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World Psychiatry. Oct 2007; 6(3): 129–130.
PMCID: PMC2174591

The dialogal basis of our profession: Psychiatry with the Person

A recent historical opportunity to engage critical user groups - groups that traditionally protested outside on the street and which for the first time joined a WPA conference in Dresden, Germany - encourages us to reflect on the dialogal basis of our profession. To this effect, we briefly step into historical aspirations and recent public health and clinical statements arguing for a personalized and interactive approach in medicine at large and psychiatry in particular. And highlight the WPA Institutional Program on Psychiatry for the Person, especially psychiatry with the person, as a paradigmatic response to these challenges.

HISTORICAL AND CONTEMPORARY PERSPECTIVES

Ayurvedic and Chinese medical traditions, ancient and still practiced, with sound philosophical, experiential and experimental bases, focus on the patient's health rather than only on disease. Both of them articulate a comprehensive and harmonious framework of health and life and promote a highly personalized approach for the treatment of specific diseases and the enhancement of quality of life (1). Likewise, Hippocratic medicine emphasizes the wholeness of health and the value of engaging the patient as a full human being (2).

It happens that also recent major public health studies and statements are recommending a protagonic role for patients in the reorganization of health care services. The U.S. Presidential Commission on Mental Health Report (3), after a lengthy study documenting the inadequate state of mental health care in the United States, prescribed a number of necessary steps to be taken, including the development of a consumer- centered recovery-oriented mental health system. The WHO European Ministerial Conference on Mental Health in Helsinki (4) recommended, inter alia, to recognize the experience and knowledge of service users and carers and to empower them in the development of integrated health services. In the clinical field, there is increasing recognition of the crucial role of a collaborative clinician-patient relationship.

For example, Tasman (5) has cogently pointed out that this relationship must start from the first encounter and represents the fundamental matrix for the whole of care. It must ensure empathic listening, comprehensive diagnosis beyond symptom checklists, appreciation for symbolic meaning, broad treatment techniques and effective therapeutic partnership instead of narrow and reductionistic approaches. Likewise, Alanen et al (6), through a wellknown Finnish integrated model for need-adapted assessment and treatment, emphasizes the active engagement of the patient as an expert of his/her own life situation within the context of family and community.

WPA RESPONSE

Of relevance to these developments, the WPA published in 2003 the International Guidelines for Diagnostic Assessment (IGDA), at the core of which is a diagnostic model articulating standardized multiaxial and idiographic personalized components. The latter proposes the interaction among clinicians, the patient and the family to formulate together a joint statement on contextualized clinical problems, the patient's positive health, and expectations on health restoration and promotion (7). This diagnostic model is being applied in different countries, as illustrated by the Latin American Guide for Psychiatric Diagnosis (8), and is one of the starting points for the emerging development of a person-centered integrative diagnostic model (9). Even more specifically, in response to the ancient and contemporary perspectives outlined above and consistent with its constitutional purposes, the WPA adopted at its 2005 General Assembly in Cairo a Strategic Plan that included as one of its broad goals to strengthen WPA relations with patient/ user organizations. It also established the Institutional Program on Psychiatry for the Person, which aims to promote a psychiatry of the person, by the person, for the person and, last but not least, with the person. This program, through its conceptual, clinical diagnosis, clinical care and public health components, represents a paradigmatic shift from a disease-oriented to a person-centered perspective (encompassing both ill and positive aspects of health) in psychiatry in particular and medicine at large. It is already attaining significant achievements and attracting wide attention throughout WPA and other major international medical and health organizations (see 10 for a general program outline).

The fourth programmatic objective, psychiatry with the person, is in fact the focus of this editorial. In reflection of this, a fundamental feature of the Institutional Program is the affirmation of the personhood of the patient and the commitment to work in respectful and collaborative partnership with the person who consults. This includes, first, work with individuals which highlights the ethical underpinnings of this effort. It also encompasses work with patient groups including those critical of psychiatry.

AN OPENING AT A DRESDEN CONFERENCE

It is on the above grounds that the WPA Thematic Conference held in Dresden on June 6-9, 2007 represents a crucial new opening for dialogue. The conference had an intriguing and sensitive overall topic, "Coercive Treatment in Psychiatry: A Comprehensive Review". John Monahan, Scientific Committee chair, anticipated on his invitation letter that "while the fissures in this area run so deep and are so long-standing that achieving consensus is unlikely, our aspiration is that this historic meeting will sharpen moral issues, clarify political viewpoints, identify evidence-based practices, and share cutting-edge data on one of the most contested topics of our time". In fact, as reported by Thomas Kallert, Organizing Committee chair, the Conference succeeded in attracting participants from 36 different countries, with virtually all world experts on this field attending and speaking at it, all leading to an absolutely top scientific program. But there was additionally a surprising event that marked the Conference indelibly. Most of the user groups critical of psychiatry (but not all), which traditionally would be expected to protest outside, decided to come in and engage with us in a discussion of serious concerns. This opening had a crucial value for WPA as this substantially broadened our range of patients/users interlocutors which also encompass groups (including self-help groups) with which psychiatric organizations have been interacting for a long time.

In a historic encounter on June 6, requested formally and with the endorsement of World Health Organization by Mind Freedom International and other European and World networks of current and past users of psychiatric services (European Network of ex-Users and Survivors of Psychiatry, ENUSP; World Network of Users and Survivors of Psychiatry, WNUSP), the president and other top leaders of WPA met with four representatives of the user organizations. The encounter originally scheduled to last one hour, spontaneously extended to three. A range of issues were discussed and possibilities for continuing the dialogue in congresses and other settings were explored. David Oaks, Director of Mind Freedom International, describing the encounter, stated: "This conversation was different than usual. Yes, once more, the proof will be in the results. But all involved felt they were heard and respected in this discussion" (11).

During the following day, the WPA Executive Committee suspended temporarily its official meeting in order to attend the keynote lecture by Ms. Dorothea Buck on "70 Years of Coercion in German Psychiatric Institutions, Experienced and Witnessed". On the basis of her personal history she challenged a psychiatry that neglects communication with patients and demanded a paradigm shift based on the wealth of patients' experiences. After her lecture, the WPA president presented a thank you speech for Ms. Buck's articulate and moving lecture. At an immediately ensuing press and news conference, representatives of the WPA, Council of Europe, and user organizations sitting at the main table held a lively exchange of questions, answers and comments with press representatives and the general audience. The issues experienced globally by service users, the patterns and diversity of their organizations, and prospective opportunities for continuing the Dresden dialogue and for user participation in activities of the WPA and their national member societies were broadly discussed.

CONCLUDING REMARKS

We have briefly outlined and discussed the dialogal bases of our profession with an emphasis on the objective to promote a psychiatry with the person. Reference has been made to historical and contemporary perspectives in the health field and WPA's response to them. A renewed commitment to the clinician-patient relationship appears crucial as well as building an effective dialogue with patient and user groups (as well as trialogues including families) respecting the diversity of their perspectives. Let's take advantage of the Dresden opening to find creative paths to work together for the fulfillment of psychiatry's and medicine's helping soul and the advancement of health in individuals and communities.

References

1. Patwardhan B. Warude D. Pushpangadan P, et al. Ayurveda and traditional Chinese medicine: a comparative overview. Evidencebased Complementary and Alternative Medicine. 2005;2:465–473. [PMC free article] [PubMed]
2. Jouanna J. Baltimore: Johns Hopkins University Press; 1999. Hippocrates.
3. US Presidential Commission on Mental Health. Achieving the promise: transforming mental health care in America. Final report. Rockville: US Department of Health and Human Services; 2003.
4. World Health Organization European Ministerial Conference on Mental Health. Mental health action plan for Europe. Facing the challenges, building solutions. Copenhagen: World Health Organization European Office; 2005.
5. Tasman A. Presidential address: the doctor-patient relationship. Am J Psychiatry. 2000;157:1763–1768. [PubMed]
6. Alanen YO. Lehtinen V. Lehtinen K, et al. The Finnish integrated model for early treatment of schizophrenia and related psychoses. In: Martindale B, Bateman A, Crowe M, et al., editors. Psychosis. Psychological approaches and their effectiveness. London: Gaskell; 2000. pp. 235–265.
7. Mezzich JE. Berganza CE. von Cranach M, et al. Essentials of the WPA International Guidelines for Diagnostic Assessment (IGDA) Br J Psychiatry. 2003;(Suppl. 45)
8. Asociación Psiquiátrica de América Latina. Guía Latinoamericana de Diagnóstico Psiquiátrico (GLADP) Guadalajara: Asociación Psiquiátrica de América Latina; 2004.
9. Mezzich JE. Salloum IM. Towards innovative international classification and diagnostic systems: ICD-11 and person-centered integrative diagnosis. Acta Psychiatr Scand. 2007;116:1–5. [PubMed]
10. Mezzich JE. Psychiatry for the Person: articulating medicinés science and humanism. World Psychiatry. 2007;6:1–3. [PMC free article] [PubMed]
11. Oaks D. World Psychiatric Association meets with psychiatric survivor movement groups. www.mindfreedom.org.

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