The Clinician in the Psychiatric Diagnostic Process

238 Pages·2022·2.395 MB·English

by  Massimo Biondi (editor), Angelo Picardi (editor), Mauro Pallagrosi (editor), Laura Fonzi (editor)

The Clinician in
the Psychiatric
Diagnostic Process
Massimo Biondi
Angelo Picardi
Mauro Pallagrosi
Laura Fonzi
Editors
123
The Clinician in the Psychiatric Diagnostic
Process
Massimo Biondi • Angelo Picardi
Mauro Pallagrosi • Laura Fonzi
Editors
The Clinician
in the Psychiatric
Diagnostic Process
Editors
Massimo Biondi Angelo Picardi
Department of Human Neurosciences Centre for Behavioural Sciences and
Sapienza University of Rome Mental Health
Rome, Italy Italian National Institute of Health
Rome, Italy
Mauro Pallagrosi
Community Service for Prevention and Laura Fonzi
Early Intervention in Mental Health National Institute of Training
Rome 1 Local Health Unit Italian Psychoanalytic Society
Rome, Italy Rome, Italy
ISBN 978-3-030-90430-2 ISBN 978-3-030-90431-9 (eBook)
https://doi.org/10.1007/978-3-030-90431-9
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Foreword
Several years ago, as a junior doctor I had just joined the Maudsley Hospital in
London to be trained to become a psychiatrist. We were a group of young clinicians,
having an induction on mental state and risk assessment, and at one point our tutor
said to us “sometimes you are sitting with a patient, and you will have a subjective
feeling, which you will find difficult to relate back to their words or categorise, but
you should pay attention to that, and not ignore it just because it is not explicit in the
words of that person.” I have never forgotten that day and that advice, which just
brought to us what many psychopathologists had extensively written about, and
which has continued to resonate in my clinical practice even now as a senior consul-
tant. It is thus with great pleasure that I see in this book an entire, sophisticated body
of work able to capture the essence, implications, and full potential of the clinician’s
subjective experience in the diagnosis and treatment of mental health problems.
To fully appreciate the contemporary relevance of this work, it would be helpful
to take a step back, and look at the use, right or wrong, we have been making of
diagnostic manuals. On one side, these manuals have allowed us to speak a “com-
mon language” in the diagnosis of mental disorders, with great advantages in having
a more reliable and comparable way to study mental disorders, across countries and
across cultures. Still, these manuals have not left space to the role of intersubjectiv-
ity or of the clinician’s subjective experience, in fact, rather the opposite. Generations
of clinicians have been trained, and entire services evaluated on the basis of either
DSM or ICD diagnostic criteria, with little space to the development of other clini-
cal skills, or to the understanding of the complexity of mental health problems and
their diagnosis, management, treatment, and outcomes. Furthermore, the distinct
nosological categories of diagnostic manuals have not found the same discrete cor-
respondence in the neurobiology of such categories. If anything, genetics, biology,
neuroimaging, or cognitive sciences have shown us that the areas of overlap are so
many that distinct neuropathological processes or biomarkers for separate diagnos-
tic categories are yet to be identified. Some of the limitations imposed by these
symptom-based diagnostic systems were the push for the creation of the RDOC
framework, which has aimed to offer an integration of multiple levels of informa-
tion (from genomics and circuits to behavior and self-report) to allow the evaluation
of dimensions of functioning spanning the full range of human behavior, of which
mental illnesses could be seen as extremes.
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vi Foreword
While both diagnostic manuals or RDOC constructs could, to an extent, help
research investigations, they cannot help exploit the potential that the consideration
and evaluation of the intersubjective experience offers to our understanding of men-
tal illness and psychopathology. As Jaspers argued after all, human communities, in
contrast to animal communities, are “mediated through a relation to something
other: through a relation to commonly known purposes in the world, through a rela-
tion to truth, through a relation to God (transcendence)” (Jaspers K: Vernunft und
Existenz, ed 4. München/Zürich, Piper, 1935/1987; p. 59), and like him we should
recognize the impact that intersubjectivity has for us as human beings.
The time is thus ripe for the body of work presented in this book. Starting from
a historical perspective of the contribution that many psychopathologists have made
to our understanding of the role that the intersubjective clinician–patient interaction
can play in the diagnostic process, moving to a critical appraisal of how to approach
the diagnostic and semi-structured interview, with a discussion of the implications
of first-second- and third-person relations. The chapters then run from the knowl-
edge that can be derived from the understanding of the other, to the potential that an
appraisal of intersubjectivity has in informing the therapeutic relationship and pro-
cesses. A central key part of the book is devoted to how neuroscience can help us
understand the basis for the intersubjective experience, and how it is actually pos-
sible to obtain a reliable psychometric assessment of the multidimensional profile of
the psychiatrist’s lived experience during the interview, which can then be validated
back to specific psychopathological characteristics.
Although much has been written about the quantification of the intersubjective
experience in psychiatry, here we find in fact presented in detail the validation and
clinical application of a psychometric instrument (the “Assessment of Clinician’s
Subjective Experience (ACSE)” scale), which investigates clinicians’ feelings,
thoughts, and perceptions related to the clinical encounter in a measurable and
quantifiable way. This represents an excellent endeavor in capturing the reliability
of the intersubjective experience, on which clinicians themselves can reflect and
from which they can then draw to learn about the ongoing relationship, such that the
experience derived from the clinical encounter truly informs the diagnostic and
therapeutic process, from the very initial phase.
As a clinician and a researcher, I cannot but be incredibly attracted by the state-
ment of Fonzi and colleagues in this book (Chap. 8) that “the data collected so far
seem solid enough to claim that the clinician’s subjective experience, far from
being an individual volatile and idiosyncratic reaction, should be seen as an intrin-
sic, meaningful and exploitable part of the psychiatric assessment.” This shows us
that we can not only learn at the individual level, but we can also use this experi-
ence to understand more about the psychopathology that is presented to us and
about the possible neurobiological underpinnings of such presentation and
interaction.
Reading this book and learning about the role of intersubjective experience in
psychiatry should not be limited to a niche of passionate phenomenologists, but
Foreword vii
instead used as a precious resource to raise more questions, and attract the attention
of educators and trainees, as well as of those already trained, and at the same time
be a source of inspiration for those interested in studying the neuroscientific basis of
the human experience.
Paola Dazzan
July 2021 Institute of Psychiatry, Psychology and Neuroscience
King’s College London
London, UK
Preface
It was the year 2008 when the four of us, a small group of researchers of different
ages, with diverse clinical experiences and professional lives, teamed up to reflect
on the role of the clinician’s subjectivity in the process of psychiatric assessment
and therapeutic intervention. While some of us were more involved in clinical work
and others in research, we all shared a deep interest in the rich psychopathological
literature about the psychiatrist’s ability to “feel” the patient. We were puzzled by
the degree to which the concepts in this literature, which we found useful in our
clinical work, were largely neglected by the mainstream scientific discourse.
At that time, we were all collaborating with the psychiatric department of the
Sapienza University of Rome, where interest in phenomenological psychopathology
dated back to the days of the direction of Giancarlo Reda, who in the 1970s had spread
Minkowski’s thinking through the wards of the psychiatric clinic. Since then, it has
always been a major concern, in the department, to teach classical psychopathology to
young psychiatrists and to promote the development of a sharp clinical eye.
Possibly, our group drew strength from the fact that we were at different stages of
our careers and that our professional interests ranged from clinical psychiatry to psy-
chotherapy, research, and teaching. At any rate, given that we all shared a deep interest
both in the clinical diagnostic process and in scientific research, we felt we could try to
pursue the aim of approaching the heritage of the classical authors from a new, empiri-
cal perspective, from which this body of scholarship could command greater attention.
After all, during those very years, new empirical instruments, such as the
Examination of Anomalous Self-Experience (EASE), began to spread across aca-
demic and clinical settings. These new instruments encouraged novel approaches to
clinical assessment and a reappraisal of the “old-fashioned” phenomenological and
psychopathological concepts.
However, when we started our reflection, we faced the reality of a world where
mainstream psychiatry ignored the clinician’s subjectivity altogether, while a small
professional niche deeply rooted in the phenomenological tradition believed in the
diagnostic value of the clinician’s feelings despite the absence of solid empirical
support for this notion. It was, after all, impossible to provide such support, given
the lack of validated measures of the psychiatrist’s subjective experience during the
clinical assessment.
In order to have any hope of being able to substantially contribute to the field, it
was necessary, as daunting as such a task appeared, to attempt to develop and
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x Preface
validate a measure of the clinician’s subjective experience. Such an instrument
would be necessary to test whether the great phenomenological psychopathologists
of the twentieth century were on a reasonably valid path.
In this book, we provide a detailed overview of the theoretical background, the meth-
odology, the findings, and the future perspectives of our decade-long work along this
line of research. The common thread of the book is the role of the clinician’s subjective
experience in clinical diagnosis, including its theoretical and practical implications. The
diversity of views on the subject is also illustrated, through the lens of a number of con-
temporary scholars in phenomenology, psychopathology, and psychotherapy.
In Chap. 1, we present an overview of the classical authors, who more than other
leaders in psychiatry have dealt with the significance of feelings, empathy, and intu-
ition in diagnostic reasoning, thus building the foundations for the current reflection.
In Chaps. 2 through 5, a philosophical and clinical outline of the fundamental
nature of the processes involved in the psychiatric encounter is drawn, with a focus
on the modes of human knowing and psychopathological understanding.
Chapter 6 explores the question of whether neuroscience can help, and how, in
the development of a better conceptual understanding of the explicit and implicit
processes related to intersubjective dynamics.
In Chaps. 7 and 8, we describe in detail the development and research applica-
tions of the Assessment of Clinician’s Subjective Experience (ACSE) self-report
questionnaire, while Chap. 9 illustrates a different empirical approach to the con-
cept of Praecox Feeling and its use in the diagnosis of schizophrenia.
In Chaps. 10 and 11, the psychotherapeutic perspective is highlighted and dis-
cussed, starting with the classical and contemporary psychoanalytic view and end-
ing with viewpoints from the field of cognitive therapy.
Finally, Chaps. 12 and 13 offer a deep and thoughtful look at the most profound
sense of mental illness, which—as a fundamentally human experience—requires
human comprehension as well as human care.
This comprehensive overview should allow the reader to become familiar with
both the theoretical and practical aspects of studying the clinician’s subjective emo-
tions and perception during the diagnostic process, and how this experience can be
used to gain insight into the patient’s condition. Indeed, we hope that our readers, be
them students, residents, trainees, experienced clinicians, or researchers, will be
intrigued by the possibility of regaining their own centrality as irreplaceable and
scientifically valid instruments of knowing.
We deeply thank Claudia S. Copeland, PhD, for her masterful help in editing the
chapters. We also express our gratitude to Prof. Paola Dazzan for kindly writing an
inspiring foreword to this book.
Rome, Italy Massimo Biondi
Rome, Italy Angelo Picardi
Rome, Italy Mauro Pallagrosi
Rome, Italy Laura Fonzi
Contents
1 The Clinician’s Subjective Feeling in Psychiatric Diagnosis:
A Historical Excursus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Matteo Buonarroti, Laura Fonzi, and Mauro Pallagrosi
2 The Psychiatric Assessment: First Person, Second Person,
and Third Person Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Thomas Fuchs and Eugenio Dalpane
3 A Cookbook Recipe for the Clinical and Phenomenologically
Informed, Semi-structured Diagnostic Interview . . . . . . . . . . . . . . . . . 37
Mads Gram Henriksen, Lennart Bertil Jansson, and Julie Nordgaard
4 T he Distinction Between Second-Person and Third-Person
Relations and Its Relevance for the Psychiatric Diagnostic Interview . . . . 51
Felipe León, Maja Zandersen, Patricia Meindl, and Dan Zahavi
5 Understanding Other Persons. A Guide for the Perplexed . . . . . . . . . . 71
Giovanni Stanghellini
6 Intersubjectivity and Neuroscience in the Diagnostic Process . . . . . . . 81
Massimiliano Aragona
7 Origin and Development of the Assessment of Clinician’s
Subjective Experience (ACSE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Mauro Pallagrosi, Angelo Picardi, Laura Fonzi, and Massimo Biondi
8 Evidence Supporting a Role for the Intersubjective
Dimension in the Clinical Encounter:
Empirical Findings from ACSE Research . . . . . . . . . . . . . . . . . . . . . . . 115
Laura Fonzi, Mauro Pallagrosi, Angelo Picardi, and Massimo Biondi
9 Clinical Judgment of Schizophrenia: Praecox Feeling
and the Bizarreness of Contact—Open Controversies . . . . . . . . . . . . . 135
Marcin Moskalewicz and Tudi Gozé
10 The Diagnostic Use of Countertransference in
Psychodynamic Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Annalisa Tanzilli and Vittorio Lingiardi
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