An Approach to Psychiatry PDF

2 An Approach to Psychiatry George Szmukler I N 1879, at the age of 26, Vincent van Gogh began to preach in the Borinage, a deprived mining area in Belgium. He evangelised unrelentingly. Extreme self- neglect resulted, for example, in a face dirtier than a miner’...

2 An Approach to Psychiatry George Szmukler I N 1879, at the age of 26, Vincent van Gogh began to preach in the Borinage, a deprived mining area in Belgium. He evangelised unrelentingly. Extreme self- neglect resulted, for example, in a face dirtier than a miner’s. He gave away his possessions (including his bed), lived in a dirty hovel, wore shirts he made of sackcloth and subjected himself to every privation. Later, in 1889, he sliced off the lower lobe of his left ear with a razor and deposited it with a prostitute, saying, ‘Keep this object carefully’. How can we make sense of such behaviour? Psychiatrists attempt to do so by using a number of perspectives. I will discuss these with the aim of clarifying their methods, scope and limitations, demonstrating that no perspective on its own can offer a complete account of a patient’s mental functioning. Two fundamental ways of reasoning about mental illness Deriving ultimately from the mind–brain ‘split’ are two fundamental ways of making sense of the experiences or behaviours of others. The first is understanding, the second explanation. Understanding Daily, each of us attempts to make sense of the behaviour of others. We may not give much thought to how we do this, but we are sufficiently adept at the task so as to feel that we more or less understand why they act as they do, or what ‘makes them tick’. The means we use are based on our ability to empathise with the experiences of another: we are able to put ourselves in their shoes and to imagine how it must be to feel as they do. The data we use include statements about what they believe, feel, perceive, intend and so on, and, of course, reasons they themselves give for behaving as they do. Furthermore, we are likely to take into account their past experiences, their habitual ways of feeling and thinking and their current circumstances. We might thus arrive at a ‘common-sense’, satisfying understanding of why a particular person has reacted to a particular event as they have. This way of reasoning considers the other person as a subject and approaches their world from the inside. It seeks meaning or rationality in behaviour and constructs an understanding or interpretation based on meaningful connections between experiences and events. Psychic events follow each other comprehensibly, with a logic of their own. The same event—for example, failing an examination— may have a different meaning for different people depending on their previous experiences and aspirations, competing interests, the company of others in the same situation and so on. This approach deals with data that are intangible: the contents of the mental (or phenomenal) world of others, their thoughts, motives, intentions, feelings and so on, and their status as an experiencing self or agent. Our understanding is inbuilt; connections seem obvious, compelling or satisfying as a narrative or life story. As the German philosopher and psychiatrist Karl Jaspers put it: We can understand directly how one psychic event emerges from another. This mode of understanding is only possible with psychic events. In this way we can be said to understand the anger of someone attacked, the jealousy of the man made cuckold, the acts and decisions that spring from motive. Novices, without training, bring a well-developed capacity for understanding, and this will take them some way in reasoning about mental disturbance. While it represents a good start, and remains indispensable in practice, it is limited. Some limitations are inherent (as will be discussed later); others derive from the encounter with experiences and behaviours of patients that do not seem meaningful, and in which mental events succeed each other apparently incomprehensibly. Explanation The methods of explanation are distinct from psychological understanding. Here the experiences and behaviours of the subject are studied as objects. Particular mental phenomena are defined and studied as forms. For example, hallucinations, delusions, obsessional thoughts or panic attacks have properties that can be discerned regardless of their content. A belief may be concerned with persecution, grandiosity or bodily decay, but what makes it a delusion rests on formal attributes of the belief—for example, its being held with conviction despite the absence of adequate reasons, and its imperviousness to appeals to contrary evidence. Such forms represent recurring regularities in abnormal mental experiences and often cluster in observed patterns or syndromes. They are studied using methods of the natural sciences. We see the person from the outside, as an object or organism. We seek explanations in terms of causes—for example, how the ‘machinery’ of the brain or its processes are disrupted. As in the natural sciences, explanations aspire to the detection of law-like relationships between events that are generalisable and that permit precise prediction of these forms when particular factors are operating. Aetiological factors and pathogenic mechanisms are proposed as scientific hypotheses, and research studies are designed to test them. What patients have in common, rather than what makes them singular, is the focus of interest. This approach is used to study disease. Causal explanation is clearly represented when abnormal mental or behavioural states are seen as diseases and their aetiology sought in disruption of brain or other biological processes. The data are tangible and the realm is of ‘matter’ rather than meaning. This powerful perspective has resulted in important discoveries, including characterisation and differentiation of psychotic disorders, elucidation of genetic factors in specific mental disorders, definition of disturbed brain function associated with particular mental states, and discovery of effective treatments—for example, lithium in the affective disorders. The resulting diagnosis encapsulates information about causes, prognosis and effective treatments, and applies to the group of patients who share it. The gulf between understanding and causal explanation derives from the gap between mind and brain, between mental and physical events. While it is possible to correlate some mental and neural events, the way in which the latter are transformed into the former remains a mystery. We find it hard to see how a description of neural activity, no matter how detailed, would enable an observer to understand why someone wants to become an opera singer, or how it feels to be the victim of a malicious rumour. A case history: Vincent van Gogh We return to Vincent van Gogh, not because of his reputation as a great artist but because his life has been so richly documented, both in letters in which he expressed much about his inner life and through descriptions by others. Excellent biographies have also been published. Space prohibits much detail; the interested student can determine from sources in the Further reading at the end of the chapter how far this account is convincing.* The major dates and events in van Gogh’s life are shown in Table 2.1. Table 2.1 Vincent van Gogh’s life history Age Date Event 30 March: Born in Zundert, Holland; birth occurred one year to the day after his mother gave 1853 birth to a stillborn son, also named Vincent 11 1864 October: Sent to boarding school in Zevenbergen 13 1866 September: Sent to a new school in Tilburg March: Left school; returned home 16 1869 July: To The Hague as apprentice to Goupil’s, art dealers; arranged by uncle, Vincent, a partner January: To Goupil’s Brussels branch 20 1873 June: Transferred to London branch June: Proposed marriage to Eugenie Loyer, but rejected; lost interest in art dealing; solitary, 21 1874 absorbed in religion March: Dismissed from Goupil’s due to poor performance April: Obtained post as assistant teacher at small school in Ramsgate 23 1876 July: Became a ‘sort of curate’ under a Methodist minister at Isleworth December: Returned to Holland with intention of becoming a pastor January: Took job in bookshop in Dordrecht 24 1877 May: Moved to Amsterdam, commencing studies for entrance to the faculty of theology at the university July: Abandoned studies in Amsterdam 25 1878 August: Went to mission school in Laeken November: After a three-month trial period, failed to be accepted January: Appointed as unqualified mission preacher in the poor mining district of Borinage July: Dismissed because of excessive self-sacrifice and embarrassing behaviour 26 1879 August: Lived a ‘vagabond’ existence, unable to settle; regarded himself as an ‘outcast and a tramp’. A period of silent misery August: Decided to become an artist 27 1880 October: Lived in Brussels, mainly drawing April: Returned to parental home, now in Etten August: Rejected by widowed cousin, Kee Vos; family scandal 28 1881 December: Left home again, moving to The Hague, where he briefly stayed with a cousin, Mauve, a painter; tense relationship April: Met an alcoholic and pregnant prostitute (‘Sien’), lived with her, and devoted himself 29 1882 to her and her children July: Began painting seriously in oils September: Broke with Sien; moved to the bleak environment of Drenthe, followed by lonely wandering 30 1883 December: Returned to father’s home, now in Nuenen, where he remained for the next two years; relationships remained strained; distressing affair with Margot  Begemann resulting in her suicide attempt; painted productively 26 March: Father died 32 1885 November: Moved to Antwerp January: Registered as a student at Academy of Art in Antwerp March: Left academy; moved to Paris to stay with brother Theo (an art dealer) for almost two 33 1886 years; during this period met a group of modern painters including Gauguin, Toulouse-Lautrec and Emile Bernard; brief period in Cormon’s studio; began drinking heavily; many quarrels 20 February: Moved to Arles in Provence May: Took rooms in ‘the Yellow House’ 20 September: Gauguin visited Arles following invitation from van Gogh; relationship soon 35 1888 became tense 23 December: Van Gogh sliced off part of his ear and deposited it with a prostitute; hospitalised the next day under Dr Rey 7 January: Discharged from hospital mid-January: Theo engaged to be married to Johanna van Bonger 21 January: His friend, the postman Roulin, transferred to Marseilles 4–19 February, and from 26 February to mid-April: Further episodes of mental illness requiring readmission 19 March: Put in a cell in hospital after a petition alleging he was a dangerous madman was 36 1889 presented by neighbours and upheld by the mayor; rejected by local villagers April: Theo married; Johanna pregnant soon after 8 May: Of his own free will, decided to enter the Saint-Paul-de-Mausole asylum at nearby Saint-Rémy-de-Provence where he stayed for a year 8 July to mid-August and from 24 December to 1 January 1890: Further episodes of mental illness 23–30 January, and from mid-February to mid-April: Further episodes of mental illness 1 February: Theo’s son born, named Vincent 17 May: Left St Rémy; spent four days in Paris with Theo 37 1890 21 May: Moved to Auvers-sur-Oise, just north of Paris, under the supervision of Dr Gachet, who had a special interest in art 27 July: Vincent shot himself; died two days later 1891 Theo died six months later of chronic nephritis; psychotic at the end Family history Vincent was born to an austere Dutch, middle-class family. His father, an untalented pastor in the Dutch Reformed Church, was consigned to obscure parishes. He was much helped by his worldly brother Vincent, a prominent art dealer. His mother married late and was a strong woman, unusually talented in writing and painting. Van Gogh’s family tree is represented in Figure 2.1. Note those named Vincent and Theo, and their relationships. Two professions dominate: the church and dealing in art. Note also the family history of mental illness; in addition, van Gogh’s uncle, Vincent, was subject to nervous complaints, frequently fleeing to the southern sun for recuperation. A family history of epilepsy existed on his mother’s side. Figure 2.1 Vincent van Gogh’s family tree Early life Accounts of van Gogh’s childhood are inconsistent. Some suggest an unremarkable child; others portray him as solitary, ‘not like other children’, and estranged from his family. He was passionate about nature. He briefly attended the village school and then, from 11 to 16, two boarding schools. His progress was unexceptional, but he read prolifically and became a gifted linguist. Work Table 2.1 shows an unsettled career, despite excellent connections. Through the mentorship of his wealthy uncle, Vincent, he became an apprentice art dealer with the famous firm Goupil’s. The prospect of eventually inheriting his uncle’s mantle was obvious. However, after rejection in love by Eugenie Loyer, his landlady’s daughter, he lost interest and became fanatically religious. He began to preach in England. Attempts to study theology in Amsterdam and later to become an evangelist through a mission school were unsuccessful, largely because of his provocative behaviour. Determined to become an evangelist, van Gogh was appointed as an unqualified preacher in the Borinage. His extreme self-sacrifice was unacceptable to his superiors and he was dismissed. He then withdrew into solitude and spent almost a year in silent misery. In 1880, he emerged from this period of what he termed ‘moulting’ and announced his intention to become an artist. Studies in conventional academies were broken off because of further disputes. He returned to his parents’ home for two years, then lived with his brother Theo (now a successful art dealer in his uncle’s stead), then moved to Arles and finally to Auvers-sur-Oise. He painted prolifically: more than 800 paintings are catalogued, most dating from the last seven years of his life. Relationships The only enduring, close relationship was with his brother, Theo, although this was not free from recriminations on Vincent’s part. They corresponded frequently from 1871, and by 1886 he was entirely financially dependent on his brother. Van Gogh had four significant relationships with women, all of which ended in ‘shame and humiliation’. In London, a passionate proposal of marriage was rejected by Eugenie Loyer, who was already engaged to another. In April 1881, he fell in love with a widowed cousin, Kee Vos. He was again rejected, and his stubborn persistence in his suit resulted in much family bitterness. In 1882, he had a liaison with an unmarried, pregnant prostitute, ‘Sien’, already with a five- year-old daughter. She was described as unbalanced in mind and ‘forsaken like a worthless rag’. Despite his care, she lapsed into her old ways and he felt he had no choice but to leave her. In 1884, he was subject to the infatuation of a lonely, melancholic spinster ten years older than himself, Margot Begemann. She wished to marry him but her family bitterly disapproved. In the ensuing crisis she attempted suicide and was sent to a sanatorium. Van Gogh formed intense relationships with a number of friends but none of these survived more than a brief period of intimacy. The most significant was with the artist Gauguin in Arles, where after two months the atmosphere between them was described as ‘electric’. It culminated in Gauguin’s plans for departure and a severe episode of mental disturbance for van Gogh. Personality Van Gogh complained that he was ugly and coarse (‘as thick skinned as a wild boar’). He felt unloved and inferior. From the age of 20 he was regarded as an ‘eccentric’, and at times as a ‘madman’. He was impetuous, moody and obstinate. Yearnings for human ties were constantly frustrated. Numerous references testify to his self-abasement and melancholy. There were prolonged periods of misery, as in 1879. Van Gogh’s descriptions of his mood are vivid: ‘A terrible discouragement gnawing at one’s very moral energy … fate seems to put a barrier to the instincts of affection, and a flood of disgust rises to choke one’; ‘I am a prisoner in I do not know what horrible, horrible cage’; ‘stultified to the point of being absolutely incapable of doing anything’. Depression occurred regularly in the winter. There were also periods when he felt remarkably energetic: ‘The emotions are sometimes so strong that one works without knowing one works’; ‘Ideas for my work come to me in swarms’; ‘I go on like a steam-engine at painting’; ‘I am working like one actually possessed, more than ever I am in a dumb fury of work’; ‘I only count on the exaltation that comes to me at certain moments, and then I let myself run into extravagances’. After such a burst of energy, depression was almost certain to follow. He neglected his appearance and physical welfare. He exposed himself to the elements in Herculean hikes, sometimes slept in the cold and often ate little. In Paris, and later in Arles, he drank heavily: ‘If the storm gets too loud, I take a glass too much to stun myself’. Medical history In June 1882, he suffered from gonorrhoea and required a three-week admission to hospital, where he was catheterised. He may also have suffered from syphilis in 1886. He often complained of somatic symptoms, including intestinal trouble, anorexia, dizziness and headaches. Psychiatric history At least seven episodes of severe mental disorder occurred between 24 December 1889 and mid-April 1890. The first followed his stormy relationship with Gauguin in Arles, when he sliced off the lower lobe of his left ear and left it with a prostitute. Most episodes were characterised by an abrupt onset of confusion accompanied by frightening auditory and visual hallucinations, with gradual improvement over a few weeks (but on at least one occasion lasting two months). His talk was rambling and there were delusions of an ‘absurd religious’ nature and of being poisoned. He could be assaultive without provocation, at least on one occasion because of delusions of persecution by the Arles police. He made frenzied attempts to eat his paints and to drink turpentine or kerosene. During recovery, his mind was ‘foggy’ and there was partial amnesia. He later described these episodes as ‘frightening beyond measure’, and the thought of recurrence filled him with a ‘fear and horror of madness’. Also associated were ‘moods of indescribable anguish’, and he was observed to sit immobile for many hours. At times he rejected all food. He voluntarily spent a year in a mental asylum, although for most of this time he remained very productive. Finally, at the age of 37, he committed suicide. Discussion The psychiatrist will see in this life story unusual behaviours that might prove meaningful, but also elements likely to be better accounted for by an analysis of forms and causes. Van Gogh’s mood disturbances, the ‘ear episode’, the psychotic episodes and his suicide are subjects of particular interest. Mood disturbances From the age of 20, van Gogh suffered from mood swings, predominantly depression but also excitement. Psychological interpretations have been proposed to account for these. One biographer, A. J. Lubin, gives a detailed account as follows: van Gogh’s childhood was dominated by the stillbirth of his older brother, Vincent, one year to the day before his own birth. His mother continued to grieve the loss and was unable to commit her love to her new child. He had to replace, and compete with, an idealised lost child whose tomb he saw every day in the adjacent graveyard. This led to a profound sense of inferiority, of being unloved and unlovable, and to an acute sensitivity to rejection. This was later played out in, and reinforced by, his unsuccessful love affairs. Failed relationships were followed by depression associated with self- punishment and estrangement from an apparently rejecting world. At the same time, he craved intimacy, but with intolerable demands on others since he sought the kind of unreserved love that had been denied him earlier. He began to seek solace in a loving God, which required further suffering through self-denial and service to others. In this manner he could also seek out those who, like him, had been rejected and give them the love he had never himself received. Van Gogh’s estrangement from his family is further supported by the absence in his letters of affectionate remarks about his mother and by the omission of his family name when signing his work. Associated with his religiosity, there developed an identification with Christ —similarly suffering, rejected, misunderstood and devoted to the oppressed. This provided the comforting possibility of remaining aloof from humankind yet eventually of being universally loved. The liaison with ‘Sien’ can be understood as a consequence of his poor self-regard. But she was also his Mary Magdalene, outcast and wretched, the whore who would be transformed by compassion into a ‘good’ woman. He rejected the conventional church and hypocritical ‘pharisees’ like his father. Periods of exaltation, ‘terrible lucidity’ and frenzied work were associated with his spiritual labours. Finally, van Gogh’s decision to become an artist represented a fusion of his—and his family’s—spiritual and artistic heritage. His intense immersion in his painting, often associated with a numbing of his senses through starvation, exposure, exhaustion and alcohol, acted to ward off morbid feelings. This interpretation, based on understanding, accounts for many aspects of van Gogh’s personality. It does not seem to completely account for the intensity of his mood swings or their seasonal periodicity. There were spells when he was virtually paralysed; he was oblivious to his surroundings, stared bleakly into space, was apparently lost in his thoughts and stopped eating. At other times his mind was a tumult of loosely related ideas, he dressed outlandishly, and he talked and laughed embarrassingly. At such times he worked frenetically at strange projects—for example, a simultaneous translation of the Bible into four languages (instead of attending to his job in a bookshop). Van Gogh described his moods as sudden ‘unaccountable but involuntary emotions’. Others did not doubt that he had at these times passed from ‘eccentricity’ to insanity. Causal explanation in terms of a biologically based liability to mood swings (a cyclothymic personality) and, at times, illness (bipolar disorder) seems warranted. The form of his experiences and behaviour was consistent with typical symptoms of depressive and manic episodes. Genetic factors may have been predisposing, while unhappy events and physical disorders may have played important precipitating roles. But meaningful connections do not end here. We can understand how van Gogh’s awareness of his vulnerability to these uncontrollable episodes and the jeers of people around him might have exacerbated his underlying sense of inferiority and alienation. The ‘ear’ episode Several psychological interpretations have been proposed, but none seems to fully account for this bizarre act. A psychotic illness, probably organic in nature, is the likely explanation for the form his mental state assumed. Precipitation by heavy consumption of absinthe (an alcohol containing a neurotoxin, thujone, known to be associated with mental disturbances, including delirium and hallucinations) is likely. Van Gogh’s poor nutrition and physical self-neglect may also have contributed. His apparent amnesia for the episode is consistent with this explanation, as well as with his doctor’s diagnosis—since questioned—of an epileptic disorder (perhaps of temporal lobe origin). Nonetheless, a full account would take cognisance of the timing and the content (or meaningful aspects) of his psychosis, as well as of its form. Van Gogh’s personality vulnerabilities were exposed in his deteriorating relationship with Gauguin. The weather was miserable and the two spent a number of days in enforced close proximity in the ‘Yellow House’. Christmas was always a dangerous time. Vincent probably also knew about Theo’s prospective marriage, and could see the implications of this for his continued support. Immediately before the episode, he had quarrelled violently with Gauguin, throwing a glass of absinthe at him, and later he was reported as having threatened him with a razor. Gauguin, like so many others in a significant relationship, had ‘betrayed’ him. In guilt, van Gough directed his anger inwards, mutilating himself. Why the ear? Why did he present it to a prostitute? A number of possibilities exist to account for his ‘choice’ of an ear. Bullfights, a popular pastime in Arles, culminated in the ear being sliced from the vanquished animal to be presented by the toreador to his favourite lady. Fifteen stories about Jack the Ripper’s bodily dismemberment of his prostitute victims, sometimes involving an ear, appeared in the local paper at this time. Gauguin was a great success with the prostitutes of Arles and presentation of the ear may have represented for van Gogh a compensating ‘gift’. He was preoccupied with the story of Christ in the Garden of Olives (Gethsemane). He destroyed two canvasses on this subject because they frightened him. In this story of betrayal, Simon Peter cut off the ear of Malchus, a servant of the high priest, who had come to seize Christ. It is also possible that the attack on his ear was an attempt to excise the apparent source of auditory hallucinations, which he thought of as a ‘diseased nerve’. Psychotic episodes There were obvious stressors in van Gogh’s life at the time. Most critical among these was the threatened loss of Theo’s support, undivided until now, on which he was totally dependent. In quick succession between January and April 1889, Theo had become engaged, married and an expectant father. An understandable reaction to these events might have involved preoccupations on this theme, but these were absent. Seeking solace in religion would not have been surprising given his past behaviour, but his religious ideas took a bizarre and frightening form that was incomprehensible to others and, in retrospect, to himself. These episodes thus appear non-understandable. Eventually, van Gogh believed himself unfit to govern his life and accepted the suggestion of a prolonged period of asylum. A definite diagnosis is difficult to make, but an organic contribution is possible, especially in view of the confusion, amnesia and brief duration of the episodes. Absinthe may again have been implicated, especially as most recurrences followed visits to Arles. Further severe depressive episodes may also have occurred. Schizophrenia is very unlikely; there was no deterioration in his personality, and he remained extraordinarily productive. Furthermore, his paintings showed no evidence of loss of control or disorganisation as might have been expected in someone developing this illness. The suicide It is difficult to reconstruct van Gogh’s mental state at the time of his suicide, due to insufficient information. Depressed moods continued in Auvers. A month before his death, he wrote, ‘My life is threatened at the very root, and my steps are also wavering’. The famous painting Crows over the Wheatfields carries a chilling atmosphere of evil foreboding, but this was not his last canvas. He had certainly lost faith in the ability of his medical attendant, Dr Gachet, to help him, and described him as being as sick as himself. This was important because fear of recurrence plagued him, and it is possible he felt an impending relapse. There were unaccountable explosions of anger directed at Gachet. During one of these, the doctor feared that he might have turned violent, perhaps using the pistol he eventually turned on himself. These incidents are reminiscent of his hostility towards Gauguin prior to the self-mutilating ‘ear’ psychosis, and it is possible that he had relapsed. The threatened loss of Theo’s support had become more apparent. Theo now had a child with the perhaps ominous name Vincent, who, to make matters worse, had been ill. Theo’s own health was declining (he died six months later); he had money worries, and was thinking about quitting his job. Although repeatedly begged by van Gogh to spend his vacation at Auvers rather than in Holland, Theo declined. Van Gogh had on a number of occasions stated that his ‘life or death’ depended on Theo’s help. He could not easily express his resentment openly, and it is understandable, particularly in the light of his previous self-destructive acts, that he again turned his hostility inwards. Another factor—showing how apparently desirable events can have a disturbing meaning, dependent on the subject—may be relevant. For the first time, van Gogh had received laudatory reviews of his work. In response to one, he wrote, ‘But when I had read the article I felt almost mournful, for I thought: I ought to be like that, and I feel so inferior. My back is not broad enough to carry such an undertaking’. Guilt-ridden, he could not tolerate success; it was yet another burden to be endured. Thus, in reviewing van Gogh’s suicide, we see again an interplay, albeit inconclusive, of elements of understanding and explanation. Limitations of understanding Students will have recognised limitations to the method of understanding. Despite a conscientious attempt to find meaning in a particular experience or behaviour, a barrier may be encountered. The behaviour does not emerge coherently from what has gone before; a discontinuity occurs in the life story. At this point we might conclude that it is meaningless, non-understandable or ‘crazy’ that the person has become mentally ill. Another perspective is required to make sense of the behaviour. Recourse to analysis of the phenomenon in terms of forms is the usual solution (e.g. symptoms of a psychotic illness); knowledge is consequently sought in the realm of explanation and causes involving extraconscious mechanisms (e.g. neural factors). Further limitations characterise the method. No proof can exist that a particular understanding is ‘correct’. It is an interpretation of a sequence of events and it may be seen differently by different observers. Equally plausible interpretations may be constructed in which certain features may be given greater prominence in one than in another. However, a sound interpretation is not a fiction either. It can be subject to critical evaluation and tested against the evidence on which it is based—how it fits the ‘facts’ of the case. Inconsistencies are sought in the same way as a barrister attempts to undermine a plausible account by a witness during cross-examination. A convincing interpretation will survive close scrutiny, and one may be chosen as superior to its competitors. Understanding may also be revised as new information comes to light. A new act by the subject may force a change in the interpretation so that previous acts are seen as having a different set of meanings; these make the new act consistent with what has gone before. Furthermore, new information may lead to deeper understanding, which may assume greater complexity or subtlety. The experienced clinician, through scrutiny of many life stories, becomes aware of a wider range of meaningful connections than the layperson, and is more skilled at eliciting significant information about the patient’s mental life and behaviour. In clinical practice, an understanding is constructed in the interaction between subject (patient) and interpreter (clinician), and each contributes to and may influence the other in shaping the emergent story. A risk exists that the interpreter will see in the subject a confirmation of connections that they are looking for, perhaps based on a favoured psychological ‘theory’. In turn, the subject may, if the clinician is seen as an authority to be pleased, produce material to support the interpretation.  The logic underlying understanding does not lead to the formulation of general laws, nor is it a reliable way of predicting behaviour. Patients with similar experiences may share similar patterns of meaningful connections, but there will always be individual variation, and for some the patterns will be quite different. At best, such regularities as exist assume the status of maxims. Limitations of explanation The methods of the natural sciences have made a crucial contribution to psychiatry, and will continue to do so through rapid progress being made in, for example, the neurosciences. However, this approach, especially in the minds of its more fervent advocates, can be overstated. Some claim that only through this method can ‘real’ knowledge be acquired and that most, or all, of psychiatry will one day be reduced to causal explanation. While this method may have useful things to say about people who find themselves in predicaments easily understood in terms of life circumstances (e.g. grieving the loss of a near one), it would appear that such a person is better understood in psychological terms, and more appropriately helped through such means. Furthermore, even when a patient suffers from a clear-cut mental illness, the nature of which is best elucidated through causal explanation, contact with this patient is made through appreciation of them as a subject rather than an object. Understanding what it means for the patient to have the experiences arising from the illness is essential. Even if an important treatment is prescription of a drug, compliance with it will often be determined by the quality of the relationship between patient and clinician. The impact of the illness on patient and family and key processes in recovery will often be best appreciated through understanding. Psychotherapy, the cornerstone of much treatment in psychiatry—indeed in medicine—is conducted between two experiencing subjects and is ultimately concerned with a search for meaning: What is the meaning of the patient’s distress? How does it emerge from their life story? How can these meanings be recast or altered so as to allow distress to be alleviated? The complementary nature of both forms of reasoning is well described by Phillip Slavney and Paul McHugh: The methods of explanation and understanding are both formal modes of  reasoning in psychiatry. Though they have different assumptions about and consequences for our views on mental life, they stand on an equal footing and in a complementary relationship to one another. We will emphasize explanation or understanding, depending on whether the issue is one of form or content, mechanism or meaning, brain or mind. This choice must be made knowingly rather than simply because we find one method more appealing. Explanation is no more ‘fundamental’ than understanding, nor is understanding more ‘profound’ than explanation; they are only different methods, with different strengths and weaknesses. As long as we continue to view human beings as object/ organisms and subject/agents, both methods are essential to our practice. Additional perspectives in psychiatry Psychiatrists employ a number of further, related perspectives when thinking about psychiatric disorders. These consider mental phenomena as forms and have their own sets of concepts. They are studied within the framework of the behavioural or social sciences. The formal aspects of these perspectives are distinct from the perspective of understanding, but most of the influences studied can also be seen from the subject’s viewpoint. Some of these perspectives will now be described briefly. The first, the psychodynamic, is very closely related to the methods of understanding, and the extent to which it also involves explanatory theories is controversial. Psychodynamic perspective Psychoanalysis and derivative theories clearly involve the methods of understanding and aim to unravel meaningful connections that are at first sight obscure. This is facilitated by encouraging the patient to allow thoughts, feelings, memories, perceptions and fantasies to emerge unhindered. Important insights arise that give subtle but satisfying meanings to many of the patient’s thoughts and behaviours—meanings of which the patient has been previously unaware (or unconscious). Some theorists make the further claim that there are organising principles behind these meanings that are law-like. These may include a number of drives that press for expression but that are disguised, and an ‘apparatus’ of the mind (e.g. the ego, id and superego) that operates on the drives, producing what may initially appear as meaningless thoughts or acts. Such a claim is difficult to substantiate, largely because the postulated forms are so problematic to define and measure, and impossible to control experimentally. The status of psychoanalysis as a science remains the subject of philosophical debate, turning largely on the question of what is meant by a science. It is accepted that it does not fall within the orbit of the natural sciences. Dimensional perspective Diseases are generally seen as categories, either present or not. Many human characteristics are dimensional in type; people have more or less of a characteristic such as height or intelligence, or of a personality trait such as impulsiveness. Dimensions of personality are important in psychiatry since they define enduring dispositions to behave in consistent ways under similar conditions. Those who lie towards extremes in any dimension may be handicapped or, less commonly, advantaged in their ability to adjust to the world. Van Gogh’s cyclothymic personality is a good example. When applying the methods of understanding in psychiatry, the subject’s personality assumes major significance. It is in the interaction between this and the patient’s current life circumstances that meaningful connections with current problems emerge. As we have seen with van Gogh, aspects of the personality may be taken as constitutionally ‘given’, or attempts may be made to see how it might have been formed out of earlier life experiences. Personality dimensions may be studied as forms. Measures having satisfactory reliability and validity have been developed for a number of such traits, and relationships between these and a variety of other factors have been studied. These include genes (e.g. monozygotic versus dizygotic twin comparisons, or comparative resemblances between adopted subjects and their biological and adoptive parents, respectively), structural and functional magnetic resonance imaging (MRI), electroencephalogram (EEG) patterns, neurotransmitter functioning, cerebral damage, early parental loss, childhood deprivation and so on. A useful body of information has evolved for antisocial personality traits, for example. Behavioural perspective Learning theories, as derived from animal laboratory studies, express law-like relationships between specific behaviours and environmental contingencies or reinforcements. ‘Operant conditioning’, where emitted behaviour is shaped by regularities in subsequent reinforcements, is an example. These theories have also been applied to human learning, but translation is made difficult by the complexity both of the behaviour and of the plethora of environmental cues that might become reinforcers. The latter often involve symbolic (or meaningful) content that is difficult to specify or measure. Cognitive components of behaviour receive much attention nowadays, with the structure of thinking, such as basic assumptions about the self or the world, analysed in relationship to behaviour. A learning-theory perspective may be of value in attempting to make sense of behaviour that seems non-understandable. While maladaptive, the abnormal behaviour may, for example, be viewed as having been acquired according to normal learning mechanisms in the presence of unusual environmental contingencies. Some have suggested that van Gogh’s self-mutilation was a learned behaviour aimed at eliciting care from others. Or the learning process itself may be abnormal, as when learned fear responses fail to extinguish normally when the maintaining conditions no longer operate. Necessary for these approaches is a careful analysis of antecedents, specific behaviours and consequences of the behaviours. Therapeutic principles have also been derived from learning theories. Family perspective As in the case of van Gogh, a description of a person in the context of their family is usually illuminating. Such an account is framed in terms of what the experience would be like of growing up in that family. This clearly falls within the scope of understanding. Concepts have evolved that describe the ways in which families function and that seem to transcend individual experiences. They operate at a different level of abstraction, referring to the family as a system rather than to the people comprising it. Examples include repetitive patterns of interaction between members, regulation of ‘boundaries’ between groupings (parental dyads versus siblings; males versus females), ‘homeostatic’ mechanisms leading to resistance to change in the patterns of relationships, the role of a member’s symptoms in preserving family relationships and in turn being sustained by them, and the repetition of family patterns across generations. Van Gogh’s family tree shows striking transgenerational repetitions in naming and the destinies these names imply, and in relationships between brothers—namely, a strong devoted to a weak (Theo supported Vincent; their father Theo was supported by Uncle Vincent)—and the relationships between uncles and nephews (Uncle Vincent’s mentorship of Vincent; that of Vincent’s grandfather, Vincent, by his uncle). One wonders what this might have implied for van Gogh’s relationship with his own nephew Vincent. Sociocultural perspective The influence of the society in which a person lives may also be understood through an imaginative reconstruction of what it might be like to live in a particular setting (understanding), or it might be apprehended at a separate conceptual level with its own methods of analysis (of forms)—examining relationships between mental disorders and, for example, social class, urban versus rural environments, cultural groups, patterns of help-seeking and service provision, unemployment, social alienation, or societal reactions to deviance. The way in which one experiences and thinks about the world is strongly shaped by one’s culture, as is the expression of behaviour. Van Gogh’s Calvinist environment was central to many aspects of his life. The ways in which distress or symptoms of illness are expressed may be culturally conditioned or ‘coloured’. In many cultures, the ‘idiom’ for the expression of psychological distress involves the experience of bodily unease, and presentations to doctors may thus be somatic rather than psychological. Certain disorders, termed ‘culture-bound’, appear determined by such factors. The content of the symptoms may also reflect particular societal or cultural values, even when their form is determined by a disruption of brain processes. For example, van Gogh’s delusions were of a religious nature, albeit severely distorted, in keeping with his social background. We should also bear in mind that the way in which the doctor thinks about illness, the way in which relationships with patients are prescribed, and their expectations of treatment are also strongly influenced by culture. Conclusion Relevant clinical information is selected and organised in the formulation, as described in Chapter 6. Important components are the diagnostic evaluation and consideration of influences leading to the disorder. Management plans flow logically. Diagnosis rests on an analysis of forms and on ‘rules’ for collecting these into validated syndromes or disease categories. Inherent in some are aetiological or pathogenic ascriptions. An acute organic brain syndrome implies a clear ‘physical’ disruption of mental processes. Most diagnoses in psychiatry are clinico-descriptive, but contain important information about likely associations, course and treatment. They derive from a body of empirical knowledge that has generalisability and is not unique to an individual. When asking why a particular patient has become ill, both understanding and causal explanation play a role. They guide the clinician towards a comprehensive elucidation of causes, in so far as they are known, and of meaningful connections unique to that person. The formulation integrates the two modes into a complementary synthesis. The other perspectives discussed above further enhance our appreciation of the patient’s problems. Further reading McHugh, P. R. and Slavney, P. R. (1998). The Perspectives of Psychiatry. 2nd edn, Johns Hopkins University Press, Baltimore. A detailed discussion of understanding and explanation, and the other perspectives presented in this chapter. Shergill, S., Greenberg, M., Szmukler, G. I. and Tantam, D. (2003). Narratives in Psychiatry. Jessica Kingsley, London. Through detailed case studies, shows how a comprehensive view of a patient’s problems can be developed. For details about the life of Vincent van Gogh, the following are recommended: Blumer, D. (2002). ‘The illness of Vincent van Gogh’, American Journal of Psychiatry, vol. 159, pp. 519– 26. An analysis of the artist’s psychiatric diagnosis. Lubin, A. J. (1975). Stranger on the Earth. Paladin Press, St Albans. A comprehensive biography of van Gogh. Van Gogh, V. (1958). The Complete Letters of Vincent van Gogh. Thames & Hudson, London. A fascinating insight into van Gogh’s life and mind. Vincent van Gogh Gallery: www.vggallery.com. An excellent resource, including paintings, biography and letters. * I thank eric Cunningham-Dax and Andrew Firestone for sharing valuable insights into Vincent van Gogh.