, 2019: p. 285-286). This suggests that there is a similar degree of therapeutic uncertainty in general medicine and psychiatry. As for certainty of diagnosis, there are similar degrees of diagnostic agreement in psychiatry compared to general medicine (Huda, 2019: p.120-143). Finally, problematic adverse effects are frequently found in treatments used in general medicine (Huda, 2019: 288-289). One argument that could be used by Bartlett is that he is discussing enforced treatments not treatments in everyday practice but the comparison presented here is relevant – that treatments in psychiatry are similar in some important respects to those used in general medicine and fulfil therapeutic criteria. The question of whether they should be enforced then rests on the necessity.

An article by Curtice summarised several of the crucial issues when it comes to necessity:

Margin of appreciation …clinical decisions that are proportional, therapeutically necessary and in keeping with accepted clinical practice are very unlikely to be outside this margin…
Proportionality Clinical intervention needs to balance the severity of the effect of the intervention with the severity of the presenting clinical problem, i.e. be a proportionate response to a clinical scenario.
Threshold of severity to engage Article 3 Ill-treatment must attain a minimum level of severity; assessment of this minimum is relative. ...” (Curtice, 2008: p. 390)

The concept of necessity requires balancing several factors to demonstrate that the therapeutic intervention is “proportionate response to a clinical scenario” (Curtice, 2008: p.390). These factors include “severity” of the problem (degree of symptoms, degree of impairment and probability of improvement if no treatment is offered as well as probability and nature of consequent risks) and “severity” of proposed treatment (the nature of the treatment, the probability and nature of adverse effects). There is also the question of probability of the treatment being effective but this also needs balanced with the consequences of not treating the problem – the worse the prognosis the more likely a low chance of success would be regarded as justified by necessity. Examples from clinical practice are now discussed.

An elated manic patient may wish to continue in this state (though there are often periods of mixed moods including depressed mood) and not see any problem with spending large amounts of money or reckless impulsive decisions that may cause problems such as sexual activity with people other than their spouse. The clinician may decide that the priority is to reduce the manic symptoms which should also have the benefit of preventing complications in the person’s life by their disinhibited behaviour. (One patient told me “you spoilt my fun” when I had reduced their manic symptoms). A depressed patient who is suicidal may not agree with the doctor for starting treatment with the therapeutic goal of reducing symptoms and preventing occurrence of suicide: they may believe they deserve to suffer and die because of guilt, they may think treatment is pointless because of depressive pessimism, they may prioritise harm avoidance of treatment side-effects A patient with what the doctor regards as delusions or hallucinations may believe in the truth of what the doctor describes as psychotic symptoms. They may want to have any associated distress reduced but in consonant with their beliefs/ hallucinations (such as the persecution ending from persecutors). Apart from reducing distress the doctor may wish to prevent the occurrence of events – such as self-harm or aggression- that may be associated with the psychosis.
Weighing up the potential harms with treatment with the consequent risks of not treating is easier for certain risks – if the patient is a higher risk to others or self and harder for others – such as for continued presence of what seems mild-moderate distress or impaired functioning. Deciding on necessity depends on how one values these different factors. Sometimes the conclusion of weighing up these factors is that no treatment is indicated. This type of weighing up these factors is the heart of clinical practice with the additional complication of over-riding autonomy.  Although Bartlett expresses the view that decisions about enforced treatment are more than medical decisions (Bartlett, 2012: p.367) these decisions take place within the context of a legal framework with limits on medical decision-making, often with guidance such as the Code of Practice in England and Wales to provide the principles that should guide the values used to underpin decision-making  with supervisory procedures such as appeals and Tribunals to oversee the use if compulsory treatments. Bartlett focusses on the right of autonomy but ignores other rights such as the right to life.
Bartlett’s own values are at a minimum highly sceptical about psychiatric treatments. He puts forwards his own view that “benefits of psychiatric medication are not necessarily clear-cut, and the risks can be significant” (Bartlett, 2011: p.517) despite the overlap in effectiveness and adverse effects with treatments used in general medicine as discussed above. Contrary to his own claim to want a “balanced reflection” (Bartlett 2011; p. 517) barely mentions any benefits but instead discusses at length adverse effects including a claim that antipsychotics kills more people that it saves which is contradicted by the research evidence that antipsychotics reduce mortality (Tiihonen et al, 2009). This illustrates the perils of relying on balanced accurate evidence from someone advocating a legal argument.

Bartlett describes psychiatric medication as “mind-altering drugs” (Bartlett, 2011: p.535) – a highly value-laden term that makes the medication sound frightening but just highlights conceptual confusion. After all, psychiatric medication is used to benefit people with mental health conditions whom are regarded as having unpleasant, distressing or impaired functioning of mind– hence the therapeutic aim would to be alter the state of mind in a beneficial way surely? Which begs the question what does Bartlett think psychiatric treatment should alter? The feet? These values may inform Bartlett’s views that only reversing the underlying causes of the condition or better (unspecified) outcomes but not reducing symptoms should be regarded as valid therapeutic necessity to justify enforced treatment. However, given most psychiatric treatments are justified on clinical grounds for reducing symptoms and does not reverse underlying mechanisms of mental disorders (many of which are unknown) (see discussion above) Bartlett’s proposals -perhaps influenced by his values towards psychiatric treatment - would rule out of bounds most psychiatric treatments as fulfilling therapeutic necessity criteria.

Therapeutic objectives apart from affecting underlying causes pf disorder or preventing outcomes – such as reducing distress or limiting deterioration – are regarded as legitimate in general medical practice. Psychiatric treatments overlap in effectiveness with treatments in general medicine and setting too high a threshold to justify enforced treatment would leave only electroconvulsive therapy as the only compulsory treatment option. Uncertainty of treatment response also occurs in general medicine. Necessity involves a balancing of the likelihood and nature of benefits and harms of proposed treatment versus the likely outcomes and risks of the patient’s clinical state. There are various laws, guidance and supervisory procedures to oversee the medical decision making. Bartlett’s statements on psychiatric treatments suggest his values are against medication which influence his criteria for therapeutic necessity.

4. Conclusion

Bartlett set out restrictive criteria for therapeutic necessity over-riding autonomy and justifying enforced treatment for mental disorder – affecting underlying causes of the disorder and /or affecting outcomes apart from reducing symptoms as well as requiring lack of uncertainty over benefits and expressed scepticism over psychiatric treatment in terms of effectiveness and adverse effects. He argued these are not solely medical decisions.
I argued therapeutic necessity is a conjunction of two terms – what is therapeutic and what is necessity. Therapeutic involves a broad series of potential therapeutic goals such as preventing occurrence of negatively perceived outcomes or relieving distress (Sackett et al, 1991: 189) rather than Bartlett’s narrow definition. Psychiatric treatments are in many ways similar to treatments in general medicine in terms of effectiveness, uncertainty over benefit and propensity to adverse effects. Bartlett’s scepticism over psychiatric treatments seem to be underpinned by values biased against psychiatric medication. Necessity involves judgements by clinicians as to the current severity and risk of adverse outcomes of the patient’s current clinical situation and that of the proposed treatment. These judgments and actions by clinicians are limited by statute with guidance on how to implement the laws and supervision of clinical practice for example by review tribunals.

References

Bartlett, P., 2011. ‘The necessity must be convincingly shown to exist’: Standards for compulsory treatment for mental disorder under the Mental Health Act 1983. Medical law review19(4), pp.514-547.
Bartlett, P., 2012. Chapter 14 Rethinking Herczegfalvy: the Convention and the control of psychiatric treatment in Brems, E. ed., 2012. Diversity and European human rights: rewriting judgments of the ECHR. Cambridge University Press.
Bloch, S.E. and Chodoff, P.E., 1991. Psychiatric ethics. Oxford University Press
Curtice, M., 2008. Article 3 of the Human Rights Act 1998: implications for clinical practice. Advances in Psychiatric Treatment14(5), pp.389-397.
Emanuel, E.J. and Emanuel, L.L., 1992. Four models of the physician-patient relationship. Jama267(16), pp.2221-2226
Fulford, K.W.M., Smirnov, A.Y.U. and Snow, E., 1993. Concepts of disease and the abuse of psychiatry in the USSR. The British Journal of Psychiatry162(6), pp.801-810
Hope, T., 2004. A very short introduction to medical ethics.Oxford University Press, Oxford
Huda, A.S., 2019. The Medical Model in Mental Health: An Explanation and Evaluation. Oxford University Press, Oxford.
Lieberman, J.A., Small, S.A. and Girgis, R.R., 2019. Early detection and preventive intervention in schizophrenia: from fantasy to reality. American Journal of Psychiatry176, pp.794-810
Leucht, S., Hierl, S., Kissling, W., Dold, M. and Davis, J.M., 2012. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. The British Journal of Psychiatry200(2), pp.97-106.
Leucht, S., Helfer, B., Gartlehner, G. and Davis, J.M., 2015. How effective are common medications: a perspective based on meta-analyses of major drugs. BMC medicine13(1), p.253.
Matthews, E., 2000. Autonomy and the psychiatric patient. Journal of applied philosophy, pp.59-70.
Sackett D.L., Haynes R.B., Guyatt G.H. & Tugwell P., 1991 Clinical Epidemiology: A Basic Science for Clinical Medicine (Second Edition) Boston/Toronto/London. Little, Brown and Company
Tiihonen, J., Lönnqvist, J., Wahlbeck, K., Klaukka, T., Niskanen, L., Tanskanen, A. and Haukka, J., 2009. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). The Lancet, 374(9690), pp.620-627.
Yeomans, D., Moncrieff, J. and Huws, R., 2015. Drug-centred psychopharmacology: a non-diagnostic framework for drug treatment. BJPsych Advances21(4), pp.229-236.

Sunday, 8 December 2019

Values underpinning "therapeutic necessity" in mental health legislation

Why is there disagreement over “therapeutic necessity” in mental health law?

Introduction

In Herczegfalvy v Austriathe European Court of Human Rights ruled that imposed psychiatric treatment without consent did not breach Article 3 of the European Convention of Human Rights (freedom from torture and inhuman or degrading treatment) in situations of medicalor therapeutic necessity(Bartlett, 2011: p. 525). In order to grant this warrant to override the usual ethical position of respecting patient autonomy it is necessary to define what medical ortherapeutic necessityis. Bartlett, a legal expert, suggested therapeutic necessity should involve “treating the underlying disorder or improving outcomes” in situations of severity (Bartlett, 2011: p. 525). The courts on medical matters tend to take the view of medical experts in their field of expertise. 
I will argue that therapeutic necessityis a conjunction of two terms – what is therapeuticand what is necessity.Therapeuticinvolves a broad series of potential therapeutic goals such as preventing occurrence of negatively perceived outcomes or relieving distress (Sackett et al, 1991: 189) rather than Bartlett’s narrow definition but these goals ostensibly are supposed to be based on patient values not imposed medical values (Sackett et al, 1991). Necessityinvolves judgements by clinicians as to the current severity and risk of adverse outcomes. These judgments involve values and the decision as to whether they justify compulsion also involves value judgements.
Although much work on enforced detention and treatment is centred on autonomy even if this issue is resolved satisfactorily these ethical warrants for therapeutic necessitystill heavily involve value judgements. In particular people may value autonomy differently versus other rights such as the right to life the disputes over this issue are unlikely to be resolved.

When is enforced psychiatric treatment legally justifiable?

“A characteristic feature of mental health legislation … is the provision which is made for waiving, in certain cases, that respect for patients’ autonomy, their right not to be treated without their explicit consent, … regarded as a requirement in most fields of medicine.” (Mathews, 2000: p.59)
Psychiatric detention and treatment without consent may be regarded by some as breaching Articles 3 (freedom for torture and inhuman/ degrading treatment),  5 (liberty and security of the person) and 8 (respect for private and family life) of the European Convention of Human Rights (Bartlett, 2012:  352). On the specific issue of enforced treatment without consent the case of Herczegfalvyv Austria is “key” in establishing under which circumstances Article 3 has not been breached (Bartlett, 2011). 

Mr Herczegfalvy was detained and treated for “paranoia querulans” – essentially a diagnosis used for people who are suspicious and excessively questioning - (after transfer from prison where he was violent) which involved use of prolonged physical restraints, use of restraint to administer antipsychotic medication which involved him suffering broken bones and lost teeth and being force fed. (Curtice, 2008). The European Court of Human Rights ruled Article 3 rights were not contravened and in paragraph 82 outlined their thinking on enforced psychiatric treatment and Article 3.
“82. … the position of inferiority and powerlessness
which is typical of patients confined in psychiatric hospitals calls for
increased vigilance in reviewing whether the Convention has been complied
with. While it is for the medical authorities to decide, on the basis of
the recognised rules of medical science, on the therapeutic methods to be
used, if necessary by force, to preserve the physical and mental health of
patients who are entirely incapable of deciding for themselves and for
whom they are therefore responsible, such patients nevertheless remain
under the protection of Article 3…

The established principles of medicine are admittedly in principle decisive
in such cases; as a general rule, a measure which is a therapeutic
necessity cannot be regarded as inhuman or degrading. The Court must
nevertheless satisfy itself that the medical necessity has been convincingly
shown to exist.” (Bartlett, 2012: p.365)

An article by Curtice summarised several of the crucial issues:

Margin of appreciation Domestic states have different accepted clinical practices and standards... Consequently, clinical decisions that are proportional, therapeutically necessary and in keeping with accepted clinical practice are very unlikely to be outside this margin…
Proportionality Clinical intervention needs to balance the severity of the effect of the intervention with the severity of the presenting clinical problem, i.e. be a proportionate response to a clinical scenario.
Threshold of severity to engage Article 3 Ill-treatment must attain a minimum level of severity; assessment of this minimum is relative. ...” (Curtice, 2008: p. 390)

Specific advice has been given firstly for necessity(Article 18) and what constitutes therapeutic(Article 19).

The Recommendation of the Committee of Ministers to Member Statesconcerning the protection of the human rights and dignity of persons with mental disorder, Rec(2004)10,.. sets out different criteria for involuntary treatment and involuntary detention. The substantive recommendations concerning involuntary treatment are as follows: Article 18 – Criteria for involuntary treatment A person may be subject to involuntary treatment only if all the following conditions are met: i. the person has a mental disorder; ii. the person’s condition represents a significant risk of serious harm to his or her health or to other persons; iii. no less intrusive means of providing appropriate care are available; iv. the opinion of the person concerned has been taken into consideration. Article 19 – Principles concerning involuntary treatment 1. Involuntary treatment should: i. address specific clinical signs and symptoms;ii. be proportionate to the person’s state of health; iii. form part of a written treatment plan; iv. be documented; v. where appropriate, aim to enable the use of treatment acceptable to the person as soon as possible.” (Bartlett, 2012: p.374)
Legal justification for enforced psychiatric treatment without consent relies on the condition of therapeutic necessity and split into two further conditions – what is therapeuticintervention and what is necessity.  In the next two sections I will discuss what therapeutic means in  medical practice and what may be considered necessity, how values complicate both matters and how these values will prevent agreement in all parties involved in such discussions of the legal justification of enforced treatment – clinicians, patients, carers and lawyers. It is important to be clear what therapeutic necessity refers to before the issuing of ethical warrants for doctors to breach their usual convention of respecting patient autonomy.

What is Therapeutic?

What does therapeuticmean in this context? The Recommendation of the Committee of (EU) Ministers to Member States defined therapeuticas having an intention to “address specific clinical signs and symptoms” (Bartlett, 2012: p.374). Bartlett, a legal academic defines therapeuticas “treatments may appropriately be prescribed which are not therapeutically necessary. Treatments which attack the symptoms of a disorder but not the underlying disease are an obvious example” (Bartlett, 2011: p. 533) as well as “treating the underlying disorder or improving outcomes” (Bartlett, 2011: p. 531). The Code of Practice of the Mental Health Act (1983) requires that appropriate treatment “must be treatment which is for the purpose of alleviating or preventing a worsening of the patient’s mental disorder or its symptoms or manifestations” (Bartlett, 2011: p.533). So whereas Bartlett does not regard lessening symptoms as part of therapeutic necessity – only those treatments that target “underlying disease” or improve outcomes (but not outcomes such as improving symptoms) – the official viewpoints such as the Code of Practice are that improving or preventing deterioration of symptoms may count as therapeutic. These are legal and statutory viewpoints. What is the medical opinion which is the key factor (Bartlett, 2012: p.365)?
Critical psychiatrists offer two models of prescribing – one a “disease-centred model” where medication reverses hypothesised mechanisms of disease producing the symptoms (similar to Bartlett’s definition) or a “drug-centred model” where a drug is regarded as always harmful and producing many effects of which some may be regarded by the patient as beneficial such as blunting of painful emotions (Yeomans et al, 2015). A more sophisticated view of therapeuticregards medical interventions as having three potential goals:

 “alleviation of symptoms without affecting the disease course; prevention of progression, but not curative …; and curative or preventive …” (Lieberman et al, 2019: p.794

Sackett - one of the prime movers behind the “Evidence Based Medicine movement” - along with his co-authors outlined a list of objectives of treatments to be decided with the patient (Sackett et al, 1991: p. 189). I have listed them below with my suggested modifications and additions in italics.
“1.           Cure
2.              Prevent recurrence/occurrence
3.              Limit structural or functional deterioration
4.              Prevent later complication
5.              Relieve current distress/reduce symptoms
6.              Deliver appropriatereassurance
7.              Allow to die with comfort and dignity/avoid overzealous treatment”(Huda, 2019; p. 79) adapted from Sackett et al, 1991; p. 189)

Describing these in order, cure should be applied to circumstances such as a reversal of disease process but in layman terms often refers to situations where the symptoms are eliminated or a disease mechanism is compensated for (such as when pharmaceutical insulin is prescribed to replace the body’s own insulin). Prevent recurrence refers to situations where treatment is aimed at preventing a return of the medical condition (or maintenance antipsychotics in schizophrenia) and I expanded it to interventions are given to prevent a first occurrence of a condition (such as vaccination to prevent infections). Limiting deterioration are where interventions are given to prevent further problems such as the use of plasters and surgical fixation to prevent displacement of fractures. Many medical conditions are treated to prevent known complications associated with the condition such as the use of antihypertensives in high blood pressure to prevent cardiovascular disease. Relieving distress or symptoms is an important therapeutic goal as it is often distress or other unpleasant experiences labelled as symptoms that bring people to seek out medical help. Examples include painkillers for pain or antidepressants in depression. Sometimes patients they are worried their symptoms may be caused by a dangerous medical condition but the results of tests are negative so doctors offer reassurance as the intervention. Finally, good medical practice in certain situations is not to carry out intensive interventions with little chance of success as well as to allow someone to have a ‘good death’ according to their wishes. 

This list of therapeutic objectives is broad not all could be regarded as justifying compulsory treatment (for example providing reassurance) and avoiding overzealous treatment by definition is not an imposed treatment without consent. Sackett et al emphasise the importance of patient choice for these treatment objectives.

“Since any decision about the ultimate objective of treatment is made for the sake of the patient, most clinicians involve, and even defer to, the patient’s wishes (or those of an impaired patient’s family) in this decision. And when assessing the risks and benefits (especially as they involve trade-offs between the quantity and quality of life) may not only be useful but crucial (Sackett et al, 1991: p. 188).”

Values clearly have a role in deciding which treatment objectives are valid and which should be chosen in specific circumstances. Bartlett’s own values are at a minimum highly sceptical about psychiatric treatments. He puts forwards his own view that  “benefits of psychiatric medication are not necessarily clear-cut, and the risks can be significant” (Bartlett, 2011: p.517) and contrary to his own claim to want a “balanced reflection” (Bartlett 2011; p. 517) barely mentions any benefits but instead discusses at length adverse effects including a claim that antipsychotics kills more people that it saves which is contradicted by the research evidence that antipsychotics reduce mortality (Tiihonen et al, 2009). This illustrates the perils of relying on balanced accurate evidence from someone advocating a legal argument. As for effectiveness of psychiatric treatments there is an overlap in effectiveness between medication used in psychiatry and general medicine in achieving therapeutic objectives (Leucht et al, 2012 and Leucht et al, 2015). 

Bartlett further reveals his attitudinal values towards psychiatric medication by describing them as “mind-altering drugs” (Bartlett, 2011: p.535) – a highly value-laden term that makes the medication sound frightening but just highlights conceptual confusion. After all, psychiatric medication is used to benefit people with mental health conditions whom are regarded as having unpleasant, distressing or impaired functioning of mind– hence the therapeutic aim would to be alter the state of mind in a beneficial way surely? Which begs the question what does Bartlett think psychiatric treatment should alter? The feet? These values may inform Bartlett’s views that only reversing the underlying causes of the condition or better (unspecified) outcomes but not reducing symptoms should be regarded as valid therapeutic necessity to justify enforced treatment. However, given most psychiatric treatments are justified on clinical grounds for reducing symptoms and does not reverse underlying mechanisms of mental disorders (many of which are unknown) (see Huda, 2019: p. 258-304 which also contains a discussion of how many general medical medications do not reverse underlying mechanisms either) Bartlett’s proposals -perhaps influenced by his values towards psychiatric treatment - would rule out of bounds most psychiatric treatments as fulfilling therapeutic necessitycriteria.

Enforced treatment without consent contrasts with the typical situation in medicine where therapeutic goals are supposed to be chosen at least in conjunction at the least if not actually led by the patient and their values (Sackett et al, 1991: p. 188). Here the clinician’s values (usually the doctor’s but recent changes to the Mental Health Act have allowed other clinicians to have this power) has the ultimate power in deciding the therapeuticgoals; the Code of Practice may reinforce the importance of consultation and taking on board patient views and values but the clinician’s values have the golden vote. 

Several examples of clashes of values will now be discussed. The first obvious one is the allocation of states of mind and behaviour to the category of ‘mental disorder’ by the clinician. Whilst evaluative processes are involved in both physical and mental disease concepts these are more so in mental disorder (Fulford et al (1993): 806-807) as values underlying designation of states as physical disease are more commonly shared and thus less problematic for physical illness compared to mental disorder (Fulford in Boch & Chodoff (1991): 80-82). As a corollary, deciding that certain states of mind and behaviours are ‘symptoms’ that need ‘reduced’ is an evaluative judgement that may not be shared between clinician and patient.

A patient in an elated manic state may wish to continue in this state (though there are often periods of mixed moods including depressed mood) and not see any problem with spending large amounts of money or reckless impulsive decisions that may cause problems such as sexual activity with people other than their spouse. The clinician may decide that the priority is to reduce the manic symptoms which should also have the benefit of preventing complications in the person’s life by their disinhibited behaviour. (One patient told me “you spoilt my fun” when I had reduced their manic symptoms). The clinician is making the value judgement that these therapeutic goals are sufficiently desirable to have the chance (not certainty) of achieving them by having treatment imposed despite the negatives such as enforcing treatment and potential side effects. A depressed patient who is suicidal may not agree with the doctor for starting treatment with the therapeutic goal of reducing symptoms and preventing occurrence of suicide for several reasons: they may believe they deserve to suffer and die because of guilt, they may think treatment is pointless because of depressive pessimism, they may prioritise harm avoidance of treatment side-effects rather than taking a chance on feeling less depressed or they may think the treatment is intended to punish them because the doctor dislikes them.  A patient with what the doctor regards as delusions or hallucinations may believe in the truth of what the doctor describes as psychotic symptoms. They may want to have any associated distress reduced but in consonant with their beliefs/ hallucinations (such as the persecution ending from persecutors). They may not therefore agree with taking medication for psychosis they do not believe they have, they may worry the medication can sedate them making them vulnerable to attack or they may think the medication is part of the persecution to discredit them or even poison them.

Clinicians may be choosing therapeutic aims that are similar to those in medicine as a whole but in enforced treatment against consent, the values that “doctor knows best” trumps the patient’s values in an “authoritarian” model of physician-patient relationship and given the role of state authorised enforced treatment some may regard it as an “instrumental” model in which the physician is acting as the instrument of the authorities (Emanuel & Emanuel, 1992). These value differences persist regardless of the question of impaired autonomy. One can argue that these value clashes are state-dependent and will change when they are not in such mental states but as Bartlett describes there are mixed views on compulsion as a whole afterwards (including presumably the question of enforced treatment) after the detention ends (Bartlett, 2011:p.520) which suggests that even if autonomy was impaired then after restoration of autonomy the clashes in values about the decision can persist.  

What is Necessity?

Situations of necessityjustifying legal detention and enforced treatment of mental disorders require sufficient severity with sufficient risk to health of the patient or to others and where compulsion is still necessary despite consultation with the patient who is judged to lack decision-making capability at the time and the proposed measures are proportionate to the situation (Curtice, 2008: p. 390, Bartlett, 2012: p.365 and Bartlett, 2012: p.374).
This definition of necessityinvolves values – for example the concept of margin of appreciationrecognises that in different EU states different standards and judgements will apply as to what is acceptable clinical practice (Curtice, 2008: p. 390) and this must be due to different local values not merely what specific treatments are available. 
Severity of mental disorder usually involves subjective judgements based on interviews and observations rather than more objective biomarkers which contrasts with the common use of investigation results to underpin decisions in general medicine (see Huda, 2019: p.187-206 for further discussion) and a values-influenced statement of severity such as ‘moderate’. This obviously is prone to be affected by values at various levels from culture to the individual. In mental health severity judgements may be based using ‘anchoring’ observations of such as ability to fulfil occupational demands, self-harming behaviours or self -care – these may display inter-rater reliability but are affected by values. 
Judging the risk involved is also subjective, often involving the collection and weighing up of protective and risk factors and the history of the patient but still involving an element of personal judgement and allocation to a category such as ‘high risk’ which is inevitably affected by values. Psychiatric assessments of risk may not be particularly reliable or accurate (Hope, 2004: p.81) which means that the weightone places on them and in their construction inevitably involves values.
Let us assume these psychiatric assessments of risk ARE reliable and accurate. Say a person with depression is estimated to be at a risk for suicide of 1% in the next week. Personal values influence how we weigh this information up as to whether it justifies enforced treatment let alone detention. Those whose personally value autonomy greatly (not least the patient whose autonomy is being threatened) or those who have an antipathy to psychiatric services (sometimes with good reason due to bad personal experiences of “care”) will focus on the absolute nature of the figure – 99% will not commit suicide and point to the usual civil justice standard of ‘balance of probabilities’ i.e. greater than 50% chance needed. Others will prize autonomy so greatly they will demand a higher threshold or even accept no imposition on autonomy at all. Those whose values regard mental health problems as clinical problems that require treatment or place great emphasis on the right to life may focus on therelativeincrease in risk – in the nature of several thousand fold increase in risk for the average member of the population (assuming an annual suicide rate of 10:100,000) and several hundred fold for people with depression (assuming a lifetime risk of 5-10% for suicide that operates over several decades of a recurrent illness).This great relative increase in risk may need a further justification to convince those wavering between autonomy and right to life – such as the availability of treatment that has a chance to benefit (there are no guarantees in medicine but there can be a reasonable possibility of benefit) and if it is enforced without consent it has a reasonable chance to reduce the symptoms of depression and improve the patient’s quality of life and maybe reduce the risk of suicide. 
The occasions where patients with mental disorders may pose a risk to others might be regarded as being more likely to lead to shared agreement over justification to detention and enforced treatment without consent as people are more likely to agree that autonomy does not allow one to ham others. On the other hand concerns about the reliability and accuracy of risk to others still applies (Hope, 2004: p.81) and the use of preventative detention on the grounds of a health condition posing a risk to others is still a value choice to treat people with mental health problems differently from ‘ordinary criminals’ who pose a risk to the public (Hope, 2004 p.81) even if an argument can be made that mental illness causing somebody to be aggressive implies reduced responsibility as well as a possibility of reducing this aggression with suitable interventions which justifies this different ‘treatment’.  Those whose values justify detaining and enforcing treatment on the basis of health alone are relying on judgments of what constitutes health and illness based on values which are less likely to be shared in mental health conditions (Fulford et al (1993): 806-807and Fulford in Boch & Chodoff (1991): 80-82) and therefore less agreement with those who prioritise autonomy.
Judgements as to necessity involve value judgements – on deciding the level of severity and the level of risk. Further value judgements are involved in deciding whether severity and the associated risks justify breaching autonomy and often involve weighing up different rights such as autonomy and the right to life – these values differ amongst people hence their conclusions for the same clinical scenario will vary.

Discussion

The ethical warrant to allow doctors to enforce detention and treatment without consent in situations of therapeutic necessitygoes against the usual position of respecting patient autonomy (Mathews, 2000 p.59) and much focus has been on trying to demonstrate patients subjected to these breaches of autonomy-based rights do not have ‘autonomy’ due to their mental disorder (for example, Mathews, 2000: p. 66-69) thus allowing the doctor to act as substitute decision maker. There seems an assumption that if this is demonstrated satisfactorily then this make such enforced detention and treatment without consent uncontroversial or at least a largely value-free action.
Unfortunately for this point of view values will continue to be a source of dispute even if it can be demonstrated that patient autonomy is always impaired by mental disorder in situations of enforced detention and treatment without consent justified by therapeutic necessity. This is because deciding what are the appropriate therapeuticobjectives – such as reducing symptoms or preventing occurrence of events such as suicide – involves value judgements from the clinicians - such as what experiences are symptoms, what is a mental disorder – trumping those of the patient who may not agree that they have a mental disorder or with the therapeutic objectives when the mental disorder has improved (Bartlett, 2011:p.520). Further, many people have values that object to many psychiatric treatments regarding them as “mind-altering” in a perjorative sense (Bartlett, 2011: p.535). Deciding what is necessity further involves the role of values in deciding how severe the mental disorder is and how great the risks are as well as a value judgement in do they justify detention and treatment without consent.
One obvious clash of values is how to weigh up competing demands of autonomy versus other rights such as those of a right to life and some people may regard the restoration to what they regard as health as a right. People weigh these different entitlements differently and some people will never accept breaches of autonomy in any circumstances. 
Enforced detention and treatment without consent will never be universally accepted due to differences in values between people.

References

Bartlett, P., 2012. Chapter 14 Rethinking Herczegfalvy: the Convention and the control of psychiatric treatment in Brems, E. ed., 2012. Diversity and European human rights: rewriting judgments of the ECHR. Cambridge University Press.
Bloch, S.E. and Chodoff, P.E., 1991. Psychiatric ethics. Oxford University Press
Curtice, M., 2008. Article 3 of the Human Rights Act 1998: implications for clinical practice. Advances in Psychiatric Treatment14(5), pp.389-397.
Emanuel, E.J. and Emanuel, L.L., 1992. Four models of the physician-patient relationship. Jama267(16), pp.2221-2226
Fulford, K.W.M., Smirnov, A.Y.U. and Snow, E., 1993. Concepts of disease and the abuse of psychiatry in the USSR. The British Journal of Psychiatry162(6), pp.801-810
Hope, T., 2004. A very short introduction to medical ethics.Oxford University Press, Oxford
Huda, A.S., 2019. The Medical Model in Mental Health: An Explanation and Evaluation.Oxford University Press, Oxford.
Lieberman, J.A., Small, S.A. and Girgis, R.R., 2019. Early detection and preventive intervention in schizophrenia: from fantasy to reality. American Journal of Psychiatry176, pp.794-810
Leucht, S., Hierl, S., Kissling, W., Dold, M. and Davis, J.M., 2012. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. The British Journal of Psychiatry200(2), pp.97-106.
Leucht, S., Helfer, B., Gartlehner, G. and Davis, J.M., 2015. How effective are common medications: a perspective based on meta-analyses of major drugs. BMC medicine13(1), p.253.
Matthews, E., 2000. Autonomy and the psychiatric patient. Journal of applied philosophy, pp.59-70.
Sackett D.L., Haynes R.B., Guyatt G.H. & Tugwell P., 1991 Clinical Epidemiology: A Basic Science for Clinical Medicine (Second Edition)Boston/Toronto/London. Little, Brown and Company
Tiihonen, J., Lönnqvist, J., Wahlbeck, K., Klaukka, T., Niskanen, L., Tanskanen, A. and Haukka, J., 2009. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). The Lancet374(9690), pp.620-627.
Yeomans, D., Moncrieff, J. and Huws, R., 2015. Drug-centred psychopharmacology: a non-diagnostic framework for drug treatment. BJPsych Advances21(4), pp.229-236.



Saturday, 10 August 2019

Jaspers’ un-understandability of delusions and the strong psychological model of psychosis


Jaspers’ un-understandability of delusions and the strong psychological model of psychosis 

1.Introduction
The strong psychological psychosis model states that for all the speech, gestures, behaviour etc labelled as functional psychosis we can show how they came about purely in terms of psychological events in a social context in the same way as anxiety or shyness, are continuous with normal psychological processes i.e. are not qualitatively different states and that the meaning of what is communicated can also be understood (Cooke, 2017).  The strong psychological psychosis model applies to ‘functional psychosis’ i.e. where no biological cause is present that is likely to explain the psychosis (such as intoxication with LSD or a brain tumour) (Cooke, 2017).

I will be using Jasper’s phenomenological approach to delusions to critique the strong psychological psychosis model. Jaspers explains “primary delusions” of schizophrenia as the observed manifestation of a global change in awareness of the world with altered meanings of experiences. This differentiates “delusions proper” (also known as “primary delusions” – the terms will be used interchangeably) from “delusion-like ideas” resulting from understandable responses to morbid events e.g. depressive guilt (Jaspers, 1963): 96). In “delusions proper” there is a core to the underlying experience that is not accessible to others understanding as they do not share this changed awareness of the world (Jaspers, 1963: 282). Jaspers describes this phenomenon as a qualitative change from normal or everyday experience that cannot be understood due to lack of shared meanings. This concept if true is problematic for the strong psychological psychosis model that emphasizes continuity with normal experience and that we can understand the meaning of utterances and behaviour in psychosis.

In this essay I will describe initially how the strong psychological psychosis model views understandibility of psychosis symptoms and continuity with normal experience before discussing how Jaspers characterises “delusions proper” as being the external manifestation of an “ununderstandable” experience. I will then discuss this specific meaning of “ununderstandable” for “delusions proper” and why this contradicts the strong psychological psychosis model.  I will then discuss some objections that can be made to Jasper’s ideas by strong psychological psychosis model advocates and how these can be answered.

2. The Strong Psychological Psychosis Model
Now I will briefly summarise the assumptions of the strong psychological psychosis model.

For ‘moral’ reasons including reducing stigma some emphasise continuity between psychological phenomena labelled psychosis and those regarded as normal (David, 2010). Some interpretations of research findings can also be said to demonstrate psychosis being at the severe end of a continuum with normality (Jones et al, 2003; David, 2010 and Linscott and Van Os, 2010). The utterances and behaviour of people experiencing psychosis are said to able to be understood through the joint process of creating a collaborative psychological formulation -
 “assumption is that this process will render even the most unusual or disturbing behaviour and experiences understandable: ‘…at some level it all makes sense’ (Butler, 1998, p.2)” (Division of Clinical Psychology, 2011: 6).
The strong psychological psychosis model asserts that experiences, utterances of behaviour that are labelled as psychosis can be
“understood and treated in the same way as other psychological problems such as anxiety or shyness” (Cooke, 2017: 6)
An example of how psychological formulation is presented as understanding the patient’s psychosis can be found in ‘Understanding Psychosis’ (Cooke, 2017: 51-52). This formulation however demonstrates connections between life experiences  and relevant aetiological factors (such as substance abuse) with the  onset and maintenance of psychotic symptoms as a general class but not why they had such specific experiences such as thought broadcasting through a lump in his throat. It also gave no impression of how did this feel to the person having these experiences. This issue is ignored in ‘Understanding Psychosis’. This contrasts with panic disorder formulations (for example Wells, 1997: 105) where it is easier for me to place myself in the patient’s mind and body and experience what they are going through with increased anxiety leading to physical symptoms such as heart racing and breathlessness and fears of having a heart attack. 

The strong psychological psychosis model holds that in ‘functional psychosis’ there is a continuity between psychosis and normal experience, that the utterances and behaviour in ‘functional psychosis’ can be understood and that the occurrence of psychosis and the content of utterances and meanings behaviour can be explained entirely through psychological processes in a social context.

3. Jaspers Concept of Primary Delusions and Delusion-like Ideas
Now I will describe the phenomenological model of delusions which clashes with the strong psychological psychosis model (Picardi et al, 2018) of which Jaspers is the most renowned exponent.

Jaspers has been influential on psychiatry in general and on psychosis specifically (Stanghellini and Fuchs, 2013) and psychiatry has a substantial influence on the conception and treatment of psychosis despite the objection of strong psychological psychosis model advocates (Cooke, 2017 and Cooke et al, 2019). Jaspers’ phenomenological method consists of
“classifying psychic phenomena” (Jaspers, 1968: 1314), “the sorting out, defining, differentiating and describing of specific psychic phenomena, which are thereby actualized and are regularly described in specific terms” (Jaspers, 1968: 1315-1316) and “must set aside all outmoded theories, psychological constructs or materialist mythologies of cerebral  processes” (Jaspers, 1968: 1316).
This classification of “psychic phenomena” is the essential foundation of further classification, research and clinical practice.  A comparison is made with the histologists describing what they see of the relevant morphological features that others can recognise (Jaspers, 1968; 1316). Jaspers concept of “primary delusions” with global change in awareness of reality with changed meanings permeating many aspects of experience (Jaspers, 1963: 93, 103-104) has a convincing ‘face validity’ for explaining the unusual, baffling enigmatic experiences, behaviour and utterances that clinicians who see patients with psychosis encounter. This is reinforced by the phenomenological descriptions of patients’ experiences in ‘General Psychopathology’ (Jaspers, 1963) of which elements can be readily recognised for clinicians seeing patients in their own practise as Jaspers hoped with his histology comparison. For my own clinical practise in an Early Intervention in Psychosis team I find Jaspers’ concepts of “primary delusions” and “delusion-like ideas” useful as an explanans for why patients that I assess have highly unusual experiences and behaviour whilst also using elements of the weaker psychological psychosis models especially for “delusion-like ideas”.  In my own clinical practice, I find that the claims of strong psychological models of psychosis fall short in helping me to understand why this person is having this particular experience and what it feels like and why are they saying what they are saying (see 2.).

How does Jaspers separate “primary delusions” and “delusion-like ideas”? The “external aspects” used to recognise delusions are “vaguely applied to all false judgements…1…held with an extraordinary conviction…incomparable subjective certainty; 2….imperviousness to other experiences and to compelling counter-argument; 3. Their content is impossible.” (Jaspers, 1963: 95-96). Jaspers is identifying a group of “false judgements” that can be recognised using these “external aspects”  including “delusion-like ideas” or “delusions proper” but could also include some examples of strongly held extreme political or religious beliefs due to “master interpretive systems” (Bentall in Bortolotti, 2018: 79-81 and 87). The “impossible” criterion is discarded nowadays as what is regarded as impossible varies with different cultures and some delusions e.g. of jealousy are possible.

These external aspects are themselves products of “judgments” based on “experience”. These experiences may be morbid events such as depression or hallucinations leading to “delusion-like ideas” but “delusions proper” are caused by “psychologically irreducible” “alien” experiences (Jaspers, 1963: 96).  What is distinctive about the underlying form or mode of experience associated with “delusions proper” that is different from other “false judgements” even if the content is similar (Jaspers, 1963: 58-59)? Jaspers distinguishes between the content of experience and its form which describes the nature of how the experience is presented to consciousness. Jaspers uses “hypochondriacal concerns” to demonstrate the difference – it may be experienced as a recurrent intrusive concern that one is unwell, or it may be a strong belief of being ill despite evidence to the contrary or hearing a voice saying that one is sick. Whilst the content is similar, the mode of its experience is different (and different clinically useful implications for diagnosis, prognosis and treatment).

 In “delusion-like ideas” the mode of experience can be grasped empathically as an understandable consequence of another morbid psychic event (see 5.). For “delusions proper” we cannot achieve “static understanding” (see 4.) of the mode of experience that underlies the delusion producing “judgements” expressed in utterances and behaviour for reasons I shall discuss now.

Jaspers notes that people’s experiences and perceptions of the world involve meanings – when we perceive an object it is accompanied simultaneously with implications –
“a house is there for people to live in…If I see a knife, I see a tool for cutting” (Jaspers, 1963: 99)…“experiences of primary delusion are analogous to this seeing of meaning, but the awareness of meaning undergoes a radical transformation. There is an immediate intrusive knowledge of the meaning and it is this which is itself the delusional experience” (Jaspers, 1963: 99).
People or everyday objects can acquire new often threatening or otherwise significant meanings. This can occur in several types of experience – such as perceptions, ideas, memories or awareness. The radically changed meanings then spread throughout interpretation of memories, current and recent past experiences and interpretation of current and future experience.
“Later the identical experience of significance is repeated, though in other contexts. The trail is blazed and the preparedness for the significant experience then permeates almost all perceived contents. The now dominant delusion motivates the apperceptive schema for all future percepts.” (Jaspers, 1963: 103-104).
Delusional mood is described as one example where initially subtle then progressively more compelling changes in the meanings of experiences are accompanied by mood changes such as anxiety which result in formation of a “primary delusion” (Sass and Pienkos, 2013).

The incorrigible nature of “delusions proper” is not like the “normal errors” of people reinforced by the values and beliefs of a social group (as would occur for extreme religious or political views that may meet the external characteristics criteria for delusions) nor is it like understandable psychological consequences to a prior morbid event of “delusion-like ideas” but is instead an
 alteration in the nature of personality, the nature of which we are so far unable to describe, let alone formulate into a concept” (Jaspers, 1963: 105).

Jaspers holds that in “delusion-like ideas” there is a connection with other morbid events such as depression but in “delusions proper” there is a global change in awareness of experience with changed meanings of experience but why does this make such states “ununderstandable”?

4. Ununderstandibility of delusions proper
In this section I will outline what Jaspers means by “understanding” of experiences and “ununderstandibility”.

Jaspers separates “genetic understanding” from “static understanding”.  “Genetic understanding” describes
“empathy, of perceiving the meaning of psychic connections and the emergence of psychic phenomenon from another” (Jaspers, 1963: 27). “Psychic events ‘emerge’ out of each other in a way which we understand” (Jaspers, 1963: 302).In terms of the content of the patient’s utterances, “if we understand the contents of the thoughts as they have arisen out of the moods, wishes and fears of the person who thought them we understand the connexions psychologically or empathically…called ‘psychological understanding’…empathic connexions leads us into the psychic connexions themselves.” (Jaspers, 1974, 83).
The “static understanding” of any experience which is not directly visible to the senses of the observer such as a delusion is a
“subjective symptom” that has “to be grasped by transferring oneself… into the other individual’s psyche; that is, by empathy. They can only become an inner reality for the observer by his participating in the other person’s experiences, not by any intellectual effort. .. Then there are all those psychic experiences and phenomena which patients describe to us and which only become accessible to us at secondhand through the patient’s own judgment and presentation. Lastly, subjective symptoms also include those mental processes which we have to infer from fragments of the two previous kinds of data, manifested by the patient’s actions and the way he conducts his life” (Jaspers, 1968: 1313).

When Jaspers refers to “primary delusions” being “ununderstandable” this seems to be referring to “static understanding” rather than “genetic understanding” of meaningful connections and to the underlying experience that leads to the manifestation of the delusion (Gorski, 2012). Jaspers concept of what is “psychologically irreducible” (Jaspers, 1963: 96) in “delusions proper” refers to his concept of
  “irreducible quality of psychic phenomena, which can only acquire identical meaning for numbers of people through the incentive and the multiple clues and leads mentioned previously, may already be found in the case of the simplest sensory qualities, such as red, blue, colour, tone; it comes into play also with spatial awareness, object awareness, perception, imagery, thought, etc.” (Jaspers, 1968: 1317).  “We can have no psychological understanding without empathy into the content (symbols, forms, images, ideas)” (Jaspers, 1963: 311).

Understanding thus requires empathy which in this context requires shared meanings. In the underlying experience all or some experiences may have changed meanings and they are not shared i.e. are not “identical” between the person with the delusion and the person trying to understand them. The basic shared meanings for time, perception or object awareness and so forth may not apply.  An example of these altered meanings as part of the underlying experience has been described by Renee (quoted in Sass, 2003: 130).
“I looked at a chair or a jug, I thought not of their use or function—a jug not as something to hold water and milk, a chair not as something to sit in—but as having lost their names, their functions and meanings; they became “things” and began to take on life, to exist.”
 Note the disjunction between object and typical shared meaning. We can view this experience as a whole description of a world with different/ lost meanings at higher levels but not at the level of shared meanings as every experience or object needs to be checked what the meaning is to the person. Hence “chair” is not a shared meaning between Renee and the person talking to her – the shared meaning would have to be at a higher level – a translation guide for these different experiences/ objects i.e. the “psychologically irreducible” level is the translation guide for this anomalous experience describing the experience in terms of altered meanings. As Sass pointed out Renee is unusual in being able to convey these differences in meanings, in producing a translation guide, often such a guide is absent with the patient saying ‘I don’t have the words to describe it [the experience underlying the delusion].’

One of the key difficulties in understanding the experience that lies behind the “delusion proper” is that it is difficult for other people to “grasp” this experience by “transferring into the other individual’s psyche” because of the changed meaning of experience. The person trying to understand the person with the “delusion proper” is trying to navigate an experiential space where what seems like it could have identical meaning may have a different meaning to the person having the experience unpredictably. This is seen in patients displaying ‘double orientation’ where their behaviour is different from what is suggested by what they say – the classic example of people saying they are royalty but apparently content to stay on psychiatric back wards – which suggests more than one meaning may be held by the same person for the same term.
The patient
 “lives in two worlds simultaneously, the real one …and his psychotic one” (Jaspers, 1963: 150).

 This inconstancy of meanings and difference in meanings mean no easy shared understandings is possible when trying to form “static understanding”. The necessity of using a guide, to continually stop and check whether they have got the meaning right prevents the “grasp” by “empathy” involving a lack of “intellectual effort” that Jaspers describes is the essence of “static understanding”. Even if accurate translation guides are present the resultant staccato “intellectual effort” nature of the exploration of the experience stops the rapid empathic processes. In some cases there is an absence of this guide preventing any sort of “grasp” at all. Since we lack the same meanings we cannot directly perceive them by empathy and require interpretation by the patient these
 “phenomenological elements…. which can in principle never be seen by us,...we term ‘statically ununderstandable’” (Jaspers, 1963: 578).

If one could produce an accurate translation guide that could be applied reliably this may lead to an interpretation of the patient’s “subjective symptoms” but interpretation is not the same as “static understanding” as defined above. Even so, it could be argued that if the rules and meanings of this experience manifesting in “delusions proper” are radically different to everyday commonplace ones then we still may not be able to make sense of these different ways of meanings attached to the world (Thornton, 2004: 223-224). If one could understand through shared meanings of the same experiences i.e. that “static understanding” is possible Jaspers would state that is not a “primary delusion” but is instead a “delusion-like idea”.

Jaspers concept of “un-understandability” does not mean that the contents of utterances or the gestures of behaviours associated with the experiences underlying “delusions proper” are valueless. He noted that
“in psychotic reality we find… fundamental problems of philosophy…the extremest of human possibilities…the philosopher in us cannot but be fascinated by this extraordinary reality and feel its challenge” (Jaspers, 1963: 309).


Jasper’s concept of “ununderstandability” refers to the difference in meanings of experiences caused by the global change in awareness of the environment,
“a mutation in the ontological framework of experience” (Sass and Byrom, 2015),
 and this lack of shared meanings means that “static understanding” is not possible because observers are not able to rapidly grasp empathically what the patient experiences.

5. Delusion-like ideas, genetic understanding and the strong psychological psychosis model
In this section I will focus on delusion-like ideas and where there is compatibility between the strong psychological model and Jasper’s concepts.

 In the strong psychological psychosis model there is a core assumption that delusions are wholly   understandable through psychological formulation (Division of Clinical Psychology, 2011: 6) and for this to happen then the form of experience underlying “delusions proper” has to be eliminated and replaced with analysis of the content. The form of “primary delusion” involves disjunction not continuity with everyday psychological phenomena which is emphasised in the strong psychological psychosis model. For “delusion-like ideas” the mode of the experience has continuity with everyday psychological phenomena so this form does not have to be rejected. Jaspers says that
“the  psychologist  who looks  for  meaning  will  find  content  essential  and  the  form  at times unimportant” (Jaspers, 1963: 59).
Jaspers drew a distinction in understandability between “delusions proper” and “delusion-like ideas”.
“The most profound distinction ….between what is meaningful and allows empathy and what…is ununderstandable, ‘mad’ in the literal sense…Pathological life of the first kind we can comprehend…as an exaggeration or diminution of known phenomena…Pathological psychic life of the second kind we cannot adequately comprehend in this way. Instead we find changes…for which we have no empathy but which…we try to make comprehensible from an external point of view” (Jaspers, 1963: 577).
 For “delusion-like ideas” they are an “exaggeration or diminution” of psychological phenomena we can grasp at with empathy through shared meaning – if someone was depressed we can grasp they may feel guilty and then form delusions of guilt that their family is ruined–something that can be grasped by us and is not a disjunction with normal psychology in contrast to “delusions proper”. Here we can see common ground between the strong psychological psychosis model and “delusion-like ideas” in that they are regarded as being at the extreme end of continuum with normal psychology that we can achieve “static understanding” of.

Further common ground also exists in the strong psychological psychosis model’s assertion that if we knew a patient’s life history and their personality then we can appreciate why they experience “delusion-like ideas” in the same way we can for anxiety or shyness (Cooke, 2017). The DCP guidelines on formulation (Division of Clinical Psychology, 2011: 6) emphasise how the utterances and associated behaviour that are called delusions should be framed in terms of the person’s context, life experiences and psychological processes continuous with normality and that if we do it “makes sense”.  This is what Jaspers refers to as “genetic understanding” (see section 4.) using empathy in a specific sense
 “We sink ourselves into the psychic situation and understand genetically by empathy how one psychic event emerges from another.”(Jaspers, 1963: 301) “When we understand how thoughts rise from moods, wishes and fears we are understanding the connections in the true psychological sense, that is by empathy (we understand the speaker)” (Jaspers, 1963, 304).
This could easily apply to the part of the psychological formulation (see 2.) as to how a clinical problem came about. For “delusions proper” there may be some aspects from a patient’s life history and previous morbid psychological events that we can see linking together as part of “genetic understanding” but at some point this fails as we are unable to follow the psychological connections to the experience underlying “delusions proper” as we cannot achieve “static understanding” of important aspects of this state (Sass and Pienkos, 2013 in Fulford et al, 2013: 644) for reasons explained in 4. We may see a patient with a history of childhood trauma then a triggering life event that we can grasp as generating vulnerability for mental health problems but understanding is lost when they talk about Martians are passing electricity through their body.

Psychological Formulations also include ‘maintenance factors’ i.e. why does the problem not resolve itself. In the cognitive model of delusions several maintenance factors are outlined including anomalous states (Freeman, 2016). There is often also a diagram showing a variety of thoughts, feelings and behaviour in an environment interact with each other. Jaspers may refer to this interlocking system of beliefs and processes as “rational understanding” and “relational understanding” (how mental contents relate together).
 “Rational…understanding…is a purely cognitive understanding of rational content, common to all (e.g. we can understand the logical structure of a delusional system in which an individual lies submerged)” contrasting with “empathic understanding - is the proper psychological understanding of the psyche itself” (Jaspers, 1963: 307).

Jaspers conception of “delusions proper” does not necessarily rule out one contention of the strong psychological model of psychosis – that the aetiology of ‘functional psychosis’ is always due to psychosocial causes so long as a mechanism for these causes to cause this disjunctive state can be demonstrated.

The strong psychological psychosis model would not recognise the distinction between “delusion-like ideas” and “delusions proper” and just view them all as delusions. The definitions of delusions in classification systems used in research - for example, DSM-V (American Psychiatric Association, 2013: 87) - or rating scales used to measure delusions in research - for example, PANNS (Kay et al, 1987) – are based on the external characteristics of delusions which are shared between “delusions proper” and “delusion-like ideas”. As these are lumped together in classification and measurement then advocates of the strong psychological psychosis model will often not be presented with research that contradicts their view. On the other hand the research demonstrating continuity with normal psychology often fails to convince in the clinic when faced with examples of “delusions proper” due to failure to achieve “static understanding”.   

In summary, some elements of the strong psychological psychosis model is compatible with Jaspers especially for “delusion-lie ideas” but the disjunction with every day experience and psychology and inability to achieve “static understanding” which Jaspers proposes as underlying “delusions proper” is not.

6. How can the Strong Psychological Psychosis Model deal respond to Jaspers?
I will now discuss how one prominent strong psychological psychosis model advocate Bentall questions the phenomenological method. Bentall states the difficulties of people reporting on their own experiences, whether phenomenologists can “bracket out” preconceptions completely and the problems of trying to understand what people are communicating about private experience often using metaphor (Bentall, 2015). The second concern seems to be about the true objectivity and reliability of the method but any observation is impacted upon by preconception, the important matter is whether like the histologist the resultant description allows recognition by others and Jaspers’ vivid descriptions and subsequent classifications passes this test. The first point also refers to what Jaspers refers to as “subjective symptoms” and his answer may be that it relies on the skill of the phenomenologist but to ignore “subjective symptoms” for “objective symptoms” would seriously impair understanding what patients experience by focussing on measuring external aspects  Jaspers, 1968: 1313). The third point would be used by Jaspers to say Bentall has proved Jaspers’ point – the patient is forced to use inadequate metaphor because of the lack of shared meaning. People in the same culture often use common metaphors for inner experience such as “butterflies in the stomach”.  These descriptions are sound odd but because they are shared metaphors we can at the least come close to what they feel like or mean unlike experiences underlying “delusions proper” which are so different from everyday experience that shared descriptions seem impossible – how does it feel to have one’s thoughts be broadcast or withdrawn and how to communicate this to somebody not having these experiences?

Bentall could point to phenomenological theories on understanding “delusions proper” such as from Minkowski, Blankenburg and Kimura (Sass, 2001), Maher,(Maher, 1974), Sass and various colleagues (Sass and Byrom, 2015 and Sass and Pienkos, 2013), Rhodes and Gipps (Rhodes and Gipp, 2008) but they all involve complicated mental steps that preclude “effortless” static understanding and in any case are based on qualitatively different experiences discontinuous from normal psychology.

7. Conclusion
Jaspers concepts of “delusions proper” and “delusion like ideas” with former term used to describe experiences that are qualitatively different from normal experience (and are “ununderstandable” due to the subsequent lack of shared meanings) with the latter term used for delusions that can be understood as responses to prior morbid mental events These concepts seem closer to the reality of psychosis encountered in the clinic than the strong psychological psychosis model which regards all psychosis as continuous with normal psychology and is always able to be understood.


Bibliography
American Psychiatric Association, 2013. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Publishing
Bentall, R., 2015. Prospects and problems for a phenomenological approach to delusions. World Psychiatry14(2), p.113.
Bortolotti, L. ed., 2018. Delusions in Context.  Palgrave Macmillan.
Cooke, A., 2017. Understanding psychosis and schizophrenia: why people sometimes hear voices, believe things that others find strange, or appear out of touch with reality… and what can help. British Psychological Society.
Cooke, A., Smythe, W. and Anscombe, P., 2019. Conflict, compromise and collusion: dilemmas for psychosocially-oriented practitioners in the mental health system. Psychosis, pp.1-13.
David, A.S., 2010. Why we need more debate on whether psychotic symptoms lie on a continuum with normality. Psychological medicine40(12), pp.1935-1942.
Division of Clinical Psychology., 2011. Good practice guidelines on the use of psychological formulation. Leicester, UK: British Psychological Society
Freeman, D., 2016. Persecutory delusions: a cognitive perspective on understanding and treatment. The Lancet Psychiatry3(7), pp.685-692.
Gipps, R.G., 2012. The indefinability and unintelligibility of delusion. Philosophy, Psychiatry, & Psychology19(2), pp.91-95.
Gorski, M., 2012. Karl Jaspers on delusion: Definition by genus and specific difference. Philosophy, Psychiatry, & Psychology19(2), pp.79-86.
Linscott, R.J. and van Os, J., 2010. Systematic reviews of categorical versus continuum models in psychosis: evidence for discontinuous subpopulations underlying a psychometric continuum. Implications for DSM-V, DSM-VI, and DSM-VII. Annual review of clinical psychology, 6, pp.391-419.
Jaspers, K., 1963. General psychopathology (transl. J. Hoenig). Hamilton MW. Manchester University Press, Manchester.
Jaspers, K. , 1968. The phenomenological approach in psychopathology. British Journal of Psychiatry, 114 pp. 1313–1323
Jaspers, K., 1974. Causal and meaningful connexions between life history and psychosis. Themes and variations in European psychiatry, pp.80-93.
Jones, H., Delespaul, P. and Van Os, J., 2003. Jaspers was right after all–delusions are distinct from normal beliefs. The British Journal of Psychiatry183(4), pp.285-286.
Kay, S.R., Fiszbein, A. and Opler, L.A., 1987. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia bulletin13(2), pp.261-276.
Linscott, R.J. and van Os, J., 2010. Systematic reviews of categorical versus continuum models in psychosis: evidence for discontinuous subpopulations underlying a psychometric continuum. Implications for DSM-V, DSM-VI, and DSM-VII. Annual review of clinical psychology6, pp.391-419.
Maher, B.A., 1974. Delusional thinking and perceptual disorder. Journal of individual psychology30(1), p.98-113
Owen, G., Harland, R., Antonova, E. and Broome, M., 2004. Jaspers' concept of primary delusion. The British Journal of Psychiatry185(1), pp.77-78.
Parnas, J. and Henriksen, M.G., 2014. Disordered self in the schizophrenia spectrum: a clinical and research perspective. Harvard review of psychiatry22(5), p.251.
Picardi, A., Fonzi, L., Pallagrosi, M., Gigantesco, A. and Biondi, M., 2018. Delusional Themes across affective and non-affective Psychoses. Frontiers in psychiatry9, p.132.
Rhodes, J. and Gipps, R.G., 2008. Delusions, certainty, and the background. Philosophy, Psychiatry, & Psychology15(4), pp.295-310.
Sass, L.A., 2001. Self and world in schizophrenia: Three classic approaches. Philosophy, Psychiatry, & Psychology8(4), pp.251-270.
Sass, L.A., 2003. Incomprehensibility and understanding: On the interpretation of severe mental illness. Philosophy, Psychiatry, & Psychology10(2), pp.125-132.
Sass, L. and Pienkos, E., 2013. Delusion: The phenomenological approach in Fulford, K.W., Davies, M., Gipps, R., Graham, G., Sadler, J., Stanghellini, G. and Thornton, T. eds., 2013. The Oxford handbook of philosophy and psychiatry. OUP Oxford.
Sass, L. and Byrom, G., 2015. Phenomenological and neurocognitive perspectives on delusions: a critical overview. World Psychiatry14(2), pp.164-173.
Stanghellini, G. and Fuchs, T. eds., 2013. One century of Karl Jaspers' general psychopathology. Oxford University Press.
Thornton, T., 2004. Wittgenstein and the limits of empathic understanding in psychopathology. International Review of Psychiatry16(3), pp.216-224.
Wells, A., 1997. Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. John Wiley & Sons.