Comment
policy makers have failed these patients, it now I declare no competing interests.
becomes mental health professionals’ duty, in close Livia J De Picker
collaboration with community stakeholders, families [email protected]
and carers, to continue the advocacy efforts, to reach University Psychiatric Hospital Campus Duffel, 2570 Duffel, Belgium;
Collaborative Antwerp Psychiatric Research Institute, University of Antwerp,
out in any way possible, and to remove any and all Antwerp, Belgium
barriers that stand in the way of vaccination of people 1 Tzur Bitan D, Kridin K, Dov Cohen A, Weinstein O. COVID-19
hospitalisation, mortality, vaccination, and post-vaccination trends
with severe mental illness.9,10 among people with schizophrenia in Israel: a longitudinal cohort study.
Unfortunately, scientific evidence on vaccine hesitancy Lancet Psychiatry 2021; published online Aug 5. https://doi.org/10.1016/
S2215-0366(21)00256-X.
and the attitudes of people with schizophrenia towards 2 Vai B, Mazza MG, Delli Colli C, et al. Mental disorders and risk of COVID-19-
vaccination is a knowledge gap. Although Tzur Bitan and related mortality, hospitalisation, and intensive care unit admission:
a systematic review and meta-analysis. Lancet Psychiatry 2021; published
colleagues’ study provides a first attempt to characterise online July 15. htps://doi.org/10.1016/S2215-0366(21)00232-7.
determinants of vaccine uptake among patients with 3 Nemani K, Li C, Olfson M, et al. Association of psychiatric disorders with
mortality among patients with COVID-19. JAMA Psychiatry 2021; published
schizophrenia, no study to date has stratified patients’ online April 1. htps://doi.org/10.1001/jamapsychiatry.2020.4442.
4 MacKenna B, Curtis HJ, Morton CE, et al. Trends, regional variation,
COVID-19 outcomes or vaccination rates by their clinical and clinical characteristics of COVID-19 vaccine recipients: a retrospective
psychiatric status or involvement with psychiatric care. cohort study in 23.4 million patients using OpenSAFELY. medRxiv 2021;
published online Jan 26. htps://doi.org/10.1101/2021.01.25.21250356
The potential effect of psychiatric care on the pandemic (preprint).
outcomes of these patients thus remains a blind spot. 5 Tzur Bitan D, Krieger I, Kridin K, et al. COVID-19 prevalence and mortality
among schizophrenia patients: a large-scale retrospective cohort study.
The organisation of care for patients with psychotic Schizophr Bull 2021; published online Feb 19. htps://doi.org/10.1093/
schbul/sbab012.
disorders is notoriously complex and heterogeneous. 6 Warren N, Kisely S, Siskind D. Maximizing the uptake of a COVID-19 vaccine
Consequently, the pandemic offers a unique opportunity in people with severe mental illness: a public health priority.
JAMA Psychiatry 2020; 78: 589–90.
to study the individual (eg, clinical predictors of at-risk 7 The Lancet Psychiatry. A matter of priority: COVID-19 vaccination and
groups), mental health-care (eg, treatment setting), and mental health. Lancet Psychiatry 2021; 8: 551.
8 De Picker LJ, Yolken R, Benedetti F, et al. European COVID-19 exit strategy
macro-organisational (eg, country health-care system) for people with severe mental disorders: too little, but not yet too late.
determinants of COVID-19 outcomes and vaccine uptake Brain Behav Immun 2021; 94: 15–17.
9 Usher K. Ensuring COVID-19 vaccine uptake by people with severe mental
among patients with mental disorders. I consider this illness: a mental health nursing priority. Int J Ment Health Nurs 2021;
30: 587–89.
a priority in the research agenda of mental health-care 10 De Picker LJ, Casanova Dias M, Benros ME, et al. Severe mental illness and
researchers worldwide. Evidence is the prerequisite for European COVID-19 vaccination strategies. Lancet Psychiatry 2021;
8: 356–59.
effective action, during and after the COVID-19 pandemic.
Three dialectics of disorder: refocusing phenomenology for
21st century psychiatry
An Editorial in The Lancet Psychiatry1 provided a welcome in being pre-reflective) is not normally something
addition to the growing chorus of voices calling for of which we are aware. Thus, although descriptive
the restoration of phenomenology in psychiatry. psychopathology focuses directly on the contents of
Fanatic Studio/Science Photo Library
Although we agree with these calls, we believe that lived experience, phenomenology digs below the surface
phenomenology needs to be refocused around the to examine the pre-reflective framework that shapes
principles of dialectical philosophy if it is to serve the and gives meaning to that experience. This is why, as
needs of 21st century science-based, but person- the Lancet Psychiatry Editorial indicates, contemporary
centred, mental health care. neuroscience has been impoverished by focusing on
Phenomenology is distinctive among disciplines descriptive psychopathology to the exclusion of the pre-
concerned with the subjective lived experience (or reflective insights of phenomenology.
lifeworld) of mental distress and disorder, in focusing Dialectical phenomenology adds to other phenom
on the pre-reflective framework within which that enological approaches in focusing on the relationships
experience is set. This pre-reflective framework (simply between opposite pairs of elements of the pre-reflective
www.thelancet.com/psychiatry Vol 8 October 2021 855
Comment
framework. This approach builds on the dialectical mental health is also about achieving recovery, namely, a
philosophy of the German philosopher, Georg Hegel— good quality of life as defined by the values of the person
working back-and-forth between thesis and antithesis concerned.8 This is where the dialectics both of position
until a novel synthesis is achieved by integration and value and of ambiguities become important. These
without elimination or reduction. dialetics speak directly to the strengths-based assessment
Dialectical phenomenologies have been developed that is crucial to recovery in several areas, including
widely in recent decades. Early in the field were primary psychosis.9 Eliminating a given symptom,
seminal figures such as Ludwig Binswanger, we should emphasise, is important for some people’s
Wolfgang Blankenburg, and Otto Dörr-Zegers. Contem recovery. But focusing on symptoms without regard to
porary approaches have focused on three par ticular how they fit within an individual’s lifeworld of values
dialectics of disorder, involving failures, respectively, might be unproductive and even actively harmful.8
of anthropological proportions (of the proportionate Recovery, so defined, depends on collaborative
balancing between opposite elements of our sub working between clinicians and patients as reflected in
jective lifeworlds), of position and value (these being coproduction and in shared clinical decision making.10
a specific pair of lifeworld opposites of particular What is required for collaborative working of these
importance in phenomenological psy chopathology), kinds is a balance of voices, with neither clinician nor
and of ambiguities (of the ambiguous bad or good patient having the dominant voice. This balance might
aspects of specific elements within our lifeworlds). of course be highly challenging where (as in mental
Each of these dialetics has yielded important insights health) clinician and patient could have different views.
into a variety of psychopathologies. As with other Thus, it is precisely here that dialectics—a back-and-
phenomenological approaches, this work, in enriching forth process aimed at integration without elimination
our understanding of the subjective lived experience or reduction—comes into play. So understood, indeed,
of mental distress and disorder, complements neuro coproduction and shared decision making are, no more
scientific and other empirical studies of the objective and no less, dialectical exchanges.
(brain) basis of experience. However, consistent with To repeat, dialectical phenomenology is and should
the requirements of contemporary person-centred always be a partner to the descriptive psychopathology
mental health care, dialectical phenomenology adds a of contemporary empirical psychiatric classifications.
highly individualised understanding of psychopathology. But partnership between two such different but
Dialectically understood, psychopathological experiences complementary approaches is deeply challenging. Which
are no longer defined by the presence or absence of this suggests that dialectics—a back-and-forth process aimed
or that constitutive lifeworld element (construed as at integration without elimination or reduction—might
individual symptoms shared across several subjects), prove important not only in refocusing phenomenology,
but rather by the relative proportions of—and tensions but also in bringing phenomenology together with
between—opposite poles of these elements within a empirical science in meeting the needs of contemporary
particular individual’s lifeworld. science-based, person-centred clinical care.
Work on depression provides a case in point, with We declare no competing interests.
studies showing disproportions in different individuals in *Guilherme Messas, Bill K W M Fulford
a number of different lifeworld elements: time (excessive [email protected]
presence of the past and blocking of future possibilities),2 Santa Casa de Sao Paulo School of Medical Sciences, São Paulo, Brazil (GM);
International MetaMasters in Phenomenology and Values-Based Clinical Care,
body (loss of conative [ie, purposive] drive and increased Collaborating Centre for Values-Based Practice in Health and Social Care (GM),
materiality and resistance, culminating in what Fuchs Philosophy Faculty (BKWMF), and The Collaborating Centre for Values-Based
Practice (BKWMF), St Catherine’s College, University of Oxford, Oxford;
and Schlimme called hyperembodiment),3 and identity Philosophy, Psychiatry, & Psychology (BKWMF), Philosophy and Mental Health,
(disproportion between personal identity and social University of Warwick, Coventry, UK (BKWMF).
1 The Lancet Psychiatry. The things themselves. Lancet Psychiatry 2021;
identity).4 Other examples include, Fuchs’ bodily therapies 8: 169.
in patients with delusions,5 Stanghellini’s work on eating 2 Ratcliffe M. Varieties of temporal experience in depression. J Med Philos
2012; 37: 114–38.
disorders,6 and the work of one of us (GM) on substance 3 Fuchs T, Schlimme JE. Embodiment and psychopathology:
misuse.7 However, contemporary person-centred care in a phenomenological perspective. Curr Opin Psychiatry 2009; 22: 570–75.
856 www.thelancet.com/psychiatry Vol 8 October 2021
Comment
4 Kraus A. Role performance, identity structure and psychosis in melancholic 8 Slade M, Amering M, Farkas M, et al. Uses and abuses of recovery:
and manic-depressive patients. In: Freeman HL, ed. Interpersonal factors in implementing recovery-oriented practices in mental health systems.
the origin and course of affective disorders. London: GASKELL—The Royal World Psychiatry 2014; 13: 12–20.
College of Psychiatrists, 1996. 9 Maj M, van Os J, De Hert M, et al. The clinical characterization of the patient
5 Fuchs T, Röhricht F. Schizophrenia and intersubjectivity: an embodied and with primary psychosis aimed at personalization of management.
enactive approach to psychopathology and psychotherapy. World Psychiatry 2021; 20: 4–33.
Philos Psychiatry Psychol 2017; 24: 127–42. 10 Hughes JC, Crepaz-Keay D, Emmett C, Fulford KWM. The Montgomery
6 Stanghellini G, Mancini M. The therapeutic interview in mental ruling, individual values and shared decision-making in psychiatry.
health—a values-based and person-centered approach. Cambridge: BJPsych Adv 2018; 24: 93–100.
Cambridge University Press, 2017.
7 Messas G. The existential structure of substance misuse.
A psychopathological study. New York: Springer, 2021.
Call for emergency action to limit global temperature
increases, restore biodiversity, and protect health
The UN General Assembly in September, 2021, will bring and cardiovascular and pulmonary morbidity and Published Online
September 6, 2021
countries together at a critical time for marshalling mortality.5,6 Harms disproportionately affect the most https://doi.org/10.1016/
collective action to tackle the global environmental vulnerable, including children, older populations, S2215-0366(21)00364-3
crisis. They will meet again at the biodiversity summit in ethnic minorities, poorer communities, and those with
Kunming, China, and the UN Climate Change Conference underlying health problems.2,4
of the Parties (COP26) in Glasgow, UK. Ahead of these Global heating is also contributing to the decline
pivotal meetings, we—the editors of health journals in global yield potential for major crops, falling by
worldwide—call for urgent action to keep average global 1·8–5·6% since 1981; this, together with the effects
temperature increases below 1·5°C, halt the destruction of extreme weather and soil depletion, is hampering
of nature, and protect health. efforts to reduce undernutrition.4 Thriving ecosystems
Health is already being harmed by global temperature are essential to human health, and the widespread
increases and the destruction of the natural world, a destruction of nature, including habitats and species,
state of affairs health professionals have been bringing is eroding water and food security and increasing the
attention to for decades.1 The science is unequivocal; a chance of pandemics.3,7,8
global increase of 1·5°C above the pre-industrial average The consequences of the environmental crisis fall
and the continued loss of biodiversity risk catastrophic disproportionately on those countries and communities
harm to health that will be impossible to reverse.2,3 that have contributed least to the problem and are least
Despite the world’s necessary preoccupation with able to mitigate the harms. Yet no country, no matter
COVID-19, we cannot wait for the pandemic to pass to how wealthy, can shield itself from these impacts.
rapidly reduce emissions. Allowing the consequences to fall disproportionately
Reflecting the severity of the moment, this Comment on the most vulnerable will breed more conflict,
appears in health journals across the world. We are food insecurity, forced displacement, and zoonotic
united in recognising that only fundamental and disease—with severe implications for all countries and
equitable changes to societies will reverse our current communities. As with the COVID-19 pandemic, we are
trajectory. globally as strong as our weakest member.
The risks to health of increases above 1·5°C are now Rises above 1·5°C increase the chance of reaching
well established.2 Indeed, no temperature rise is “safe”. tipping points in natural systems that could lock the
In the past 20 years, heat-related mortality among world into an acutely unstable state. This would critically
people older than 65 years has increased by more impair our ability to mitigate harms and to prevent
than 50%.4 Higher temperatures have brought increased catastrophic, runaway environmental change.9,10
dehydration and renal function loss, dermatological Encouragingly, many governments, financial institu
malignancies, tropical infections, adverse mental tions, and businesses are setting targets to reach net-
health outcomes, pregnancy complications, allergies, zero emissions, including targets for 2030. The cost of
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