Instytut Psychologii Stosowanej UJ
An attempt is made to develop a basic framework for an existential-phenomenological perspective on personality disorders. Its starting point is taken from the psychiatrist Antoni Kępiński and the philosopher Józef Tischner. The former provides a clinical framework capacious enough to allow ethical, existential, and phenomenological explorations. This conceptual “space” is then explicitly recognized, addressed, and fulfilled by the latter’s investigation of personality dynamics proper to “the hideout.” In order to supplement this thread of thought with a specific illustration, a “case” provided by Fyodor Dostoevsky in his Notes from the Underground is investigated. Then, in turn, Paul Tillich’s The Courage to Be is referred to, so that the deepest roots of personality disorders can be identified with an ontological dynamic proper to the avoidance of non-being. Finally, some brief remarks are made concerning how all the above relates to the idea of a normatively neutral science and how it can be integrated with more up to date clinical practice.
Keywords: personality disorders, philosophy of psychiatry, phenomenology, Kępiński, Tischner, Dostoevsky, Tillich.
Antoni Kępiński (1918–1972) was a Polish psychiatrist influential both within professional clinical circles and, more broadly, among those interested in mental health and the alleviation of suffering entailed by mental disorder. His close embeddedness in the intellectual climate of Kraków, including some connections with phenomenology (via the philosopher Roman Ingarden, a disciple of Edmund Husserl), places him in a very good position to influence not only physicians, but also humanists and, last but not least, the general public (as far as his typical reading audience is concerned Kępiński seems to be much closer to authors such as, say, Thomas Szasz or Carl Rogers than to more narrowly oriented scientists or philosophers of psychiatry).
The work of Antoni Kępiński has usually been discussed in terms of some particular theoretical developments such as his (1) theory of information metabolism1 or (2) contribution to the studies of concentration camps survivors (KZ syndrome), with the latter being a recognizable antecedent of what would later become a research on post-traumatic stress disorder.2 As such, his clinical thought is arguably as appreciated and influential in Poland as it remains relatively unrecognized in other countries. But even if this reason alone could justify an attempt to re-address his views, a present paper will focus on a topic which seems to be neglected universally, both in Poland and elsewhere. The topic in question is Kępiński’s approach to personality disorders with its specific, and independently interesting, existential or phenomenological perspective. An attempt to pay some attention to his take on this domain is made to show how Kępiński can be revealing and still applicable today; not only in strictly clinical contexts, but also in those belonging to philosophy of psychiatry.
The most influential writings by Kępiński concern an already extensively explored area of mostly psychotic phenomena, including schizophrenia, depression, and anxiety,3 as well as some issues pertaining to everyday diagnostic practice.4 Less coverage has been granted to his investigation of personality-related issues, embodied mostly in a work titled Psychopatie [Psychopathies].5 It is this short book that will be a starting point for the following scrutiny.
The very general ambition proper to Psychopathies as well as an overall arrangement of topics characteristic of it, make the book in question comparable to such classics as Psychopathic personalities by Kurt Schneider6 or Neurotic styles by David Shapiro.7 And both these books indeed come to mind if one focuses on a nosological background against which Kępiński operates. His monograph, just like those by Schneider and Shapiro, involves a relatively short introductory and theoretical chapter as well as a concluding one addressing issues of more general character. Everything in-between, which constitutes the most substantial part of the book, is a series of chapters devoted to what Kępiński (and Schneider) called “psychopathies,” and what in terms of contemporary parlance would be more accurately called personality disorders.8 Kępiński’s explorations are rooted in an apparently eclectic, “common” (“pospolity”)9 classificatory system, from which the list of the types analyzed is taken including: the hysterical, psychastenic, anankastic, epileptoid,10 impulsive, paranoid, and sado-masochistic ones. Four of these types were already investigated by Shapiro (the anankastic one was addressed under a somewhat more contemporary label of an obsessive-compulsive style). Three of them, what is more, are directly present in Schneider’s study (attention-seeking psychopaths, asthenic psychopaths, and insecure anankasts reflecting, in this order, first three classes depicted by Kępiński).11
The significance of Schneider, which needs to be emphasized, goes well beyond mere nosological parallels and consists in his overall theoretical importance to Kępiński, who explicitly develops his own model on the basis of the former’s definition of psychopathy.12 The latter can be easily understood along the classical lines of the genus and the differentia. The respective nearest kind is a notion of an abnormal personality understood as “a variation upon an accepted yet broadly conceived range of average personality.” It refers to a genus in a sense that all psychopathies belong to the domain of abnormal personality (but not the other way round). As such it is conceived of in purely descriptive and statistical terms as a quality that can “be expressed as excess or deficiency of certain personal qualities.” By the same token it remains completely unspecified on the normative dimension. Whether it “is judged good or bad is immaterial to the issue”, which puts not only the saint and the poet, but also the criminal on a completely equal footing.13 As far as the differentia, or a factor applying only to those abnormal personalities that are (simultaneously) psychopathic, is concerned, Schneider refers to the concept of suffering and defines psychopathic personalities as those (and only those) “abnormal personalities who either suffer personally because of their own abnormality or make the community suffer because of it.”14
And it is exactly this definition to which Kępiński refers when he embarks on the project of developing his own account. Because of Schneider’s importance to the Polish psychiatrist, it may be worthwhile to make two additional remarks. The author of Psychopathic personalities, to begin with, goes to considerable lengths to emphasize that his notion of psychopathy “remains a clinical one and non-moral” and wants the whole clinical study of the domain in question to “be entirely removed from the sphere of moral judgment.”15 In this particular aspect his approach seems to be surprisingly contemporary and seems to arise from the very same fact-value distinction that informs the current DSM’s definition of mental disorder with its explicit claim that socially deviant behaviors and conflicts between the individual and society are not by themselves mental disorders.16
The second important point concerning Schneider’s definition is that psychopathies, in opposition to somatic conditions and so-called psychoses (like schizophrenia or depression), are not intended to be introduced as medical diagnostic categories. Rather, and in the full agreement with the approach delineated several decades earlier by Karl Jaspers,17 they are “something very different.” To describe somebody as a depressive psychopath, for instance, is not to make a nosological diagnosis. It means nothing more than making an idiographic recognition that the person in question is “a man of that sort.”18
An idiographic or non-nosological feature of Schneider’s approach can be more or less literally applied to what Kępiński, and other authors discussed in this paper, will say. It does not seem to be the case, though, with the first of the issues mentioned, i.e., Schneider’s dedication to the idea of the clinical being “non-moral.” Such an approach seems to be a direct reflection of the strict, and currently somewhat outdated, form of the fact-value dichotomy.19 It is, what is more, interestingly parallel to Gordon W. Allport’s efforts to banish the morally laden notion of character from psychology.20
All the authors explored below, as needs to be emphasized, embark on a project which is, at least nominally, directly opposite to what Schneider and Allport sought to accomplish. They want to (re)establish the investigation of the normative and the ethical within the domain of personality disorders. Their intended contribution, however, has virtually nothing in common with “morality” most scientists and most clinicians would be (justifiably) wary of. It is not, in other words, an aspiration “to be like priests”21 or an ambition to engage in a social game of passing moral judgment on others. Rather, as it seems, it can be read along the broad lines of the project to re-establish meaning and values (and not only those of moral kind) in the clinical description of human life including, a bit more specifically, the search for a framework that could overcome the limitations of the fact-value distinction.22
The broad character of the account offered by Schneider and Kępiński creates a possibility for the latter being addressed and further developed not only within the limits of a strictly understood medical framework, but also in terms of conceptual schemata more proper to humanities and/or philosophy of psychiatry. And even if, as mentioned above, Psychopathies are among the most rarely quoted Kępiński’s works, a non-trivial and philosophically very interesting attempt of this kind was made by a Polish philosopher, phenomenologist, and a Catholic priest: Józef Tischner (1931–2008). The very same author who once complimented Kępiński as “one whose knowledge of the human is richer than that of Freud, Heidegger, Levinas.” Tischner’s take on Kępiński and his Psychopathies is unfortunately very brief and all contained in a short essay titled
“People from the Hideout.”23 Even as such, however, it seems to be rich enough to at least lay a foundation for an existential-phenomenological account of personality disorder.
The point at which Tischner launches his investigations, and at the same time immediately generates tension with Schneider’s non-moral agenda, is a claim that Kępiński’s little book stretches between the arts of medicine and ethics. And it is not only the employment of ethics as potentially revealing for the analyses of Kępiński, but also the very fact that medicine is conceived as an art that are crucial for the very nature of endeavor at place. It is only when psychiatry and psychotherapy are construed in terms significantly broader than those of a somewhat technological framework proper to evidence-based practice24 or applied science25 that it can be meaningfully and fruitfully connected with the art of ethics.26 And it is only in such a case, importantly, that the connection at place may turn out to be substantive: a connection of internal or constitutive character.27
The account offered by Tischner, as mentioned, is both existential and phenomenological. It is made possible by his rich employment of the first-personal and thick descriptions of inter- and intrapersonal phenomena pertaining to both clinical and non-clinical human functioning. Such descriptions are often made via the spatio-temporal imagery of the “spaces” of hope, freedom, and values. As far as the area of personality disorder is concerned, Tischner characterizes the “spaces” inhabited by “people from the hideout” in terms of a kind of dialogical incompatibility existing between these spaces and the common experiential world of people living outside any kind of “the hideout.” It is such a discontinuity or a fundamentally distorted communication between “the hideout” and the outside world that is a permanent source of inadequate and/or unnecessary suffering and that constitutes, in most general terms, an existential-phenomenological aspect of personality disorder.28 Suffering proper to personality disorder, which needs to be emphasized, even if often unnecessary (or maybe exactly for that reason), is still a deeply human phenomenon. Accordingly, it is only a multi-dimensional approach capacious enough to address all levels of being human that can aspire to doing it full justice. Not only a strictly biomedical perspective, but also the biopsychosocial model29 and similar approaches will simply, and necessarily, fall short of the task. Rather, it is a kind of heuristically open and methodologically pluralistic framework offered once by Karl Jaspers’ perspectivism30 or Victor Frankl’s dimensional ontology31 that one should call for.
And it is exactly this kind of approach, arising what is more from the very same German philosophical tradition to which both Jaspers and Frankl belong, that is developed by Tischner, when he introduces the notion of a “hideout” (“kryjówka”). The hideout is, first of all, the opposite of the vast and open space characteristic of hope. The space of the hideout is narrow and closed and, actually, the very fact of occupying it is not an accidental feature (like being in this or that town), but rather a way of being of tremendous psychological and existential consequences. Tischner, to be clear, is ready to call it “a fall of deeply ethical character.”32 The employment of such a phrase is far from accidental on his side and it is especially so if one recalls that Tischner is both a priest and a theologian. The notion of the “fall,” in result, turns out to have as much existential richness as a notion of this kind can potentially possess and can be conceived of as referring to the most general and most capacious metaphor conveying “all that is wrong” with us humans and, simultaneously, pointing to both an original and (hopefully) ultimate condition to which we can aspire (see the notion of redemption). As such, it can be specified along the lines of the traditional Christian theology (as would be most accurate to Tischner himself), but also, if one prefers to do so, in a way universal enough to be understandable and revealing without the necessity of adopting a strictly religious perspective.33
The space of the hideout, which needs to be emphasized, is not fully devoid of hope (otherwise it would be the notion of condemnation, and not that of the fall, that would accurately convey its meaning). Rather than the complete absence of hope, it is a special quality of hope available to people in the hideout that makes that place uncommon and so difficult to inhabit. The hope typical of the hideout is fundamentally anxious: anxious both of the world and of other people. And it is such a negative reference point and, respectively, formally negative motivation (avoidance motivation) that flavors the whole experiential field of “people from the hideout.” As such it lies in direct opposition to formally positive hope and motivation (approach motivation) at the disposal of those driven by concern about values specified as something worthy of being accomplished, rather than merely as a state of successful (and always only temporarily successful) escape from harm and pain that may come.34
The anxious hope proper to people from the hideout is directly reflected in their typical way of interacting with others. The other, in brief, is not experienced as someone to believe or someone to whom one could entrust one’s hopes. Rather, he or she is seen as a source of potential danger: somebody who can first of all hurt us. Within such an experiential landscape it is simply too dangerous to allow another person freedom of self-expression. Rather, the person in question must remain under a constant, and constantly anxious, control. The fact that the other is denied space for his/her authentic being makes any genuine understanding inconceivable. Instead, in consequence, it is the possession of another human being or the enforcement of him or her into one’s own preconceived ways of interacting that is a default mode of making relationship tolerable.35
An instance of such a dynamic can be found in the hysterical, or histrionic as we would say today, person and his or her natural space of the theater.36 When I am an actor at the scene, the main question I am concerned with is naturally: “How am I seen by the others?” And the sole role allowed to other people at place (providing it is a monodrama) is that of a member of the audience. The space of the histrionic experience, as described by Tischner, is dangerous as it is experienced as a place at which it is nothing less than survival (even if only social survival) that is at stake. And one and the only way to survive among those who watch, or to “make a good performance,” is to gain possession of the audience, which is typically achieved by controlling their emotions. Emotional dimension of the whole interaction, in consequence, rather than belonging to spontaneous and free expression of a lively interchange between two parties involved, becomes a domain of manipulation. Only at such a cost a certainty that “performance will go well” can be achieved.
What is specific of the whole dynamics accounted for above, as emphasized by Tischner, is a deep suspicion concerning the other. His or her freedom including conscience or moral integrity are not real or reliable enough to be trusted. It is only emotions, which are at least partly susceptible to manipulation and control, that can be relied on.
Both Kępiński and Tischner can be better understood if referred to a literary resource that itself is not explicitly addressed in their writings. The resource in question is one of Fyodor Dostoevsky’s novels titled Notes from the Underground.37 And, actually, even the very title of the book (in Russian: Записки из подполья or Zapíski iz podpólʹya) is very indicative here, as the notion of the podpolje, the one translated as the “underground,” can be easily identified with Tischner’s hideout. And even if, what is more, such a translation was questioned on strictly linguistic grounds, there are ample reasons to believe that Dostoevsky’s main character, “the Underground Man”, inhibits the very same kind of experiential and/or existential environment not only Tischner, but also Kępiński and Schneider explore.
The novel by Dostoevsky is divided into two parts, with Part I - titled “Underground” – providing a kind of insight into the mind of the main character. And it seems to be a telling fact that this part is very difficult to summarize and it is especially so if it is an overall coherence that one wants to achieve. Apart from a reservoir of running themes that seem to be haunting the narrator, referring mostly to the variety of intellectual and moral dimensions on which he compares himself with others (sometimes favorably, sometimes unfavorably, always in a flux), it is certainly his great suffering that catches attention of the reader. Part I, what is more, can be not only extremely emotionally appealing (it’s not too difficult to become over-involved into the quandaries the character struggles with), but also simply frustrating if one approaches it with an intention of finding a clinically unequivocal picture or even a particular nosological diagnosis applicable to the “case” at hand. An experiential landscape Dostoevsky’s character inhibits is certainly painful, incoherent, and unpredictable and the narrative provided can certainly be pretty successful at evoking emotions of very similar qualities in the reader.
The second part of the novel, titled “A Propos of the Wet Snow,” is easier to interpret because it mostly describes particular events, which (providing a convention of literary realism) need to succumb to at least some most rudimentary rules of spatio-temporal human interactions. And, indeed, at least at the level of events, of what “happened” or could have been recorded by a camera, Part II is mostly unequivocal.
A relatively self-contained story included in this part begins with a brief incident when the main character passes a tavern and witnesses a fight, with one of the participants (“gentlemen”) being thrown out of the window. As surprising as it can possibly be, it provokes envy on the side of the narrator, who enters the tavern, but instead of being allowed to join the fight on a footing equal to the other “gentlemen” (and, if fortunate enough, even being thrown out of the window), is simply ignored and quite literally relocated. The officer participating in the fight, as the narrator relates, “took me by the shoulders and without a word – without a warning or explanation – moved me from where I was standing to another spot and passed by as though he had not noticed me.” Our character, as it should have already become clear, “could have forgiven blows,” but would not easily forget being treated “like a fly.”38
That Dostoevsky’s character is preoccupied, even obsessed, with his social image as well as comparisons with others on dimensions concerning intellectual and moral value could hardly have been omitted by the reader of the Part I. But it is only Part II, the one substantially richer in terms of external events reported, that shows how isolated his internal dynamics is from the norms and conventions proper to typical social exchange. More or less everybody is concerned about what others think about him/herself, but such a concern is usually intertwined and meaningfully connected with what other people do and say (including what they say about one’s merits). Here, the internal tragedy is in a non-trivial sense private and self-propelled.
From the point of view of the officer, as one has all reasons to think, the whole incident happened at the level beyond awareness and, experientially at least, was not different from, say, relocating a chair. For the main character, on the other hand, it was only a beginning of a long-lasting obsessive drama about taking revenge and regaining dignity. The narrator thought about such an equalizing act for days, developed a master plan of how exactly it could be enacted, went to great lengths to prepare (including the purchase of a new beaver collar, a decent hat and black gloves to make him “more dignified and bon ton”39) and finally, after several unsuccessful attempts, succeeded at what he had planned, i.e., met the officer at the Nevsky and, rather than being the first to move aside (as he had always done before), he closed his eyes and “we ran full tilt, shoulder to shoulder, against one another! I did not budge an inch and passed him on a perfectly equal footing.”40 The officer, what is important, “did not even look round and pretended not to notice it; but he was only pretending.” The narrator was “convinced” of the latter, but it is hard to say whether any reader would share this level of conviction.41
The story of taking revenge against the officer is only one, and arguably the simplest, of psychologically very rich narratives belonging to the second part of the novel. It is more than sufficient to show, however, not only how painful the inner world of the narrator must have been, but also how isolated it was from the common world and its rules concerning respect, disrespect, and “getting even.” Dostoevsky’s main character was leading the underground life and inhabited a kind of hideout, whose rules were inconceivable to those outside and, in consequence, constituted an inevitable source of innumerable clashes with the external world. What late Wittgenstein once described as logical problems of private language devoid of any stable rules and norms, became a purely, and very painfully, personal tragedy of a person held captive by his/her own hideout.42
The hideout is a place when one is not only suffering, but also at the danger of an everlasting existential loneliness. And it is not to say that others cannot approach the hideout. They can and quite often, as it seems, they will be actively invited to do so (the histrionic person, for instance, will always be in a desperate need for “the audience”). What is extremely difficult to do, however, is to enter the hideout without getting involved into its internal constitutive game. It is very difficult, more specifically, to enter the hideout without becoming an actor following its preconceived script (with the histrionic person, for instance, it would be as difficult as entering an auditorium without becoming a spectator). The people the person from the hideout tends to encounter, in result, are in most cases “the same” and these are simply those people the script allows to appear. It is in that sense that the person Kępiński, Tischner, and Dostoevsky describe is always close to being a lone prisoner of the underground.
Why to stay there, then? In order to find an answer, it may be helpful to refer to an existential philosopher and a Lutheran theologian, Paul Tillich (1886-1965) and his very insightful short book titled The Courage to Be.43 Tillich’s specific philosophical and theological background makes his views a very good candidate for mutually revealing and coherent combination with Kępiński, Tischner, and Dostoevsky. All these authors (1) share a broadly existential viewpoint, (2) are open to first-personal and descriptively thick analyses proper to phenomenological exploration and, last but not least, (3) operate on the basis of anthropological picture broad enough to cover areas not only far beyond the narrowly conceived biomedical model, but also outside the domain of what usually comes under the label of empirical science. Apart from such general affinity, it may be worthwhile to mention that Paul Tillich, after he fled from Nazi Germany to the USA in 1933, got deeply involved in a close circle of other exiles including psychologists and psychotherapists belonging to psychosocially oriented part of so-called Neo-Freudianism. And this included some very influential authors like Karen Horney, Erich Fromm, or Harry Stack Sullivan.44 It is this intellectual milieu that can be at least partly responsible for the fact that Tillich’s knowledge of then clinical theory, including writings of the above-mentioned authors devoted to the domain of personality disorders, was remarkably rich and deep.
At that time personality disorders were typically referred to via the notion of neurotic character. And it is of pivotal importance here to remember that the latter lied at the very center of Tillich’s Courage to Be. The concept in question was relatively new at the time Tillich wrote his book and had been introduced to address the question why a specific group of people is remarkably more prone to classical (and relatively transient) symptom neurosis and, even if successfully analyzed and “cured,” sooner or later comes back to the analyst with a new set of neurotic symptoms. It was the concept of neurotic character developed by Wilhelm Reich45 that was intended to both describe such a long-lasting propensity and explain it by reference to mechanisms postulated by psychodynamic theory. The notion of neurotic character, which needs to be emphasized, denotes the very same clinical phenomena that are today addressed via the concept of personality disorder and that were phenomenologically explored in the above sections.
What is of special value about Tillich’s approach to personality disorders is that it is not only rigorously psychological, i.e., addressing the mental dynamics pertaining to anxiety and courage, but also existential and, at the deepest level of investigation, ontological. It is the very structure of being, in other words, that ultimately provides a kind of matrix within which neurotic character can not only appear, but also be assigned a deeply and universally human meaning. The matrix in question can be described as that of a dialectical structure of reality within which being and non-being are integrally connected in a way in which the latter is being given full justice rather than simply reduced to the lack of the former.46 Being and non-being, which needs to be noted, even if interconnected, are not fully symmetrical. It is a positive element of being that in a sense maintains ontological priority as the one which “‘embraces’ itself and non-being.” And it is only against the background of such an ontological structure that both anxiety and courage are possible. The first as “the existential awareness of non-being” always present at the very root of everything that can become an object of affirmation, and the second as a self-affirmation “in-spite-of” everything entailed by non-being.
A somewhat relative character of non-being, i.e., the fact that it is always determined in terms of an aspect of being it “negates,” allows a classification of the phenomena entailed by the former (or the kinds of non-being). When it is an ontic self-affirmation that is being challenged, non-being expresses itself as either fate or death. In those cases when it is a spiritual self-affirmation that is endangered, it is either emptiness or meaninglessness that is experienced. Then, finally, when non-being is present mostly at the level of moral self-affirmation, the phenomena of guilt and condemnation become its specific instantiations. Out of these pairs, importantly, the first element (fate, emptiness, and guilt) is always somehow limited and relative, while the second (death, meaninglessness, and condemnation) is an expression of an ultimate or absolute danger proper to the aspect of being that it poses a threat to.
What about the courage and self-affirmation, then? How are they possible at all within the ontological structure in which strictly speaking every aspect of being is essentially endangered by its respective kind of non-being? The way towards affirmation according to Tillich, which is a crucial point to be made, is not an escapist effort to find an area free of non-being and anxiety. Such an area does not exist. Rather, every affirmation and every courage available are made possible due to the dialectical structure hidden behind the phrase “in-spite-of.” It is in spite of always present non-being and only in such a way that one can affirm both the world and oneself. In more content-related and less formal terms it is participation, struggle and love which are identified by Tillich as particular expressions of this kind of “in-spite-of” effort and, thus, as ways of conquering fear. Or, on a more general level of analysis, it is nothing less than an existential courage that is a necessary prerequisite for facing non-being one is challenged by and for achieving the only kind of affirmation available to human creatures.
When this kind of courage is lacking, and it is a separate (“etiological”) question why and when it will be so,47 a person in question is driven by so-called avoidance motivation: the avoidance of non-being gains priority over all potentially available affirmations (i.e., at the expense of approach motivation). And the only way of avoiding non-being (rather than courageously facing it) allowed by the dialectical structure of reality depicted above is by avoiding being. This kind of anxious avoidance, which is of crucial importance here, is proper not only to Tichner’s “hideout” or Dostoevsky’s “underground,” but actually identifies the most ontologically salient aspect of what once happened to be called psychopathy (Schneider and Kępiński) or neurotic character (Neo-Freudianism and Tillich). The author of The Courage to Be himself makes this point very clear when he identifies the latter condition with “the way of avoiding non-being by avoiding being.”
Character neurosis, to be sure, is not completely devoid of affirmation (otherwise it would not differ from death). Rather, it is confined to a very weak and reduced kind of self-affirmation satisfied with what is possible within a strictly defined limits of the hideout and without reliable hope for anything more. As such, respectively, the affirmation in question is rigid and ultimately out of touch with reality. It remains in a complete opposition to flexibility, openness, and realism characteristic of everything that participates in the struggles of psychologically and existentially rich life.
The analyses conducted by Tillich are of great value here because they can serve two purposes of non-trivial philosophical importance. First, they provide an ultimate ontological ground in terms of which the phenomena explored by Kępiński and Tischner and illustrated by Dostoevsky can be conceived as not only possible, but actually as belonging to the very existential fabric of a limited human creature. In such a way, importantly, neurotic anxiety and a courageous struggle to face it attain a universally and deeply human significance. And it is only against such a background that one can make proper sense of Tischner’s claim that Kępiński’s work belongs in-between the arts of medicine and ethics.
The connection to ethics, what needs to be mentioned, can be somehow alarming to those attached to the strict form of the fact-value distinction and worrying about the clinicians becoming “like priests.” And such a caution, importantly, is both understandable and justifiable. It is an upcoming task, respectively, to find a theoretically valid and clinically applicable framework within which the normative and the ethical could be consistently accommodated and, at the same time, steer clear of everything coming under the term of “being judgmental” and/or being simply harmful. Some promising attempts in such direction have already been made with a surprisingly refreshing reference to the age-long perspective of virtue ethics.48
Another issue to at least briefly address is how the account provided above can be integrated with currently applied clinical models. What has been achieved by the employment of somewhat anachronistic clinical parlance of Kępiński and Schneider, in other words, still needs to be reformulated as a valuable contribution to contemporary clinical theory and practice. Some potential, as it seems, lies in the idea of connecting Tischner’s “hideout,” Dostoevsky’s “underground,” and Tillich’s existential account with models rich enough to possess conceptual “space” for explicitly existential themes. An ample example of such a model has been developed by the existential psychotherapist Irvin Yalom, whose structure of four main existential concerns (death, freedom, isolation, meaninglessness) not only provides a natural comparison to Tillich’s kinds of anxiety/non-being, but also is consistently integrated with a specific practical framework and connected to the rich and various philosophical traditions.49 A considerably more serious challenge would be to refer the above-made explorations to accounts not only devoid of an explicitly existential or normative conceptual space, but also positively devoted to the naturalistic model of clinical science or the fact-value distinction as far as these are embodied in the ideas of evidence-based practice and applied science.50
An endeavor to develop a philosophically satisfying and clinically meaningful account of personality disorders, in result, has just been initiated. It seems, however, to hold considerable promise for the future.51
Kępiński (1974). ↑
See Kępiński (1968/2005); Ryn (1990). ↑
Respectively, Kępiński (1972); Kępiński (1974); Kępiński (1977a). ↑
Kępiński (1978). ↑
Kępiński (1977b). ↑
Schneider (1923/1958). ↑
Shapiro (1965). ↑
Kępiński’s and Schneider’s “psychopathies,” more specifically, are to be strictly distinguished from a much narrower, and closer to today’s usage, meaning assigned to the term by Cleckley (1941). ↑
Kępiński (1977b): 13–14. ↑
The epileptoid type was taken by Kępiński from a constitutional theory by Kretschmer (1944). ↑
Not all of the notions Kępiński uses can be easily, and without considerable reformulation, recognized in current classificatory systems. Those that are maintained in a relatively unchanged form include: the hysterical (under the heading of histrionic personality disorder), anankastic (obsessive-compulsive personality disorder), and paranoid (paranoid personality disorder). For a more detailed analysis see Tyrer, 2018. ↑
Ibidem: 9. ↑
Schneider (1923/1958): 2–3. ↑
Ibidem: 3. ↑
Ibidem: 4. ↑
American Psychiatric Association (2013): 20. ↑
Jaspers (1997). ↑
Schneider (1923/1958): 51. ↑
See Putnam (2002). ↑
Allport (1921), (1927); see Nicholson (1998). ↑
Charland (2008): 16. ↑
E.g. Zachar, Potter (2010). ↑
Tischner (1978/2011). ↑
E.g., APA Presidential Task Force on Evidence-Based Practice (2006). ↑
E.g., Wilson, O’Leary (1980). ↑
For an insightful critical account, see Woolfolk (2015). ↑
A respective counterexample of an external or non-constitutive connection could be found in those common cases when bioethics or professional ethics are being literally added to psychiatry or psychotherapy with all the discontinuity proper to the fact-value distinction not only maintained, but actually positively reinforced. ↑
See Fonagy, Adshead (2012) on psychotherapy as involving “calibration” or “re-calibration” of internal experience. ↑
Engel (1977). ↑
Jaspers (1997). ↑
Frankl (2014). ↑
Tischner (1978/2011): 455. ↑
Two exemplary images that could be fruitfully applied here are metempsychosis as depicted in Plato’s Phaedrus and the ideas of saṃsāra (cycle of incarnations) and bhāvacakra (wheel of life) belonging to the Buddhist tradition (for a psychological reading see Epstein, 2013). ↑
In his descriptions of the negative motivational dynamics proper to the hideout and the ways in which it differs from positive engagement into the world of value Tischner sounds interestingly anticipating of the framework proper to so-called acceptance and commitment therapy, ACT. See Hayes, Strosahl, Wilson (2011). ↑
Cf. the mechanism of projective identification, e.g., McWilliams (2011). ↑
How exactly “the hysteric” of Tischner refers to classical models of Shapiro and Schneider as well as to more contemporary dynamic frameworks remains unclear because he refers to Kępiński’s idiosyncratic and eclectic (or “common”) account only. Some features of the dynamics he describes, however, might belong to what Kernberg assigns to so-called borderline personality organization (see McWilliams, 2011). ↑
Dostoevsky (1864/1992). ↑
Ibidem: 34. ↑
Ibidem: 37. ↑
Ibidem: 38. ↑
See Gipps (2021). ↑
Tillich (1962). ↑
For a summary of their views see Hall, Lindzey, Campbell (1998). ↑
Reich (1933/1972); see McWilliams (2011). ↑
Such a “reductionist” approach could be ultimately connected to the Parmenidean tradition of thinking about Being. ↑
For a very complex issue of the etiology of personality disorders see Millon, Grossman, Millon, Meagher, Ramnath (2012) and Tyrer (2018). ↑
Waring (2012); Zachar, Potter (2010) ↑
For a useful review of his rich writings see Yalom (1998). ↑
See Woolfolk (2015). ↑
I owe a debt of gratitude to Richard Gipps and the journal’s anonymous reviewers, whose insightful suggestions and comments have enabled me to substantially improve this paper. Any shortcomings that remain are my responsibility alone. ↑
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