Addiction is one of the most significant problems facing contemporary society. Consequently many scholars, institutions and clinicians have sought to understand this complex phenomenon, as is evident in the abundance of etiological models of addiction in existence today. A literature review pointed that there is little consensus regarding the nature and etiopathogenesis of addiction, and integrative models have not yet been able to provide the sought-after integration. In addressing this problem, this study offers a theoretical analysis of the paradigmatic and (...) meta-paradigmatic suitability of Integral Theory in the design of an integrated metatheory of addiction. The data consisted of the most prominent etiological theories and models of addiction. The study focused on several essential features constituting the architectonic of any metatheory that attempts to provide conceptual scaffolding for the construction of a comprehensive metatheory of addiction. The criteria for the construction of a metatheory were conceptual integration, ontological span, ontological depth, empirical validity and internal consistency. Integral Theory was critically assessed in terms of each of the abovementioned criteria. The study suggests that Integral Theory is eminently suitable as a philosophical foundation for the development of an integrated metatheory of addiction. (shrink)

Theory of illness causation is an important issue in all biomedical sciences, and solid etiological explanations are needed in order to develop therapeutic approaches in medicine and preventive interventions in public health. Until now, the literature about the theoretical underpinnings of illness causation research has been scarce and fragmented, and lacking a convenient summary. This interdisciplinary book provides a convenient and accessible distillation of the current status of research into this developing field, and adds a personal flavor to the discussion (...) by proposing the etiological stance as a comprehensive approach to identify modifiable causes of illness. (shrink)

Health disparities in primary care remain a continual challenge for both practitioners and patients alike. Integrating mental health services into routine patient care has been one approach to address such issues, including access to care, stigma of health-care providers, and facilitating underserved patients’ needs. This article addresses examples of training programs that have included mental health learners and licensed providers into family medicine residency training clinics. Descriptions of these models at two Midwestern Family Medicine residency clinics in the United States (...) are highlighted. Examples of cross-training both medical residents and mental health students are described, detailing specific areas where this integration improves mental health and medical outcomes in patients. Challenges to effective integration are discussed, including larger system buy-in, medical providers’ knowledge of mental health treatment, and the skills for clinical providers to possess in order to present mental health options to patients. Patients who traditionally experience multiple barriers to mental health treatment now have increased access to comprehensive care. As a result of more primary care clinics ascribing to an integrated care model of practice, providers may benefit from not only increased coordination of patient services but also utilizing behavioral health professionals to address health barriers in patients’ lives. (shrink)

Multidisciplinary models aggregating ‘lower-level’ biological and ‘higher-level’ psychological and social determinants of a phenomenon raise a puzzle. How is the interaction between the physical, the psychological and the social conceptualized and explained? Using biopsychosocial models of pain as an illustration, I argue that these models are in fact level-neutral compilations of empirical findings about correlated and causally relevant factors, and as such they neither assume, nor entail a conceptual or ontological stratification into levels of description, explanation or reality. If inter-level (...) causation is deemed problematic or if debates about the superiority of a particular level of description or explanation arise, these issues are fueled by considerations other than empirical findings. (shrink)

Currently there is such a cornucopia of conflicting theories in the field of addiction studies that it has become exceedingly difficult for treatment providers, therapists, and policymakers to integrate this vast field of knowledge into effective treatment. Since such a chaotic overabundance of treatment theories, styles, and definitions cloud the field of addictionology, many therapists claim their field is in need of a paradigm shift. In the last 20 years an integrative and compound model has emerged known as the biopsychosocial (...) model, but without a solid and comprehensive meta-framework, syncretistic confusion can result when therapists pick and choose techniques without direction or an overall rationale. To address this problem, Guy du Plessis applies integral theory as a conceptual framework for understanding addiction, as well as a meta-therapeutic framework for therapists. The integral foundation of addiction outlined in this book provides researchers, academics, treatment providers, policy makers, and therapists with a conceptual architectonic of addiction and its treatment that is integrative, inclusive, and practical. An Integral Foundation for Addiction Treatment belongs on the shelf of every addiction treatment therapist, and anyone else who is impacted or influenced by the topic. (shrink)

BackgroundPrevious empirical work among physicians has led us to propose that clinical practice is experienced by clinicians as an engagement-in-the-clinical-situation. In this study, we pursue our exploration of clinical practice ‘on its own terms’ by turning to the experience of patients.MethodsPhenomenological analysis of in-depth individual interviews with 8 patients.ResultsWe describe the patient experience as a set of three motifs: the shock on the realization of the illness, the chaos of the health care environment, and the anchor point provided by an (...) engaged physician. We draw on Heidegger’s notion of solicitude to show that patients are actively ascertaining the physician’s engagement in their care.ConclusionsThese findings lead us to question the classical “dual discourse” of medicine that offers a dichotomous account of clinical practice as the addition of care to cure, art to science, humanism to technique, and person to medical case. We found no such distinctions in our empirical investigation of clinical practice. Rather, in our synthesis, practice appears as a unitary experience. The physician’s solicitude for the patient entrains engagement in the clinical situation. Moreover, the solicitous, engaged physician constitutes an anchor point for the patient. (shrink)

In this paper, I offer an argument for cultivating cheerfulness as a remedy to sadness and other emotions, which, in turn, can provide some relief to certain cases of depression. My thesis has two tasks: first, to establish the link between cheerfulness and sadness, and second, to establish the link between sadness and depression. In the course of accomplishing the first task, I show that a remedy of cultivating cheerfulness to counter sadness is supported by philosophers as diverse as Thomas (...) Aquinas, Baruch Spinoza, and David Hume in their writings on the passions. I also show that my argument can generalize to promote the cultivation of other emotions. In the course of accomplishing the second task, I consider different models of depression and how the emotions are related to depression. The purpose of this paper is to offer conceptual, philosophical support that is consistent with the most current empirical data on depression. (shrink)

After describing the disorder of psychopathy, I examine the theories and the evidence concerning the psychopaths’ deficient moral capacities. I first examine whether or not psychopaths can pass tests of moral knowledge. Most of the evidence suggests that they can. If there is a lack of moral understanding, then it has to be due to an incapacity that affects not their declarative knowledge of moral norms, but their deeper understanding of them. I then examine two suggestions: it is their deficient (...) practical reason or their stunted emotions that are at fault. The evidence supports both explanations. I conclude with an overview of the debate concerning whether they are morally or legally responsible for their actions. (shrink)

Today, health systems around the world are under pressure to create greater value for patients and society [81, p. 1, 119]; increasing access, improving client orientation and responsiveness, reducing medical errors and safety, restraining utilization via managed care, and implementing priority allocation of resources for high-burden health problems are examples of strategies towards this end. The quality paradigm by virtue of its strategic consumer focus and its methods for achieving operational excellence has proved an effective approach for creating higher value (...) in many sectors. If applied in a deliberate and holistic manner, the quality paradigm can bring about a more cost-effective organization of the health systems. In this article, we apply quality concepts to healthcare in a conceptual format; we characterize the health system’s customers and outputs with their quality dimensions. The product of this effort is a blueprint for a customer-driven health system which identifies six types of customers, nine types of outputs and the associated operations. As a preliminary step, a new analysis and definition of health and disease is provided. Rethinking the structure of health system in this manner and the related conceptual model can guide medical research, health sciences education, and health services policy, and help the practitioner to integrate all modern trends in healthcare delivery. (shrink)

A human being is the simultaneous composite of several different levels of being, from atomic and subatomic to the level of complex social interaction, and these levels are nested within the individual hierarchically (lower levels giving rise to higher levels, etc.). One of the most important and influential approaches developed in the history of science has been that of systems theory and systemic thinking, in which the different levels of the hierarchy, and the interactions between those levels, are considered simultaneously. (...) Although this model provides a comprehensive view of biological being, the transition from one level to the other is not well defined in it. Uexküll and Pauli (Advances: Journal of the Institute for 417 the Advancement of Health 3:158–174, 1986) suggested that semiosis is the translator of the events from one level to the other. From a psychological point of view, a myriad of semiotic events happen inside an individual, and it has been suggested that among other semiotic events, inner speech plays an important role in mediating personal agency. Dialogical theories of the self, Jungian psychology and hypnosis research evidence show that there is a semiotic multiplicity in human agency and consciousness, and that these multiple streams are all converge to a central semiotic singularity. I argue in this paper that by taking a biosemiotic point of view, human ‘agency’ may be defined as the ability of an individual to direct the incoming and internal streams of semioses and the ability to create an integrative and superordinate new stream of semiosis in addition to the upwardly and downwardly component ones, and how such a view might open a new door for research into the concept of human ‘personality’ and ‘agency’. (shrink)

The Covid-19 pandemic has challenged both medicine and governments as they have strived to confront the pandemic and its consequences. One major challenge is that evidence-based medicine has struggled to provide timely and necessary evidence to guide medical practice and public policy formulation. We propose an extension of evidence-based corona medicine to an organismic systems corona medicine as a multilevel conceptual framework to develop a robust concept-oriented medical system. The proposed organismic systems corona medicine could help to prevent or mitigate (...) future pandemics by transitioning to a bifocal medicine that extends an empirical evidence-based medicine to a theory-oriented organismic systems medicine. (shrink)

What position on dualism does medicine require? Our understanding of that ques- tion has been dictated by holism, as defined by the biopsychosocial model, since the late twentieth century. Unfortunately, holism was characterized at the start with con- fused definitions of ‘dualism’ and ‘reductionism’, and that problem has led to a deep, unrecognized conceptual split in the medical professions. Some insist that holism is a nonreductionist approach that aligns with some form of dualism, while others insist it’s a reductionist view (...) that sets out to eradicate dualism. It’s important to consider each version. Nonreductive holism is philosophically consistent and clinically unprob- lematic. Reductive holism, however, is conceptually incoherent—yet it is the basis for the common idea that the boundary between medical and mental health disorders must be vague. When we trace that idea through to its implementation in medical practice, we find evidence that it compromises the safety of patient care in the large portion of cases where clinicians grapple with diagnosis at the boundary between psychiatry and medicine. Having established that medicine must embrace some form of nonreduc- tionism, I argue that Chalmers’ naturalistic dualism is a stronger prima facie candidate than the nonreductive alternatives. Regardless of which form of nonreductionism we prefer, some philosophical corrections are needed to give medicine a safe and coherent foundation. (shrink)

We generally accept that medicine’s conceptual and ethical foundations are grounded in recognition of personhood. With patients in vegetative state, however, we’ve understood that the ethical implications of phenomenal consciousness are distinct from those of personhood. This suggests a need to reconsider medicine’s foundations. What is the role for recognition of consciousness (rather than personhood) in grounding the moral value of medicine and the specific demands of clinical ethics? I suggest that, according to holism, the moral value of medicine is (...) secured when conscious states are recognized in everyday medical science. Moreover, consciousness fully motivates traditional principles of clinical ethics if we understand respect for autonomy as respect for the dominion of an experiencer in the private, inescapable realm of bodily experience. When medicine’s foundations are grounded in recognition of consciousness, we understand how patients fully command respect even when they lack capacity to exercise their bodily dominion through decision-making. (shrink)

In recent years, the societal and personal impacts of pain, and the fact that we still lack an effective method of treatment, has motivated researchers from diverse disciplines to try to think in new ways about pain and its management. In this paper, we aim to develop an enactive approach to pain and the transition to chronicity. Two aspects are central to this project. First, the paper conceptualizes differences between acute and chronic pain, as well as the dynamic process of (...) pain chronification, in terms of changes in the field of affordances. This is, in terms of the possibilities for action perceived by subjects in pain. As such, we aim to do justice to the lived experience of patients as well as the dynamic role of behavioral learning, neural reorganization, and socio-cultural practices in the generation and maintenance of pain. Second, we aim to show in which manners such an enactive approach may contribute to a comprehensive understanding of pain that avoids conceptual and methodological issues of reductionist and fragmented approaches. It proves particularly beneficial as a heuristic in pain therapy addressing the heterogenous yet dynamically intertwined aspects that may contribute to pain and its chronification. (shrink)

The biopsychosocial model is characterized by the systematic consideration of biological, psychological, and social factors and their complex interactions in understanding health, illness, and health care delivery. This model opposes the biomedical model, which is the foundation of most current clinical practice. In the biomedical model, quest for evidence based medicine, the patient is reduced to molecules, genes, organelles, systems, diseases, etc. This reduction has brought great advances in medicine, but it lacks a holistic view of the person. To solve (...) the problem, we propose an early team based approach where the primary care physician leads a group of people that can help her/him address the psychosocial issues while she/he attends to the biomedical issues. This article addresses one case where the clinical ethicist facilitating a team based biopsychosocial model for the care of a patient worked as a bridge between the primary team, the critical care team, and the psychosocial team to advance the argument that good communication among the groups can lead to a true biopsychosocial model where the collaboration of the social worker, psychologist, chaplain, ethicist and the different medical teams can improve the overall patient experience. (shrink)

Psychosomatic medicine, with its prevailing biopsychosocial model, aims to integrate human and exact sciences with their divergent conceptual models. Therefore, its own conceptual foundations, which often remain implicit and unknown, may be critically relevant. We defend the thesis that choosing between different metaphysical views on the ‘mind–body problem’ may have important implications for the conceptual foundations of psychosomatic medicine, and therefore potentially also for its methods, scientific status and relationship with the scientific disciplines it aims to integrate: biomedical sciences, psychology (...) and social sciences. To make this point, we introduce three key positions in the philosophical ‘mind–body’ debate and investigate their consequences for the conceptual basis of the biopsychosocial model in general and its ‘psycho-biological’ part in particular. Despite the clinical merits of the biopsychosocial model, we submit that it is conceptually underdeveloped or even flawed, which may hamper its use as a proper scientific model. (shrink)

This article is intended to revive, through a critical reinterpretation, the bio-psychosocial model of George Engel. Engel’s first description in 1977, was very broad, encompassing too many aspects of medicine. In his later work, he focused his model as an epistemology for clinical medicine. However, what medicine mostly retained were minor aspects of the 1977 article, namely a multi-factorial approach to the etiology of diseases and a call to complement biomedicine with a psychosocial concern in order to re-humanize medicine. We (...) suggest that, properly understood as a clinical epistemology, Engel’s model retains its transformative potential for contemporary medicine.Our discussion begins with a.. (shrink)

The biopsychosocial (BPS) model has been of considerable utility to those researching health and illness. This has been particularly the case for critical realists and those with a systemic orientation to their work. Whilst the strengths of the model are conceded in this article, its limitations are also examined. These relate to its ontological sophistication being compromised by its proneness to epistemological naivety. It is a model to explain the emergence of disease and disability, not a reflexive theory applicable to (...) the whole field of health research. This tension is linked to the emergence of a re-orientation of medical knowledge away from bio-medical reductionism. From the outset the model was not about a general critique, or a grand theory, of health and illness. Instead it was a useful intervention, on the part of medical practitioners, like George Engel and Adolf Meyer, to create a reformed medical model on behalf of their profession. Case studies of the problematics of diagnosis and medicalization are offered to illuminate the limitations of the BPS model for health researchers. (shrink)

Twenty years ago, the biopsychosocial model was proposed by George Engel to be the new paradigm for medicine and psychiatry. The model assumed a hierarchical structure of the biological, psychological and social system and simple interactions between the participating systems. This article holds the thesis that the original biopsychosocial model cannot depict psychiatry's reality and problems. The clinical validity of the biopsychosocial model has to be questioned. It is argued that psychiatric interventions can only stimulate but not determine their target (...) systems, because intervention and outcome are only loosely coupled. Thus, psychiatric interventions have in principle limited ranges which differ according to the type of intervention and according to the system to be stimulated. Psychosocial interventions face far more obstacles to be overcome than psychopharmacogical therapy. (shrink)

The utilization of alternative medical therapies and practitioners has increased dramatically in the U.S. in the last two to three decades. This trend seems paradoxical when one considers the rapid advances taking place in biomedical knowledge and technology during this same time period. Observers both inside and outside of the medical profession have attempted to explain the rising popularity of alternative medicine by proposing that it signals a growing sense of dissatisfaction and disenchantment with professional biomedical practices on the part (...) of the lay public. This paper challenges this thesis and offers an alternative explanation, arguing that the rise of alternative medicine is a consequence of the success and expanding influence of biomedicine rather than its failure and declining authority. The argument presented draws primarily on Ulrich Beck’s “risk society” perspective and theory of “reflexive modernization,” with specific attention to his analysis of the “reflexive scientization” process. The application of this perspective allows us to understand the emergence and development of alternative medicine as an unanticipated consequence of the process of reflexive biomedicalization in the late modern era. (shrink)

While the biomedical model is still theleading paradigm within modern medicine and healthcare, and people with generalised chronicmusculoskeletal pain are frequent users of health careservices, their diagnoses are rated as having thelowest prestige among health care personnel. Anepistemological framework for understanding relationsbetween body, emotions, mind and meaning is presented.An approach based on a phenomenological epistemologyis discussed as a supplement to actions based on thebiomedical model.Within the phenomenological frame of understanding,the body is viewed as a subject and carrier ofmeaning, and therefore (...) chronic pain can be interpretedas a rational reaction to the totality of a person'slife situation. Search for possible hidden individualmeanings in painful muscles presupposes meeting healthpersonnel who view the person within a holistic frameof reference. (shrink)

The coronavirus pandemic has shattered our world with increased morbidity, mortality, and personal/social sufferings. At the time of this writing, we are in a biomedical race for protective equipment, viral testing, and vaccine creation in an effort to respond to COVID threats. But what is the role of health humanities in these viral times? This article works though interdisciplinary connections between health humanities, the planetary health movement, and environmental humanities to conceptualize the emergence of “planetary health humanities.” The goal of (...) this affinity linkage is to re-story health humanities toward promotion of planetary health and community well-being. Wellbeing is critical because the main driver of environmental destruction and decreasing planetary health is coming from non-sustainable definitions of wellbeing. We need the arts and humanities to help reimagine the possibility of a sustainable community wellbeing. For health humanities, a basic role and narrative identity starts to emerge—we should become a planetary health humanities. (shrink)

Narrative medicine is one of medicine’s most important internal reforms, and it should be a critical dimension of healthcare debate. Healthcare reform must eventually ask not only how do we pay for healthcare and how do we distribute it, but more fundamentally, what kind of healthcare do we want? It must ask, in short, what are the goals of medicine? Yet, even though narrative medicine is crucial to answering these pivotal and inescapable questions, it is not easy to describe. Many (...) of its core claims go against the grain of common sense thinking about medicine. This article argues that the best way to understand narrative medicine is to tell a story that puts its emergence in historical context. (shrink)

Multidisciplinary models aggregating ‘lower-level’ biological and ‘higher-level’ psychological and social determinants of a phenomenon raise a puzzle. How is the interaction between the physical, the psychological and the social conceptualized and explained? Using biopsychosocial models of pain as an illustration, I argue that these models are in fact level-neutral compilations of empirical findings about correlated and causally relevant factors, and as such they neither assume, nor entail a conceptual or ontological stratification into levels of description, explanation or reality. If inter-level (...) causation is deemed problematic or if debates about the superiority of a particular level of description or explanation arise, these issues are fueled by considerations other than empirical findings. (shrink)

A barrier to the development and refinement of ethics education in and across health professional schools is that there is not an agreed upon instrument or method for assessment in ethics education. The most widely used ethics education assessment instrument is the Defining Issues Test (DIT) I & II. This instrument is not specific to the health professions. But it has been modified for use in, and influenced the development of other instruments in, the health professions. The DIT contains certain (...) philosophical assumptions (“Kohlbergian” or “neo-Kohlbergian”) that have been criticized in recent years. It is also expensive for large institutions to use. The purpose of this article is to offer a rubric—which the authors have named the Health Professional Ethics Rubric—for the assessment of several learning outcomes related to ethics education in health science centers. This rubric is not open to the same philosophical critiques as the DIT and other such instruments. This rubric is also practical to use. This article includes the rubric being advocated, which was developed by faculty and administrators at a large academic health science center as a part of a campus-wide ethics education initiative. The process of developing the rubric is described, as well as certain limitations and plans for revision. (shrink)

The mental health recovery movement promotes patient self-determination and opposes coercive psychiatric treatment. While it has made great strides towards these ends, its rhetoric impairs its political efficacy. We illustrate how psychiatry can share recovery values and yet appear to violate them. In certain criminal proceedings, for example, forensic psychiatrists routinely argue that persons with mental illness who have committed crimes are not full moral agents. Such arguments align with the recovery movement’s aim of providing appropriate treatment and services for (...) people with severe mental illness, but contradict its fundamental principle of self-determination. We suggest that this contradiction should be addressed with some urgency, and we recommend a multidisciplinary collaborative effort involving ethics, law, psychiatry, and social policy to address this and other ethical questions that arise as the United States strives to implement recovery-oriented programs. (shrink)

The shift in the prevailing view of alcoholism from a moral paradigm towards a biomedical paradigm is often characterized as a form of biomedicalization. We will examine and critique three reasons offered for the claim that viewing alcoholism as a disease is morally problematic. The first is that the new conceptualization of alcoholism as a chronic brain disease will lead to individualization, e.g., a too narrow focus on the individual person, excluding cultural and social dimensions of alcoholism. The second claim (...) is that biomedicalization will lead to stigmatization and discrimination for both alcoholics and people who are at risk of becoming alcoholics. The third claim is that as a result of the biomedical point of view, the autonomy and responsibility of alcoholics and possibly even persons at risk may be unjustly restricted. Our conclusion is that the claims against the biomedical conceptualization of alcoholism as a chronic brain disease are neither specific nor convincing. Not only do some of these concerns also apply to the traditional moral model; above that they are not strong enough to justify the rejection of the new biomedical model altogether. The focus in the scientific and public debate should not be on some massive “biomedicalization objection” but on the various concerns underlying what is framed in terms of the biomedicalization of alcoholism. (shrink)

In this article, we consider how certain types of contemporary biosocial psychiatric research conceptualise and explicate biology-social relations. We compare the historic biopsychosocial model to recent examples of social defeat research on schizophrenia and cultural neuroscience work on affective disorders. This comparison reveals how the contemporary turn towards the ‘biosocial’ within psychiatric research relies upon ideas of the psychological as an interface. This is problematic because psychological notions of ‘experience’ are used as the central mechanics of biosocial processes, but lack (...) any meaningful engagement with considerable debates within psychology and cognitive science about what the mind, and indeed the psychological, actually is, its relationship to social life, and how we should study it. The psychological interface is therefore vital to these biosocial hypotheses but is remarkably underdeveloped in comparison to its biological and sociological components. We argue that biosocial psychiatric research could gain a great deal from engaging with contemporary theorisations of experience and being more critical of vague appeals to psychological phenomena. (shrink)

Personalized Medicine (PM) is an evolving and often missinterpreted concept and no agreement of personalization exist. We examined the PM discourse towards foucauldian archeological and genealogical analysis to understand the meaning of “personalization” in medicine. In the archaeological analysis, the historical evolution is characterized by the coexistence of two epistemologies: the holistic vision and the omic sciences. The genealogical analysis shows how these epistemologies may affect the meaning of “person” and, consequently, the ontology of patients. Additionally, substitutions/confusions of the term (...) PM are related to continuously evolving medical knowledge and new technologies; different etymological roots of “personalization” and “person”; and cultural differences. In conclusion, if the definition of “personalization” in medicine is not clear, patients might get wrong expectations about what is achievable for their health. Therefore, epistemological trends should not be separated as they drive same goals: providing accurate diagnosis and treatments based on large data to predict disease progression. (shrink)

Recently adopted health care practices and policies describe themselves as “patient-centered care.” The meaning of the term, however, remains contested and obscure. This paper offers a typology of “patient-centered care” models that aims to contribute to greater clarity about, continuing discussion of, and further advances in patient-centered care. The paper imposes an original analytic framework on extensive material covering mostly US health care and health policy topics over several decades. It finds that four models of patient-centered care emphasize: patients versus (...) their parts; patients versus providers; patients/providers/states versus “the system”; and patients and providers as persons. Each type is distinguishable along three dimensions: epistemological orientations, practical accommodations, and policy tools. Based on this analysis, the paper recommends that four questions be asked of any proposal that claims to provide patient-centered care: Is this care a means to an end or an end in itself? Are patients here subjects or objects? Are patients here individuals or aggregates? How do we know what patients want and need? The typology reveals that models are neither entirely compatible nor entirely incompatible and may be usefully combined in certain practices and policies. In other instances, internal contradictions may jeopardize the realization of coherent patient-centered care. (shrink)

The International Classification of Functioning, Disability and Health (ICF), designed by the WHO, attempts to provide a holistic model of functioning and disability by integrating a medical model with a social one. The aim of this article is to analyze the ICF’s claim to holism. The following components of the ICF’s complexity are analyzed: (1) health condition, (2) body functions and structures, (3) activity, (4) participation, (5) environmental factors, (6) personal factors, and (7) health. Although the ICF claims to be (...) holistic, it presupposes a monistic materialistic ontology. We indicate some limitations of this ontology, proposing instead: (a) a pluralistic–holistic ontology (PHO) and (b) a multidimensional view of the human being, with individual and environmental aspects, in relation to three levels of reality implied by the PHO. For the ICF to attain its holistic claim, the interactions between its components should be based on (a) and (b). (shrink)

In order to understand the lived experiences of physicians in clinical practice, we interviewed eleven expert, respected clinicians using a phenomenological interpretative methodology. We identified the essence of clinical practice as engagement. Engagement accounts for the daily routine of clinical work, as well as the necessity for the clinician to sometimes trespass common boundaries or limits. Personally engaged in the clinical situation, the clinician is able to create a space/time bubble within which the clinical encounter can unfold. Engagement provides an (...) account of clinical practice as a unitary lived experience. This stands in stark contrast to the prevailing notion, referred to as a dual discourse, that describes medicine as the addition of humanism to science. Drawing on Aristotle’s notion of phronesis and Sartre’s definition of the situation, we illustrate how this novel perspective entwines clinical practice, the person of the clinician, and the clinician’s situation. (shrink)

Causation is important when considering: how an organism maintains health; why disease arises in a healthy person; and, how one may intervene to change the course of a disease. This paper explores the form of causative relationships in health, disease and intervention, with particular regard to the pathological and biopsychosocial models. Consistent with the philosophical view of dispositionalism, we believe that objects are the fundamental relata of causation. By accepting the broad scope of the biopsychosocial model, we argue that psychological (...) and social constructs be considered objects. We think that this ‘biopsychosocial dispositionalism’ offers the flexibility required to describe causation throughout health, disease and intervention pathways. When constructing mechanistic chains to describe causative pathways, we argue that an object will causally connect with others through actions; transfers of energy from one object to another, initiated by the manifestation of one or more dispositional property. Finally, our analysis of causative interactions utilises the concept that a common form of interaction exists between disease and intervention pathways. This common form will always be an object, but the mode of interaction will vary with each disease. We describe how intervention may act through objects being shared between converging mechanistic chains, or through the removal and/or insertion of objects in such chains. We believe that this analysis provides novel insight to the forms of causative transactions that can occur. In addition, we hope that the findings of this analysis represent the first step towards developing a framework for appraising the composition of mechanistic theories. (shrink)

Many physicians assert that new cost-control mechanisms inappropriately interfere with clinical decision-making. They claim that high costs arise from poorly practiced medicine, and argue that effective utilization of resources is best promoted by advancing the scientific and ethical ideals of medicine. However, the claim is not warranted by empirical evidence. In this essay, I show how it rests upon aesthetic considerations associated with diagnostic elegance. I first consider scientific rationality generally. After a review of analytical empiricist and socio-historical approaches in (...) the philosophy of science, a form of Kant's aesthetic is used to explain how scientific discovery and justification are linked, and to show how meta-theoretical considerations associated with the goals and method of science work together with exemplars of practice. This analysis enables us to understand how the ideals of medicine as a science guide the initial patient history and physical exam in such a way that a parsimonious use of tests is indicated. Aesthetic considerations unite the basic scientific and ethical commitments of the modern medical paradigm and are central for rightly understanding clinical judgment. (shrink)

Sir Austin Bradford Hill’s ‘aspects of causation’ represent some of the most influential thoughts on the subject of proximate causation in health and disease. Hill compiled a list of features that, when present and known, indicate an increasing likelihood that exposure to a factor causes—or contributes to the causation of—a disease. The items of Hill’s list were not labelled ‘criteria’, as this would have inferred every item being necessary for causation. Hence, criteria that are necessary for causation in health, disease (...) and intervention processes, whether known, knowable, or not, remain undetermined and deserve exploration. To move beyond this position, this paper aims to explore factors that are necessary in the constitution of causative relationships between health, disease processes, and intervention. To this end, disease is viewed as a causative pathway through the often overlapping stages of aetiology, pathology and patho-physiology. Intervention is viewed as a second, independent causative pathway, capable of causing changes in health for benefit or harm. For the natural course of a disease pathway to change, we argue that intervention must not only occupy the same time and space, but must also share a common form; the point at which the two pathways converge and interact. This improved conceptualisation may be used to facilitate the interpretation of clinical observations and inform future research, particularly enabling predictions of the mechanistic relationship between health, disease and intervention. (shrink)

Based on therapeutic meetings with individuals who have experienced sexual violence and abuse, the challenge is how do we help these couples to establish sexual relationships on their own terms, without interference of defence or coping strategies they have used to protect themselves against the overwhelming experiences of violence or abuse in the past? This article will focus on therapeutic work with such couples and how to interact with them and support their efforts to establish satisfying sexual relationships, based on (...) sexological experience as well as experience from work with traumatisation. The basis for our treatment is a modified version of William Masters and Virginia Johnson’s approach. The technique of sensate focus is central, modified by trauma theory, including the understanding of dissociation, and the need to integrate memories from different levels: somatic, emotional, and cognitive. The traumatised client needs special attention to the experiences of predictability and safety and respect due to their history of being transgressed against. The therapists must be aware of the issue of dissociation; different dissociated inner parts can play different roles in the interaction between client and therapist. While couples therapy is a necessary frame for this therapy, the therapist often needs to work with issues unique to each individual. Each partner must be able to identify their own responses and their own sexual needs and preferences. It may therefore be valuable to have a co-therapist. The central goal is for the clients to identify responses to stimulation as a here and now experience in a setting that feels safe and welcome. (shrink)

Clinically significant delusion is a symptom of a number of mental illnesses. We rely on what a person says and how she behaves in order to identify if she has this symptom and it is clear from the literature that delusions are heterogeneous and extremely difficult to define. People with active delusions were interviewed to explore what it is like to develop and experience delusion. The transcribed interview data was analysed to identify themes and narrative trajectories that help to explain (...) the phenomenon. Results showed that delusions can sometimes provide pragmatic benefits and that the genesis of some delusions can be characterised in terms of the enactivist notion of affective framing. Affective framing is a term that captures the background emotions that enable know-how in terms of goal directed action and cognition. If a person’s affective frame alters the world is no longer understood and know-how is lost. The way in which a person relates to her environment can be highly anomalous thus requiring her to find an extraordinary explanation. I argue that delusions arise as a result of a breakdown in affective framing and offer a conceptualisation of delusion supported by empirical findings. (shrink)