João G.

Pereira - Jorge Gonçalves - Valeria Bizzari

Chapter 1

The roots and Seeds

of Humanistic Psychiatry
João G. Pereira
Romão de Sousa Foundation; Casa de Alba, Portugal
Jorge Gonçalves
Universidade Nova de Lisboa, Portugal
Valeria Bizzari
Centre for Psychosocial Medicine, Clinic for General Psychiatry
University of Heidelberg, Germany

In the 18th and 19th century, the Western World went through dramatic
changes in the understanding of mental health and in the provision of
services. William Tuke (1732 - 1822) in the UK and Philippe Pinel (1745 -
1826) in France were in the forefront of a humanizing movement known as
“moral treatment”.
This humanization of services lost ground through the 19th and 20th
centuries, giving rise to the maintenance and spreading of large mental
health institutions where people suffering mental distress were severely
separated/segregated from external reality and not given the rights of
“normal” (adapted) people. A positive idea of asylum (with certain
downsides – see below under “Critical Movements as base for a
Humanistic Psychiatry”) was replaced with segregation.
During the Second World War, a number of British doctors started the
Therapeutic Community movement in the UK, in many ways returning to
the ideas of Tuke and Pinel. They observed that transforming the
environment of the “mentally ill” would also dramatically change their
condition. A number of similar movements spread through Europe and
the US giving rise to a new understanding of mental illness, sometimes
even contesting the term illness itself, and often attempting treatment
without medication.
Alongside the growing therapeutic community movement and the
humanization of services another dominant trend was rising: the
“technologization” and commodification of interventions based on value-

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free science. Whilst not the aim of that trend, it often dehumanized
relationships. There is an implicit tension between “being-with”
(humanistic values) and “doing-to” (technical expertise).
A “doing-to” stance has often been rooted in psychiatric manuals like
DSM (Diagnostic and Statistical Manual of Mental Disorders) or ICD
(International Statistical Classification of Diseases and Related Health
Problems) which suggest the existence of objective states which are value-
free and where concepts such as “autistic” or “schizophrenic” entered daily
discourse and gained legitimacy. Increasingly we find ourselves in a “quick
fix” culture dominated by a technical-rationality model of science, a
change nicely termed by some authors as the “McDonaldization of
Society” (Ritzer, 1993).
How can Being and Doing coexist in the service of patients and families?
The relational paradigm and the scientific postmodern era arose at the
same time that positivism and empiricism are growing. There are
disparate movements of integration and sectarianism; important
differences between affective and cognitive neuroscience; large gaps
between theory and practice; contradictory evidence for and against
“broken-brain” models. Is it possible for science to go back to “the
ordinary” and start being human again, acknowledging the impossibility
of separating figure from ground?
Neurobiology can be significantly modified through medication and
psychotherapy, but also through play and occupational therapy, and by
diet and lifestyle. The right weighting of the components of mental health,
and the right measures of it can only be known through secure and
trustworthy therapeutic relationships, helping to give meaning to
interventions. The establishment of epistemic trust within psychologically
enabling relationships is perhaps the only non-controversial ingredient of
change, as research and practice consistently confirm (Pereira and
Debbané, 2018; Norcross, 2002).
With this volume, we propose to open the debate between three main
themes: psychotherapy (including psychological and philosophical
influences), neurobiology (including cognitive and affective neuroscience)
and psychopharmacology. The three main themes are clinically applied in
what we call the “Intervention Triangle”. The book is first focused on
epistemologically distinct frameworks and gradually attempts to consider
the integration of these three fundamental vertices of practice.
The volume will be particularly relevant to practitioners working towards
integrative frameworks. Although unidisciplinary integration has been a
theme in several research and theoretical publications, this book offers an

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interdisciplinary, comprehensive and reflexive view of mental health

problems and approaches, avoiding developing into mere eclecticism.
Following a number of congresses, international meetings and the
publication of Schizophrenia and Common Sense (Hipólito, Gonçalves
and Pereira, eds. 2018) the first editor has decided to put together a second
volume, grounded on the discussions undertaken during the Second
International Mental Health Congress of Romão de Sousa Foundation.
Several authors from this congress, and several others with an interest in
the subject of integration and common sense mental health, agreed to
publish and contribute towards the humanization and democratization of
mental health services. This volume results from the honest effort of all the
authors, editors, reviewers and assistants. We hope it can contribute
towards common sense in 21st century mental health.

1.1 The “illnification” of mental distress

Biomedical views and the "illnification” of mental distress (see, for
example, Szasz 1960) have dominated the field for some decades, many
times tied up with socio-economic pressures, arising from a variety of
sources, such as the pharmaceutical industry, health insurance
companies, academia, the maintenance of professional status and power,
and so on (see Florence et al. in this volume).
The biomedical model of mental health, alongside the "psychiatrization"
and "psychologization" of mental distress, are parts of a wider sociocultural
paradigm, the commodification of life in general and of mental health
services in particular (see Hinshelwood in this volume). Mental distress, in
this way, is viewed as a burden, an "illness" to get rid of, as quickly as
possible and without pain. Medication fits very well into this “culture,
providing hopes of "quick fixes". One possible problem arising from this
view is that the "function" of mental distress is not fulfilled, the "message" it
carries is ignored, and therefore the desired "quick fix" turns, in many cases,
into chronicity and long term (dis)ability.
As mentioned further below in this chapter, opposition to reductionist
biomedical and empirical views are not a new phenomenon, with the anti-
psychiatry movement of the 60's and 70's being an example. A more
balanced and integrative approach could be found in contemporary
treatment systems such as the Finnish Open Dialogue (see Seikkula and
Alakare in this volume), Mentalization-Based Therapies (see Nolte,
Campbell and Fonagy, in this volume), or other rehabilitative programs,
following WHO guidelines (see Gomes, in this volume). These models are
strongly based in the therapeutic relationship as the central element,
taking lessons from the vast amount of studies in the therapeutic alliance

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as the single most important factor for promoting change (Horvath and
Bedi, 2002; Norcross, 2002). Medication is used but cautiously and
reflexively, most notably in a selective and needs adapted way (Bergström
et al., 2017). They also have in common the strong engagement with
families, communities and other social networks, as well as the attention
paid to attachment security, ruptures and repair in the working alliance
(Safran, Murran and Eubanks-Carter, 2011). The different treatment
systems are supported by research, from experimental to naturalistic
studies (see this volume), and the results are not just promising but, as
many practitioners have mentioned, rather obvious. The importance of
consistency within services and teams is paramount, as demonstrated by
the Open Dialogue system which, to operate in its full potential, should be
adopted by the entire geographical catchment area (see Seikkula and
Alakare, in this volume).
So, if the knowledge and success exist, what is needed in 21st Century
Mental Health to make this humanistic culture dominant within mental
health treatment systems? We claim, as the title of the book suggests, that
it is Common Sense. The "manipulation" of macro-economic forces and
the “illnification” of mental distress resemble, somehow, a collective
psychosis, turning the common citizen apart from the compassion,
tolerance and understanding that mental disturbance needs.
If societies express their wounds and disturbances through "symptoms"
(rise in the number of suicides or terrorist attacks, persecutory culture,
economic collapses or the rise in authoritarianism) so thus the individual.
This essential form of communication must be heard and not silenced; it
must be understood so that transformation is possible.

1.2 The Subjectivity of the Mind

The analysis of mental disorders necessarily requires a careful and
multilayered reflection: in fact, we can affirm that psychiatry owns a
“subject-object”, since it is focused on a complex entity which we cannot
reduce to a mere empirical, spatio-temporal one. As Basaglia underlined
(Basaglia, 2000), consciousness or subjectivity is the real core of
psychiatry, its horizon of meaning. Human Beings are not objective
entities: they are social animals, individuals, and subjective entities. In
order to account for such complexity, Basaglia argued for an integrative
approach, meaning to incorporate both psychiatry and philosophy, the
only perspective able to understand mankind in its deepest core, to face
life’s struggles, to account for the peculiarity of each person and of their
authentic being.

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In this view, pharmacotherapy is not entirely forgotten but is evaluated

as a nonexhaustive perspective which cannot be considered the only
source of recovery. The clinical gaze which is aimed at finding biological
diagnosis and general treatments, following only causal-effect ways of
thinking and empirical evidences, does not grasp the specificity of pain,
which is always different, expressing itself in several ways.
On the other hand, neither a neurobiological approach can account for
the complexity of sufferance: as Schneider (1919) has clearly stated
psychiatry is not just a ramification of scientific-natural medicine, since
pathological histology will never manage to understand psychic
manifestations. Focusing only on brain disruption inevitably cuts off the
experiential domain from the clinical setting. Pio Abreu, Fradique and
Freire Lucas (2010) go even further, stating that psychiatry is a branch of
medicine dealing with “information systems”, rather than a medical
specialty. Medical Specialties deal with sub-systems of the organism,
whilst psychiatry, or to say better, psychic events, are, one way or another,
involved in all body systems.
It seems that, in the analysis and treatment of mental disorders, one
should choose between a “biological psychiatry” (according to which
psychic events are neural events that we should treat through a
pharmacological therapy) and a psychiatry which considers every
psycho(patho)logical experience in its complexity.
In this volume, we argue for a shift from the predominant biomedical,
empirical and pharmacological paradigm towards an integrative,
interdisciplinary approach where pharmacological treatments are not the
only source of healing, since the object is not a malfunctioning machine,
but a suffering person. Jaspers (1959) emphasized the epistemological gulf
between a biological perspective which tries to explain mental symptoms
in terms of neurobiological malfunctions, and a psychological approach
meant to understand mental disorders in terms of other mental
phenomena. What one should recognize is that it is possible to embrace
both perspectives, since a unilateral approach will never manage to
account for the complexity of the human mind. This multiperspectival
approach is called “methodological pluralism”. In this sense, the study of
mental disorders must stop over-relying on medication and focus on a
more human and person-centered approach to treatment, that puts
emphasis on the lived experiences of the patients and on the need for
community-based interventions. In fact, a biological, reductionist
approach is based upon a positivist epistemology which claims that
empirical observations and rules of logic are the only sources of
knowledge.

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For this reason, psychopathology should not be a kind of biology only,

but also part of the Humanities (Jaspers, 1959), because “any serious study
of the mind, or ‘psyche’ must involve the consideration of consciousness,
subjectivity, or the first-person point of view”. (Parnas et al., 2012, p. 5). In
this process, phenomenology plays a key role. This philosophical method
of analysis is primarily directed towards the study of the facts of
consciousness. Accordingly, it is also applicable to psychopathological
facts, allowing to consider the patient as a consciousness, and taking into
account the complexity of psychic life, the real core of psychological
disorders. Phenomenology could be efficacious in understanding the
patient without forgetting biological constraints: a vision of person as a
psycho-physical entity is very useful for not underestimating either the
psyche or the natural organism. This method has been used in the field of
psychopathology: Jaspers’s work (1959), in particular, represented a real
revolution in psychiatry, since he used descriptive phenomenology in
finding the implicit structures of subjectivity. Then, Binswanger (1956)
applied existential analysis to the life history of patients: his work was
primarily directed to the study of schizophrenia, but we can easily claim
that it could be helpful in the study of other psychological conditions.
The advantages of adopting a phenomenological approach are both
methodological and practical. From a methodological perspective,
phenomenology allows one to focus on subjective experiences and not
only on symptoms. Furthermore, the real object of psychopathology is the
person and her/his subjective experiences instead of biological symptoms.
From a practical point of view, phenomenology is helpful in hypothesizing
therapy (Doerr-Zeggers & Stanghellini, 2013) and in modifying the
relationship between the clinician and the patient, which becomes an
empathic attitude where clinicians’ primary purpose is understanding
what it means to be in a certain psychopathological state, not merely in
terms of brain disruptions, but in a more existential manner. The
neurobiological causality, which belongs to a descriptive account, works
together with the explanation of the first person subjective experiences
(Sass, 2010). The result is a person-centered approach (Stanghellini &
Aragona, 2016) which prioritizes patients’ experiences and allows the
clinician to consider them as individual consciousness.

1.3 Critical Movements as base for a Humanistic Psychiatry

1.3.1 Antipsychiatry
Although antipsychiatry in the general sense of the term is as old as
psychiatry itself (Quétel, 2012), which emerges in the early nineteenth

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century, it is in the 1960s and 1970s that a movement known as

“Antipsychiatry” emerges. Though some did not accept the label of
"antipsychiatrist", the names of Michel Foucault, Thomas Szasz, Franco
Basaglia, David Cooper and Ronald Laing among others were associated
with this movement. We will not give a detailed description of the
movement here, but only its general characterization insofar as it poses
problems that would significantly influence the evolution of psychiatry.
Although there are several antipsychiatries, the common denominator
to all of them is the struggle against the psychiatric institution synthesized
in the figure of the physician and his power (Foucault, 1967; Rose, 2006).
In this, anti-psychiatry met the anti-establishment movements of the
time. We think that this critique of repressive psychiatric power is the most
essential of the movement and its criticism of the concept of mental
illness and of pharmacological therapies derived from this fundamental
position.
"It seems to me that we could situate the different forms of anti-
psychiatry according to their strategy in relation to these games of
institutional power: to escape them in the form of a dual contract, freely
consented to by both parties (Szasz); establishment of a privileged
location where they should be suspended or refused if they are
reconstituted (Kingsley Hall); blasts them one by one and destroy them
progressively, inside a classic type institution (Cooper in Hall 21); to link
them to other relations of power which, from outside the asylum, could
already determine the segregation of an individual as mentally ill
(Gorizia). Power relations constituted the a priori of psychiatric practice.
"(Foucault, 1975, our translation, p. 102)
We will briefly mention here two philosophers, Michel Foucault and
Thomas Szasz, who have clearly defined the ideas of the movement in
theoretical terms. We will not present here the practices performed by the
antipsychiatrists. Madness and Civilization (Foucault, 1967) was a book
that influenced anti-psychiatrists, although Foucault's concerns were
initially more epistemological. He argued in this book that the
interpretation of madness as "mental illness" only occurs with the
emergence of psychiatry in the early nineteenth century. The mentally ill
persons are separated from other transgressors of the established order
and locked up in asylums. Foucault does not see, however, in this
movement any liberation but rather an attempt to adapt the patients to
bourgeois society by psychological methods, the so-called "moral
treatment." There appears a new figure, the doctor, a mixture of Judge and
Father who is selected more by his moral capacities than medical. Later,
under the influence of the positivist philosophy, a psychiatric knowledge

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will be elaborated, which serves essentially to justify the doctor's power

over the sick. Anti-psychiatrists aimed to challenge the power of the
institution, incarnated in the doctor's figure. They wanted to give the
patient the right to take their "madness" by removing the doctor from the
role of the one who knows what it is to be mad and to be normal.
Seeing that his book was having a lot of influence, Foucault took up the
subject again, but in the meantime, he turned away from his initial
conception of power, which he came to call the "repressive hypothesis."
According to this conception, the psychiatric institution would be a
microcosm of the society, being the power centered on the doctors. In
Psychiatric Power (2006), Foucault reformulated this idea and maintained
that power is not centralized in a subject (in this case, the medical class)
but it is something diffuse and anonymous. Psychiatry is one of the
devices of power that shapes individuals by "normalizing" them. Power is
not only externally exercised over subjects because the subject is already a
production of power (for example, the woman who "wishes" to submit to
the patriarchal order). With this new version of power, however, becomes
more difficult to understand the scope of Foucauldian criticism. Its first
version was more linked to the anti-psychiatric movement giving a more
concrete aim of action. In any case, in all of his critiques, Foucault does
not deny the existence of madness, it only circumscribes it to a specific
and contingent historical configuration.
Szasz (1960) directly attacked the concept of "mental illness",
considering that it is a myth and a categorial error. There is psychological
distress, living problems and moral conflicts, but none of these are
"illnesses." "Illness" is a physiological concept that is described in a
causal-mechanistic language while the so-called "mental illness" belongs
to the domain of rationality and intentionality (Creswell, 2008). Even if the
correlations between brain and mental illness are to be identified one day,
it is defined in terms of behaviors that only make sense in a social value
context. For example, a person only suffers from depression because she
lives in a society where one thinks that life is something good and joyful. It
is a value, not a natural fact. Thus, Szasz thinks that any power of the
psychiatric institution on the individual is unjustifiable, defending
contractual psychotherapy. Here, two individuals can come to an
agreement on a job to do of psychological transformation without
enforcing values.
We think that the antipsychiatric movement exerted considerable
influence on psychiatric thinking. On the one hand, it elicited a response
from neurobiological psychiatry that sought to reduce psychiatry to
neuronal deficit factors by neglecting motivational and social factors.

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However, we believe that it has also had an influence in the centralization

of psychiatry in the medical value of harm for an individual and not so
much in the deviation of social norms (Telles-Correia, Saraiva &
Gonçalves, 2018). An example would have been the elimination of
homosexuality from the catalog of mental illnesses, as it may be a
deviation from dominant social values, but not an illness. By revealing
how the so-called "mental illness" depends to a large extent on social
values, anti-psychiatry will have inspired the creation of movements that
aim to increase the power and freedom of patients, against a psychiatric
institution that aimed primarily at social control.

1.3.2 Critical Psychiatry

Mainstream Psychiatry continues to be criticized nowadays, under various
degrees of severity. A similar movement to antipsychiatry but also with
important differences is called “Critical Psychiatry”. This movement arose
from a response against the proposals of the British Government to amend
the 1983 Mental Health Act. A group of British psychiatrists met for the
first time in 1999 expressing concerns about the implications of the
proposed changes for human rights and the civil liberties of people with
mental health problems. The Critical Psychiatry Network arose from here,
and since then hundreds of peer-reviewed articles and dozens of books
have been written, accumulating evidence on the following themes:

• The problems of diagnosis in psychiatry;

• The problems of evidence-based medicine in psychiatry and,
related to this, the relationship between the pharmaceutical
industry and psychiatry;
• The central role of contexts and meanings in the theory and
practice of psychiatry, and the role of the contexts in which
psychiatrists’ work;
• The problems of coercion in psychiatry;
• The historical and philosophical basis of psychiatric knowledge
and the practice of psychiatry.

Linked to critical psychiatry is the more theoretical “wing” called

Postpsychiatry (Thomas and Brecken, 2004), who use similar principles to
Critical Psychiatry whilst grounding their work more specifically in
Heiddeger, Merleau-Ponty, Foucault and Wittgenstein.

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1.3.3 Therapeutic Communities

Arising from an amalgamation of critical movements, Therapeutic
Communities (TC´s) have been, and continue to be, a counterculture for
mainstream mental health services. TC´s developed from models of
treatment that broke from traditional practice and posed profound
challenges to dominant thinking at various times: at the end of the
eighteenth century (Tuke, 1813), during the Second World War (Bion, 1961;
Harrison, 1999), and in the 1960s (Foucault, 1965; Goffman, 1968; Laing,
1967; Rapoport, 1960 cited in Haigh, this volume). More recent
descriptions encourage medication reduction and use of other radical
ideas (Haigh, 2007). Pearse and Haigh (2017) have recently published an
entire volume dedicated to democratic therapeutic communities,
including past references, present status quo and ideas for the future. This
book also includes a recent RCT comparing personality disorder treatment
in TC´s and treatment-as-usual, showing superior results for TC treatment.
Contrasting to many mainstream services, the clinical work of
Therapeutic Communities takes account of the interface between the
individual and their social and cultural setting (Jones, 1956). Democratic
Therapeutic Communities use the concept of fluid hierarchy (Clarke,
2015) to sustain shared decision making and shared tasks in the day to day
running of the community. Problems are believed to be of relational
nature (Pereira, 2015; Pereira and Debbané, 2018) and symptoms are not
exempt of meaning. Peer therapy, rather than only therapist-patients
traditional therapy, ends up occurring as a consequence of the flattened
hierarchy structure (See Haigh, in this volume). An example of user
involvement in research in the context of a mental health therapeutic
community is also given in this volume (Guerra, Pereira and Sales).

1.3.4. Other Critical Movements

In the US, Robert Withaker´s book Mad in America: Bad Science, Bad
Medicine, and the Enduring Mistreatment of the Mentally Ill (Withaker,
2010) set the scene for another counter-movement that mainly criticizes
the current drug-based paradigm of care. In their “Mad in America”
website mission they claim that this model has failed society and that
scientific research, as well as the lived experience of those who have been
diagnosed with a psychiatric disorder, calls for profound change.
Also concerned with the dubious evidence about the efficacy of (long-
term) pharmacological treatment, the Norwegian minister of health has
recently advised that all psychiatric services should offer drug free wards,
according to patient choice. The nordic city of Trömso has been the first to
attempt this challenge, opening a 6-bed drug free ward for severe

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psychiatric disturbances. Patients and staff from this ward have recently
reported on the 22nd International Meeting for the Treatment of Psychosis
on what seems to be, thus far, a positive experience.
Close to Norway, the Finnish Open Dialogue system (see Seikkula and
Alakare, in this volume) has, for long, been critical of mainstream
psychiatry and abusive psychopharmacological treatment. They do not
advocate against medication but instead promote a robust psychosocial
structure in the psychiatric services and an organized, network way of
approaching problems. By working in this way, they dramatically observe
the reduction of coercive treatments and hospitalizations and well as the
need for pharmacological treatment.

1.4 General Overview of the Book

In this volume, we bring together several contributions that address
mental disorders from different but not divergent perspectives. In fact, our
aim is to show that a more humanized, person-centered approach does
not exclude neurobiological and pharmacological studies, but opens up
the possibility for new integrative and transdisciplinary perspectives,
where biological data and lived, first person experiences are equally useful
for the treatment of mental disorders.
This emerges already in the first part, “Neurobiology and Pharmacology”,
where it seems to be evident that we need a Gestaltic vision of subjectivity
and mental functions. In Neuroscientific Questions about Intrapsychic
Phenomena and Interpersonal Processes, M. David emphasizes the existence
of interesting correlations between events that occur in the brain (conceived
as a neurobiological organ) and intrapsychic phenomena and interpersonal
processes of the mind. In his view, non-conscious communication
phenomena are interfaces between neurophysiological processes and
interpersonal dynamics. In fact, the brain is a plastic, dynamic organ that is
shaped by the everyday functions of the human body, to such an extent that
we can define it as a “mediating organ” (Fuchs, 2018). Arguing for an
intertwining between neural processes and phenomenal ones, David claims
that psychotherapeutic interventions can actually influence the
neuroplasticity of the brain. In other words, psychotherapy has impact on
patients’ brains, following a circular mechanism according to which the
brain, the mind and the body holistically influence each other.
The importance of a multilayered therapy is also at the center of A.
Florence et al.’s chapter, Towards recovery-based practices in mental
health: reframing long-term effects of neuroleptics and presenting
alternatives, where the authors critically analyze the outcomes of
neuroleptic use in the treatment of individuals with psychosis and

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schizophrenia. They observe that there is limited evidence for the

effectiveness of similar treatments in the long-term, and they argue for
recovery-oriented strategies (such as the Open Dialogue approach) that
make a selective use of pharmacological treatment, which involves
network aspects and dialogue as the primary therapeutic components.
Among these components, as J. Grácio et al. remember us in the article
Embracing the Placebo effects in the treatment of depression: from
neuropsychiatry to psychotherapy, we should not undervalue placebo
effects and the power of its healing-promoting properties. Through a
careful review, the authors note that in pharmacotherapy and
psychotherapy there are small differences between real treatments and
placebo. Accordingly, they suggest considering placebo as a promotor of
clinical improvement which should be used together with other
therapeutic approaches. The efficacy of placebo is shown through the case
of depression, a mental disorder where placebo seems to have a powerful,
healing effect.
The complexity of facing mental disorders and the necessity of an
integrative approach is emphasized by A. Gomes, who describes
Psychiatric rehabilitation: the efforts for conceptualization and meaning
construction - a review. He provides a historical understanding of the
concept “rehabilitation” through a non-systematic review based on
national reports, finding out that the origins of psychiatric rehabilitation
mainly lay in historical and sociocultural events. The multidisciplinary
nature of this therapy is based on two axes: the person and the
environment, elements which are conceived in a dialectic relationship. In
other words, the psychiatrists should consider both of these spheres and
involve the patient in the community life, creating a support system able
to improve patient’s life.
Pharmacological, neurological, social and person-centered approaches
work in a non-exclusive manner for improving the quality of patient’s life,
a patient who is not a disrupted brain, but a person who lives in a
culturally-socially shaped environment which influences his behavior and
his neural structures.
The intertwining between social elements, neural structures and
behavioral components is at the center of the second part of the volume,
which hosts contributions that interestingly testify the possibility of
approaching mental health in a more human manner, focusing not only
on the subjectivity of the patient, but also on the importance of the social,
collective dimension. This involves the arising of new theoretical research
directions and of new, innovative services. In fact, the dimension of the
cure has enlarged its horizons from the study of the individual brain to the

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development of therapeutic communities. R. Haigh’s chapter on

Therapeutic communities for the future: surviving modernization and
staying at the radical edge explains how a treatment which was seen at the
forefront of progressive and radical practice in the mid-20th Century has
survived and developed in very different sociocultural times and kept its
critical stance in regard to mainstream psychiatry. Therapeutic
communities encourage medication reduction and take into account the
interface between the individual and their social and cultural setting. The
chapter focuses on how group processes have been harnessed across the
network of therapeutic communities to influence quality, training,
research and innovation – and how the underlying therapeutic philosophy
is now being used in new settings.
A concrete example of a similar practice is furnished by J. Seikkula and B.
Alakare in Open Dialogue principles and dialogical meetings for psychosis,
where they illustrate this innovative, family and social network-centered
treatment approach that was initiated in 1984 in Finland (but only named
as “Open Dialogue” in 1995). Open Dialogue involves two elements: first,
open meetings in which all relevant members in the actual situation –
including both the social network of the client and the professionals
working as a team - participate from the outset to generate new
understanding by dialogue; second, the guiding principles for the entire
system of psychiatric practice in one geographic catchment area. The
main forum for dialogues is the open treatment meeting where all
management plans and decisions are made with everyone present. This
kind of treatment seems to guarantee—among other benefits—
psychological continuity, immediate response and long-term effectiveness
for severe mental health problems. The positive outcomes presented may
indicate that psychosis no longer needs to be seen as a sign of illness but
can be viewed as one way of dealing with a crisis and that after this crisis
many or most people are capable of returning to their active social life.
The continuity between what can be considered as “pathological” and
“non pathological” is also described by M. Debbané and E. Toffel in
Mentalizing the early stages of the Psychosis Continuum, suggesting that
psychotic phenomena are expressed along a continuum ranging from
non-clinical to more serious clinically psychotic manifestations. They
focus especially on trauma and attachment insecurity, conditions that
influence a developmental trajectory that strays away from investing in
mentalizing skills, and that promotes a dissociative coping style in
individuals having experienced hostile and sometimes traumatic early
environments. This perspective could be useful in the prevention of risk.
The enlargement of the horizon by putting attention not only on

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pharmacological treatments but also on the prevention is underlined by

Nolte, Campbell and Fonagy in the paper Social communicative processes
in severe personality disorder. At the center of their analysis, there is the so-
called “p-factor”, a general vulnerability index that captures the tendency
of some individuals of being more prone to persistent and more severe
psychopathology. Combining computational neuroscience and
contemporary models of psychopathology, the authors shed light on the
fact that “p” is strongly associated with high levels of childhood
maltreatment and low mentalising capacities and emphasize aspects of
brain structure-function relationships underpinning resilience processes.
In other words, they account for a multilayered approach where
neurobiological data and social, developmental structures have the same
importance for the understanding of the pathology: broader social
networks and the wider social environments also have neural structures,
in a circular mechanism where the brain, the mind and the environment
constitute a whole.
But how can we face this complexity in the clinical practice? In the third
part of the volume we can find some examples: in Multidimensional study
of the infant population with severe and profound intellectual
developmental disorder, A. Janeco et al. take into account the case of
mental deficiency, referenced as Intellectual Developmental Disorder
(IDD). They present their work at the Center de Recuperação de Menores
D. Manuel Trindade Salgueiro, which hosts 120 female residents aged from
3 to 17 years old. Their approach tries to assess the global needs of IDD
population, evidencing the relevance of an integrated model of
intervention, as well as illustrating how to organize a similar intervention
in all technical areas in a structured and coordinated way. While the areas
of intervention include psychiatry, nursing, social services and
psychology— which are used especially in the diagnostic phase— the
therapy areas include physical therapy, psychomotricity, speech therapy
and occupational therapy, without forgetting patient’s interests and needs.
A patient-centered approach is presented by D. Guerra et al. in Practice
based research at Casa de Alba: the perspective of service users. Casa de Alba
is a residential therapeutic community which adopts a participatory
research approach, involving residents in planning and conducting
research; and carries on therapies with patients and their families. In other
words, it is a relational environment where everything is aimed at giving
voice to patients in order to allow their opinions to influence future
research and therapeutic priorities. The same happens to evaluation tools:
in fact, the paper presents a participatory research study where, by
carrying out a focus group, they explore the residents' views on the

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The Roots and Seeds of Humanistic Psychiatry 15

outcome measures used in the routine assessment of patient progress.

Participants were asked to give their opinions on the advantages and
disadvantages of two nomothetic measures and two client-generated
outcome measures (CGOMS). Results provided valuable insights into the
complementary nature of nomothetic measures and CGOMs, as well as
into the effect that weekly progress monitoring can have on patients in
residential psychiatric care.
A more human approach to mental disorders has the effects of changing
treatments —as Casa de Alba and Centro of Recuperação de Menores D.
Manuel Trindade Salgueiro testify— but also of modifying our view of
mental illness. The changes involve the shift of attention from the patient
conceived as an individual to the suffering person as being part of a
community, and from the pathology as a specific, severe situation
described by manuals that follow strict definitions, to a continuum state
which can vary in its intensity and expressions. In this sense, mental
health research and practice should be committed to creating new
research paths, and a renovate social responsibility towards every citizen.
A. Candeias et al. describe Burnout in teaching: the importance of personal
and social variables, where they take into account a phenomenon often
undervalued: the level of burnout in teachers. They present a study made
on teachers of Portuguese public schools, using the Maslach Burnout
Inventory (MBI; Maslach, Jackson & Leiter, 1996), which allows a three-
dimensional characterization of burnout: personal accomplishment,
emotional exhaustion, and depersonalization. The result leads to
conclude that there is a strong need for an intervention promoting the
health and wellbeing of teachers, oriented towards the training and
professional valorization and the prevention of the emotional exhaustion
that happens with the career advancement and years of experience.
The centrality of social dimensions in mental health is underlined by D.
Pereira in Parenting and/or Mental Health? where she notes the difficulties
in assessing parenting capacity evaluation. In this chapter, she argues for a
flexible and dynamic approach, able to find a pattern through the
difference gathered from multiples sources of information - parents,
family members, neighbors, friends, professionals – and methodologies –
home visits, interviews, psychological assessment, observation of
interactions and contact with other professionals. Then, she presents the
Parenting Capacity Assessment Guide as a tool that could help
professionals in clinical judgements about parenting behavior.
The need for a new approach is also felt in research, where what is
discussed is not only the right kind of treatment and the links among the
different approaches, but also the nature of mental disorders themselves.

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In fact, we cannot trace a line between madness and healthy: once again
Basaglia’s (2000) thought seems to be helpful in emphasizing that we
cannot know what is “normal”, since there are very thin boundaries
between mental disorders and healthy conditions.
According to this perspective, even boredom seems to be problematic:
on the one hand, there are specialists in psychology and psychiatry who
understand boredom as a pathological personality trait and propose a
wide variety of therapies to cope with it. Especially after the publication of
the DSM-V, boredom is now being treated with medication. On the other
hand, as J. R. Velasco argues in Boredom: humanizing or dehumanizing
treatment, there is also an almost unknown understanding of boredom as
an adaptive emotion through which it is possible to refocus attention on
the context from which boredom comes instead of the subject itself.
All of these elements lead us to insist, in the final part of the volume, on
the necessity of a human-centered and transdisciplinary approach: this is
the reason why we found useful to give space to subjects not always taken
into account within the debate on mental health. These subjects are
phenomenology, existentialism and psychoanalysis. Restoring these
perspectives seems to be necessary if we want to overcome the
operationalized criteria of the Diagnostic Manual Disorder, which reduced
mental disorders to a sum of signs and symptoms. The lived experience of
the patient has been somehow ignored, reducing the clinical encounter
itself to a crystalized, mechanistic relationship. Focusing on the essences
of things and on an eidetic, intuitive method, phenomenology allows for
the analysis of the substructures of consciousness (such as the formation
of meaning, action planning, temporal continuity) that are disrupted in
psychiatric pathologies. In fact, by describing and highlighting the pre-
reflective aspects of experience, the phenomenological method
emphasizes the importance of the analysis of this specific dimension as
the core of psychiatric disorders. More specifically, in the analysis of
psychiatric pathologies, the descriptive aim could be helpful also in the
explanation of such pathologies. In other words, the eidetic description
could contribute to the explanation of both the genesis and the structure
of human experience: genetic and static phenomenologies can work
together in the analysis of pathologies (cf. Sass, 2014). Furthermore,
considering the patient as a Leib, a body which follows biological laws but
is also inevitably linked to a psyche, this approach could help in
developing a qualitative analysis of mental illness, explaining psychiatric
disorders as subjective and material-bodily states.
In this way, it is possible to go beyond diagnostic classification: in fact, a
phenomenological approach allows to adopt a first person perspective on

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The Roots and Seeds of Humanistic Psychiatry 17

the disturbance; and it can be combined with developmental psychology

and other approaches, such as existential psychotherapy, opening up the
possibilities for new therapeutic directions.
These themes are faced by V. A. Rodrigues’ and V. Bizzari’s papers. In the
first—Dialectic of the first and third person accounts in mental health-
therapeutic implications— V. A. Rodrigues, drawing on phenomenology
and existential psychotherapy, describes clinical practice as a space where
the therapist goes from a third person discourse to a first person case and
back again to a third person analytic discourse. He claims that the clinical
encounter could not be either a pure subjective space nor a space of pure
reflection. In other words, the clinician owns “a position” that “is not that
of a neutral anthropologist; it is rather one of a coach or a midwife.
His/her trade is grounded on a sensitivity to the subtle indices of his
interlocutor’s phrasing, bodily language and expressiveness, seeking for
indices (more or less explicit) which are inroads into the common
experiential ground. Such encounters would not be possible without the
mediator being steeped in the domain of experiences under examination,
as nothing can replace that first-hand knowledge” (Varela & Shear, 1999,
10). Lived and first-person data are privileged with respect to scientific
analysis: following this direction, Rodrigues contrasts third-person
psychiatric and psychological reports with first-person reports of lived
experience recorded of clinical sessions and proposes a hermeneutical
critical method relevant for clinical practice.
On the other hand, in From D.I.R. to D.I.R.E: the role of Embodiment in the
treatment of self-disorders, V. Bizzari shows the usefulness of
phenomenological insights in the development of therapeutic paths: she
combines Greenspan’s “affective diathesis hypothesis” with a
phenomenological account of subjectivity as a corporeal, kinesthetic entity,
and points out the role of embodiment in the development of selfhood and
intersubjectivity. Then, she proposes a special kind of therapy integrating
Greenspan and Wider’s “D.I.R.” model—Developmental, Individual
Difference and Relationship-based— with phenomenological insights,
emphasizing the fact that, especially in the treatment of autism, we should
take into account therapies aimed at strengthening the sense of the
corporeal self.
Despite its many critics, another discipline that has played, and
continues to play, a major role in the understanding of social and
individual dynamics is psychoanalysis.
This is illustrated by R. Hinshelwood, who, in the chapter Psychoanalytic
roots of the therapeutic community, explains how the therapeutic
community movement in psychiatry (particularly, in Britain) was

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influenced by psychoanalysis. Considering the psychoanalytic encounter

as a social field, we can thus claim that it allowed the theory to be applied
in the social setting of mental hospitals, and thus emerged the practice of
therapeutic communities. According to the author, the convergence of
social field theory with object-relations psychoanalysis in the 1940s
represented the innovative foundation for what we must think of as the
group of relational therapies (psychoanalytic psychotherapy, group
therapy, therapeutic community).
Psychoanalysis and its possible influences on other fields are also at the
center of the last chapter, G. Caselli’s Ipsas Aquas Urere Consuevit.
Psychiatric praxis, analytic thought, transference love . This chapter has a
twofold aim. On the one hand—like in V. A. Rodrigues’ chapter—it reflects
on the clinical encounter, arguing for the centrality of caring to such an
extent that the therapist herself can be conceived as a relational
instrument; on the other hand the author argues for an integrative
approach where psychoanalysis (with a special attention to the notion of
transference love) can have a role in the psychiatric practice, helping in
building a renewed epistemology of psychiatry where emotions and love
are primary tools for understanding the patient.
Psychiatry seems to resolve itself in a border science, which should be
able to incorporate other disciplines, with the final aim of looking for
connections within the fragmented experience of the patient, which
should be considered as a continuous oscillation between subjectivity and
objectivity, personhood and society, mind and body, individual needs and
social expectations. In other words, psychiatry needs to become “ethic and
kind” (Borgna, 2003).

Acknowledgments
The editors would like to especially thank the authors for their
commitment. We also express our gratitude to Inês Hipólito, Cláudia Pedro
and Joana Grave for their invaluable help to the editorial team. We want to
thank Christoph Durt, Madalena Serra, Constança Biscaia, Sofia Tavares,
João Gama Marques, Adrian Spremberg and Philipp Schmidt for their
useful suggestions to improve the quality of the book. This volume would
not have been possible without the help of Fundação Romão de Sousa,
IFILNOVA from Universidade Nova de Lisboa and the Psychology
nd
Department of Universidade de Évora who jointly organized the 2
International Mental Health Congress, where some of the chapters started
to come alive.

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The Roots and Seeds of Humanistic Psychiatry 19

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