RELIEF OF SUFFERING: OUR FUNDAMENTAL THERAPEUTIC VOCATION

Pauline Pytka MD, FRCPC

Medical care in general, and psychiatry specifically, has shifted from the principle of easing suffering to specific 'approaches' to the diagnosis and treatment of illness. It is easy to forget that we are really fundamentally trying to ease another person’s suffering. 

 

Donna Orange, a philosopher and psychologist has a beautiful passage in her book “The Suffering Stranger: Hermeneutics for Everyday Clinical Practice”. I suppose in a way it's not that different than Maimonides  "May I never see in the patient anything but a fellow human in pain."

I feel it's very poetic:

“ Commitment to relief of suffering as our fundamental therapeutic vocation has several corollaries, which scarcely need stating as they are so obvious, so I will be brief: 

1. A compassionate attitude of suffering with the other is indispensable. 

2. A dialogical, non-authoritarian style is equally crucial. One can support without becoming an expert-authority. 

3. Consistency and reliability, not a propensity to wear ourselves out, are essential to working with the profoundly traumatized. 

4. We should expect to be affected by our work to the core of our being and sometimes to feel retraumatized.

 5. We need our own supports, and sources of nourishment and hospitality, if we are to continue. 

Finally, it seems important to note that our ethical response coincides exactly with our clinical vocation to restore dignity to devastated, shame-filled, degraded, and suffering human beings like ourselves.

In my view, treating the other as a worthy partner in dialogue—no matter what distress or symptoms the patient brings to the encounter, and no matter what aversive preconceptions the clinician carries or develops—creates the foundations for working within what we designate here as the hermeneutics of trust. 

Everything we can learn from every school of psycho-analysis and psychotherapy, as well as from other disciplines and from the arts, that helps us to meet and sustain the suffering other non-evasively, without too much suspicion, is both good healing therapeutic practice and good ethics”.

Donna M Orange The Suffering Stranger:Hermeneutics for Everyday Clinical Practice Routledge, New York, London 2011 p69-70

Donna Orange is Clinical Assistant Professor of Psychology at New York University and teaches at the Institute for Psychoanalytic Psychology of the Self and Relational Psychoanalysis, Milan and Rome. In New York, she teaches

and supervises at the Institute for the Psychoanalytic Study of Subjectivity.

Books:  

 Emotional Understanding: Studies in Psychoanalytic Psychology.

Thinking for Clinicians: Philosophical Resources for Contemporary

Psychoanalysis and the Humanistic Psychotherapies.

CHOICE and CRIMINAL RESPONSIBILITY of MENTALLY ILL OFFENDERS: moral reasoning as a likely mediator related to primary secondary and tertiary prevention

Abraham Rudnick, MD, PhD, CPRP, FRCPC, CCPE.

Professor Department of Psychiatry and Behavioural 

Neurosciences, McMaster University                                          Email:harudnick@hotmail.com

Abstract: The legal determination “not criminally responsible” in Canada and its equivalents elsewhere seem to be based on an assumption that severe mental illness (when active) disrupts choice and hence eliminates or reduces responsibility for the person’s behaviour. I demonstrate that choice, as a fundamental characteristic of being human, is an important determinant of behavior that is not necessarily impacted by severe mental illness (even when active). I argue that choice may be influenced in part by the person’s moral reasoning. I suggest implications for primary, secondary and tertiary prevention related to facilitating moral reasoning and hence acceptable choice and behaviour.

 

Keywords: Behaviour, choice, criminal responsibility, mental illness, moral reasoning

Acknowledgement: This article is based in part on the author's presentation at the Radical Collaborations conference in Hamilton, Ontario, Canada on December 4, 2015.
Disclosures: None.

Soon after the advent of modern psychiatry, a medico-legal assumption seems to have spread, at least in much of the Western world, such as with the M’Naghten rule in England (http://legal-dictionary.thefreedictionary.com/M'Naghten+Rule). This is the assumption that severe mental illness (when active) disrupts choice – by disrupting knowledge (of the related behaviour as harmful) or judgment (that it is wrongful to harm others with this behaviour) – and hence eliminates or reduces the person’s responsibility for the related behaviour. This seems to still be the case, such as the determination of “Not Criminally Responsible” (NCR) in Canada and equivalents in other jurisdictions. Yet the relation between severe (or other) mental illness and choice is not a simple one.

Existentialist scholars, such as Sartre, have argued that choice is fundamental to human existence, i.e., to being a person (https://www.youtube.com/watch?v=qpXNRrtuo38). Furthermore, choice is arguably constrained but never eliminated for a person, e.g., even at gunpoint or when fully paralyzed a person can choose to think in more than one way about the situation. Are people with severe mental illness such as schizophrenia excluded from this category of personhood? 

A biblical example that is not far removed from forensic psychiatry’s experience may help clarify matters. Abraham, the first Jew, chose to sacrifice his son Isaac at God’s heard command (Genesis, chapter 22, verses 2-3). In contemporary society, if someone tries to harm his or her relative because a voice (psychiatrically considered to be a psychotic experience) tells him or her to do that, they would typically be considered NCR. Could someone like Abraham choose differently? Obviously yes, e.g., at the risk of being punished by God.

For our purpose, the question of the related cost-benefit calculation is secondary to the question of the existence of choice. In this light, only if the person thought that he or she was acting in self defence, e.g., that the kin intends to kill him or her now and that there is no physical escape as an alternative to self defence, would his or her choice to harm the kin be morally acceptable, at least according to common morality (http://jme.bmj.com/content/37/10/588.full.pdf+html). So the mere fact of being psychotic while behaving violently does not necessarily remove moral responsibility of the mentally ill offender. 

What could explain such choice and related behaviour? I suggest that moral reasoning (http://plato.stanford.edu/entries/reasoning-moral/) is key to making choices, including difficult ones such as whether to follow a commanding voice to harm another person. With such moral reasoning, Abraham may have refused God’s command to sacrifice Isaac (in which case Judaism may have developed differently if at all). Thus, moral reasoning may influence choice, involving a set of mediators of choice in relation to behavior. As such, it could be rigorously studied and intervened on pre-morbidly, as part of early intervention, and for recidivism, to try to reduce risk of violence at all levels of prevention. Basic and applied research is needed to examine the relation between moral reasoning, choice and behaviour of mentally ill people and others.