"Hypermodern times" by Gilles Lipovetsky and psychiatry

In his 2005 book Hypermodern Times, the French philosopher Gilles Lipovetsky refers to the new millennium as “hypermodernity,” that is, something as paradoxical as a “modernist renaissance” characterized by hyperconsumerism, new individualism, narcissism, and a desperate need for control that remains impossible to satisfy in the absence of a belief system.

Lipovetsky puts the new era in the context of modernism and postmodernism, and elegantly describes its many paradoxes. The hypermodern times actually began when the description of postmodernism became common knowledge in the last decades of the 20th century. The predominant emotional chord is described like this:

“The ambience of this civilization of ephemerality has changed the prevailing emotional tone. A sense of insecurity has invaded all minds; health has imposed itself as a mass obsession; terrorism, catastrophes and epidemics are regularly front-page news. /…/ The only real question now is that of protection, security and defense of social benefits, of urgent humanitarian aid and safeguarding the planet.” (p 39)

And about future: “The less one has a teleological vision of the future, the more that future lends itself to being manufactured in a hyperrealist way: science and technology in combination aspire to explore the infinitely great and the infinitely small, to reshape life, to manufacture mutants, to offer a semblance of immortality, to resurrect vanished species, to programme the genetic future.” (p 43)

Psychiatry is, and always has been, medicine's—and perhaps the modern era's—most daring enterprise. Here, man uses natural science to try to explain that thoughts, feelings—even consciousness—have material causes that are subject to the laws of nature and, therefore, are possible to manipulate and predict. Even the name is edgy: the Greek word “psyche” (which few psychologists or psychiatrists can define off the cuff) is the New Testament's word for life, the soul, that which previously was seen as the immortal, God-like, free essence of being human, which, through psychiatry, becomes a part of physiology and pathology.

Mental suffering has been referred to widely divergent conceptions of causes, such as sexual experiences in infancy, capitalist alienation from work, and the “schizococcus,” but from Freud's psychoanalysis to Marxist-influenced social psychiatry, to neuropsychiatry, the same modernist insistence that psychological phenomena can be traced back to sufficient causes has characterized the different schools of thought.

In the hypermodern culture, psychiatric knowledge and tools are suddenly indispensable for people who struggle to use their minds just as their bodies. The spell of the 1970ies anti-psychiatry is broken. As the body has taken on new iconic meaning as a provider of status and bliss, the same perspective is taken on our inner selves, with identity-shaping schemes to create the “dream-me”. Anxiety is controlled with the help of computer programs, visualization techniques, meditation, and other forms of “training.” We even map our genetic predispositions using saliva DNA kits purchased online, and use inventories and websites to match our procreation, love, relationship, friendship, and existential ideals to other people's.

Young people are increasingly seeking out psychopharmacological treatments, not only for impairing conditions but also as “enhancers” of everything from attention span to love or moral judgment. The lust for self-experimentation is striking. Forty years ago, treatment with psychopharmacological agents was widely considered nightmarish. Now, it is clearly mainstream.

With structural and functional imaging methods, epidemiological and molecular genetics, national databases, and broad psychopharmacology, does psychiatry finally have the technology to realize the 1930's modernist ideals of “healthier, clearer, cooler?”

Yet the need for security and predictability is ever-increasing. Instrument-based risk assessments are increasingly used to certify people in order to point out individuals who present some sort of risk. New hospitals use cutting-edge technologies to supervise patients. Do we see the beginning of a new culture wherein neuroscience truly can influence mankind's big questions of peace, happiness, financial security, and global health?

Or will there be a huge disappointment in hypermodernist solutions on the scale of that in the late 1960-early 1970ies? After all, there is very little evidence that psychiatry is improving either general mental health, well-being or the outcome for patients. On the contrary, mental health is getting steadily worse in the hypermodern culture, treatment results have not improved in any general sense and psychiatry itself is getting more repressive, with more involuntary care, forced pharmacotherapies and long-term monitoring. Is this an early sign that hypermodernism is not really all there is to our future?

In 2014, the confidence in the progress of psychiatry seems to have started to dwindle. Funding from the pharmacoceutical industry is drying up, and molecular genetic studies implicate extremes of normal variation rather than identifiable mutations in a large majority of research subjects with common conditions such as depression or even autism spectrum disorders. If mental health problems arise along a spectrum ranging from the normal variation into out-lying pathologies without clear demarcations between disorder-health or between different diagonses, easy technical solutions will be difficult to deliver. 

(Partly excerpted from this paper, available in full text, where changes in psychiatry from modernism to postmodern and hypermodern times are described)

Professional ethics in forensic psychiatry

Even if I work at the Centre for Ethics, Law and Mental Health (CELAM) at the University of Gothenburg, I am no specialist in ethics and have never studied practical philosophy. This post is thus not written by an expert in ethics, and I doubt that my colleagues who hold such qualifications would agree with much of it. Nevertheless, I want to argue for some positions I have arrived at through my work as a clinician and researcher. Forensic psychiatry is a medical speciality operating in the interface towards law. It is sometimes argued that we have a “dual task” of promoting our patients’ health and protecting society from violent (re-)offending. I reject this idea, and will outline the reasons for this here.

My position is that, as health professionals, our sole duty is to further the best interest of our patient. By health professionals, I refer to board licensed MDs, psychologists, psychotherapists, social workers, nurses and other professions employed in the health care system. Being a health professional requires that other people put their trust in you in very special ways. Therefore, we have ethical rules that must always be adhered to. To do our work, we can literally ask a fellow human to undress or to reveal his/her innermost secrets. Sooner or later, most of us will need a health professional. In the vulnerable position of the care seeker, and to get good treatment, we must be able to trust that the professional is dedicated to promoting our health and not serving two masters. 

Before going further into the arguments for my position, let me state that it is never in the patient’s best interest to commit a violent crime, having drugs prescribed without medical indication, false certificates issued or the similar.

Psychiatrists may give court expertise on evaluations and treatment, if the patient waives professional secrecy. In cases of diminished or incapacitated accountability, special legislation is at hand to safeguard the patient’s best interest. But the model in which a psychiatrist may “change hats” and give evidence against someone, working for the state or the prosecution, putting aside normal medical ethics, damages medicine at large. 

The reason the court asks for a psychiatric or psychological opinion is that the expert has specialist training (based in the confidence of patients and research subjects) and clinical knowledge (that demands access to information that the patient has provided under the impression of confidentiality, either directly to the expert or to other experts, who have entered it into files). Being a qualified health professional also brings credibility and power imbalance, making it difficult for the person described to question the expert’s opinion.

It does not suffice to merely state that “this opinion is made as expert for XXX” as established titles, such as MD, will create certain expectations in those receiving the evaluation. In contrast, it could be possible for a psychologist to work as a behavioual analyst and give expertise in that role. Such cases have to be handled with great caution, however, in order not to confuse previous or future clients.  

But with these requirements, how could medical doctors work in forensic medicine or with societal response to contagious diseases? Frankly, I do not know how ethical frame-works, especially for the latter, have been developed, but I do not find clear analogies to forensic psychiatry. Psychiatry has a rather weak inter-rater reliability, and courts tend to believe us more easily than our colleagues do, who often disagree with our opinions. And without trust from patients, we are completely lost. So I do not find the responsibilities and benefits of assuming the role of “(s)he who knows” in the courtroom worth the risks for our profession. 

Not doing harm is our first duty. How is that possible when giving expert opinions in situations where we have no control over how the expertise is used, disseminated or understood? Instead, I think that we should use our scarce resources to develop good health services to incarcerated or otherwise sentenced persons, evidence-based treatments for aggressive behaviours and public mental health education.

Mt St Helens 1980 eruption

Some books, films or journal views make an unforgettable impression, while others, as interesting and well-presented, just fade. I will never forget the January 1981 National Geographic cover story on the eruption of Mt St Helens in Washington State. One of the Cascade volcanoes, Mt St Helens had been known to erupt in the 19th century, but had been dormant for more than hundred years. It was a very beautiful, Fuji-shaped mountain, a stratovolcanoe like Mt Teide on Tenerife, if smaller. It overlooked Spirit Lake where sport resorts and fishing lodges had among the most wonderful sites and views in America. In March 1980, a series of small earthquakes had been registered and, as there had been no volcanic eruption in the continuous US since 1915, scientists immediately flocked  to study what was going on, monitor activity and try out new predictive tools. 

The eruption started on March 27 but was considerably smaller than the scientists had thought it would be. Activity continued, and seismic activity was continuous, while chemical samples (taken from the sides of the mountain but also in the crater (!) by daredevil scientists) didn't show signs of imminent danger. In May, the sesimic activity in the mountain seemed to settle again and public pressure to lift warnings and security measures started to mount. So did, however, the magma pressure in the mountain. It was even visible for the naked eye, as a buldge had formed on the northern slope. Laser measurements assessed the growth to one meter and a half per day (!). In this situation, volcanologists could persuade the governor to keep access to the “red zone” closed, the area around the mountain thought to be directly hit if the mountain had a Plinian eruption, explosive like that described by Pliny the younger at Mt Vesuvius in 79, which destroyed Herculaneum and Pompeii. However, some residents and lumber companies refused to evacuate, tourists continued to flock around the mountain, trying to evade road blocks, and the scientists kept watch from several observation spots.  

At St Helens, volcanologists worked with three types of predictors when assessing the risk for an eruption: seismology (earthquakes), chemistry (gas and water emissions) and geology (deformation, previous eruptive history). By combining these factors in "event tree" algorithms, the accuracy of newer predictions is estimated to have moderate to good predictive ability for short term predictions (Areas under Receiver Operating Characteristics Curves of 0.78-0.81, Junek and co-workers, 2012, Algorithms, which is an estimate of the validity of the method rather than the security of a single prediction). Just as in psychiatry, a “clinical override” is also allowed for, so a senior volcanologist can have an experience-based opinion that takes precedence before the results of the algorithm. And Mt St Helens proved to be a testing ground for many new tools used routinely today to predict volcanic activity.  

On Saturday, May 17, the mountain was so calm that residents in the red zone were allowed a brief entry from 10 AM to 4 PM to collect property. A similar opening was planned for the following Sunday.  The weather was clear and sunny, with a very good visibility. Fortunately, Sunday meant the loggers had the day off. At 8 32 AM Sunday morning, the whole northern flank of Mt St Helens suddenly collapsed and gave way to a Plinian eruption, which also contained what is referred to as a “lateral blast”, a sort of eruptive column going side-ways instead of upwards. The consequences were terrible. Fifty-seven people died, among them several scientists and journalists, the most well-known being David Johnston, who had predicted just a lateral blast based on the bulge but nevertheless remained at an observation post overlooking the north face of the mountain from about 10 km. No film of the eruption survived, but several series of still shots taken in rapid succession made a very detailed reconstruction possible (below). A detailed description is given in the Wikipedia entry on the eruption. Several other interesting films describing the sequence of eruptions and its aftermath are available on YouTube. The events were also used in several movies, among them St Helens and Dante's Peak.  

Due to the lateral blast, the zone of destruction was much larger than the predicted red zone, and many victims died in areas considered medium or even low danger. Rapidly after the blast, mud flows created by rapidly melting snow on the mountain hit further victims down the river beds. After his visit, US president Jimmy Carter said that, in comparison to the devastation wrought on the countryside to the north of the volcano, the “moon looked like a golf course”.  Fortunately, as the area around Mt St Helens was sparsely populated and, at least partially, evacuated, the death toll was two-figure and not much worse.  When volcanoes like the neighboring Mt Rainier, which overlooks Seattle and many smaller cities in its river valleys, come to live, the responsibility put on the scientists will be unfathomable.

A last word of hope. At first, scientists thought that the blast zone would remain sterile and life-less for a very long time, up to a century. For the 30th anniversary of the eruption, a nature TV documentary was produced. It really shows how amazingly fast life is to reclaim lost areas and fill them with wonders anew.


On Friday, the next blog entry will deal with the science of predicting future dangers in forensic psychiatry as compared to volcanology. I also plan to read some more pappers on predictions in volcanology, as their use of event trees and short-span predictions are very interesting, and to present it in some blog post. And if you followed the path to the 2014 Bardarbunga eruption, which is currently ongoing, seismic recordings posted on the internet made it possible to see how the magma rose in the volcano day by day, and where it would eventually erupt. But also in Iceland, major risk assessments are currently performed, and can be followed on the website linked to bardarbunga (The Icelandic Met Office)

Postmodernism

This post is the first in a series that will run in the blog at weekly, or something like weekly, intervals, called ”Dilettantischer Dienstag” (dilettantish Tuesday). In it, I will develop ideas, topics and interests that are not in my field of expertise, but rather somewhere in my general reading or geeky special interests. Some may think that this is not limited to Tuesdays, but those will at least be the days when these pieces are posted. And, let me remind you that on Fridays, a more serious series called Forensic Fridays will include texts from my actual field of expertise (even if this is certainly no guarantee of infallibility). 

The first dilettantish post will address a somewhat controversial and not too easy subject: the term “postmodern” or “postmodernism”. I have noted that these are now commonly used to denominate a senseless relativism of knowledge, rooted in sloth and misguided egalitarianism. Maybe this has to do with a current faibelesse for "hypermodernism" that Gilles Lipovetsky has sharply described (more on that later). 

In several papers and speeches over the years, I have, however, used the term "postmodernism" to highlight specific aspects of epistemology or ethics (sometimes to the dismay of anonymous peer-reviewers) and often cited with great appreciation the works by Pat Bracken and Philip Thomas on “Postpsychiatry” or “Postmodern psychiatry” (http://www.bmj.com/content/322/7288/724, also a monograph in the Oxford series on Philosophy and Psychiatry, http://www.amazon.co.uk/Postpsychiatry-Postmodern-International-Perspectives-Philosophy/dp/0198526091). Therefore I will briefly try to remind you about its original and – I believe – still valid use. These texts come from a paper I published in Swedish in 2011 (the excerpts are not at all original of course, but hopefully of some educational value) and may be found here http://celam.gu.se/digitalAssets/1481/1481973_postmodern-psykiatri.pdf . 

In 1979, Jean-Francois Lyotard described his time as the ”postmodern condition”, not as a “movement” or a programmatic –“ism”, but as a condition characterized by skepticism towards “meta-narratives - sometimes ’grand narratives’, /…/ grand, large-scale theories and philosophies of the world, such as the progress of history, the knowability of everything by science, and the possibility of absolute freedom”. 

Postmodernity therefore does not entail nihilism in relation to knowledge or relativism. Instead, awareness of epistemic frames (which questions can be answered by a certain method) leads to more rigorous science. “Grand narratives” form obstacles to understanding what new information really means and lure us into drawing conclusions that are not founded in the scientific data or into extrapolating interpretations to contexts where they are not relevant. They also create artifactual conflicts between different perspectives and make it more difficult to see that knowledge is generated in “cuts” through reality, dependent on the perspective from which a phenomenon is examined, and that different contributions, as long as they are, each and every one, rigorous and epistemologically consequent, can be used as complementary rather than excluding.

I will continue to use these terms and hope to elicit some further interest for the issues at stake. 

The original Swedish quotes from the paper:

År 1979 beskrev Jean-Francois Lyotard sin samtid som det ”postmoderna tillståndet”, alltså inte som en ”rörelse” eller ”-ism” med ett program, utan som ett tillstånd präglat av skepsis mot ”meta-narratives – sometimes ’grand narratives’, /…/ grand, large-scale theories and philosophies of the world, such as the progress of history, the knowability of everything by science, and the possibility of absolute freedom”.

Postmodernitet behöver inte innebära kunskapsnihilism eller relativism. Medvetenhet om kunskapsteoretiska ramar (”vilka frågor kan denna metod besvara?”) leder istället till en mer rigorös tolkning av vetenskap. ”Stora berättelser” hindrar oss från att förstå vad ny information egentligen betyder och lockar oss att dra slutsatser utan stöd i det vetenskapliga underlaget eller att extrapolera tolkningar till sammanhang där de inte är relevanta. De skapar också artefaktiska motsättningar mellan olika perspektiv, och gör det svårare att se att kunskap genereras i olika ”snitt” genom verkligheten beroende på ur vilket perspektiv fenomen undersöks, och att olika bidrag, så länge vart och ett är rigoröst och kunskapsteoretiskt konsekvent, därför är komplementära istället för exkluderande.