Marcus Aurelius: reflection good enough for an emperor but is it good enough for medicine?

Sati Heer-Stavert very kindly asked my permission to link to the paper I wrote a while back on Marcus Aurelius, stoicism and reflective practice – here is the post that has resulted which I am very impressed by! Certainly Sati has provided an excellent framework to prompt students and learners to reflect on what reflection means and what the obstacles to it are….


Reflection is an important part of training, appraisal and revalidation for doctors based in the UK. However, for many doctors the very thought of reflection can cause feelings of frustration, non-engagement or even rejection. Where did we go wrong?

Learning objectives

1. Consider the definition of reflection used in medicine

2. Understand how reflection can be assessed

3. Encourage you to read Meditations by Marcus Aurelius

Oh no! A patient has complained about your refusal to supply antibiotics for a cold. Wow! This would make a really good entry in your learning portfolio:

“That men of a certain type should behave as they do is inevitable. To wish it otherwise were to wish the fig-tree would not yield its juice. In any case, remember that in a very little while both you and he will be dead, and your very names will quickly be forgotten.”

You have to respond to…

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Ultra Long Term Health Effects of Slavery

This is a post I wrote on the Economics, Psychology, Policy blog, which I got involved with via rather tangential links with  the UCD Geary Institute – Liam Delaney, who I got to know then, was then  Prof of Behavioural Economics in Stirling University and the blog seems now to be part of the Stirling course – but now it seems Liam is back in UCD!

I have a weakness for sword’n’sandal type historical fiction set in Ancient Rome. One author I particularly enjoy is Steven Saylor who writes detective novels set in Ancient Rome, which manage to combine a modern sensibility – with the archetypal cynical, Sam Spadeish detective hero – with a real immersion into the foreign world of the classical past. The most recent book of his I’ve read, Arms of Nemesis, really brought home how horrific it must have been to be a slave. And it got me thinking – millions of people, possibly the majority in the classical world (as far as I recall, the number of Athenian citizens, who were of course all free males, was a tenth of the number of Athenian slaves) lived in this state of permanent insecurity, literally dehumanised and debased.

This, to say the least, can’t help but have had some profound psychological effects. And considering that, presumably, of people alive at the present moment, a good proportion have slavery somewhere, perhaps very deep, in their ancestry, perhaps this underlies many of the enduring psychological difficulties we call personality disorders. After all, we are still only beginning to realise the intergenerational effects of traumas such as the post World War II exodus and expulsions of Germans from Eastern Europe Martin’s post on the enduring health effects of 9/11 rekindled this train of thought.

Obviously in the U.S. there’s an ongoing controversy about reparations for slavery, the assets of companies who profited even indirectly during the Holocaust, and other such issues. Perhaps we should all try and lobby the Italian government for reparations from the slave holding of the Ancient Romans!

Vampirism as Mental Illness: Myth, Madness and the Loss of Meaning in Psychiatry

This  is certainly the academic paper I have been involved with which has garnered the most media attention. Brendan Kelly and myself intended to write a nuanced paper on how psychiatry conceptualised vampirism, when it occurred as a clinical presentation, and how this changed over time. This reflected wider changes in psychiatry (and probably, though this wasn’t part of the paper, society itself) in that the meaning ascribed to symptoms was increasingly devalued in favour of a “checklisting” approach. Something similar has happened to dreams, in the psychiatric context.

Did we succeed in this? Here is the abstract :


Vampirism, as a clinical presentation, was formerly much discussed in psychiatric literature. In recent years this has not been the case. This article begins by exploring the history of vampiric phenomena and the various medical theories of vampirism. It discusses the change in emphasis in psychiatry from a psychotherapeutically-influenced exploration of the meaning of a particular symptom to a more ostensibly evidence-based, checklist approach. This reflects a wider shift in psychiatric culture. Articles from the psychiatric literature dealing with vampirism are reviewed in depth. The article argues that the clinical interpretation of vampirism may be useful as an indicator of shifting attitudes within psychiatric discourse.

And here is how The Sunday Times covered the article:


Perhaps not that surprisingly, this provoked a backlash from the online vampyre community, none of which seemed based on actually reading our article but on the Sunday Times and Irish Central’s even more misleading take. (most of the links to the vampyre forums where we were attacked seem to have broken.

Brendan has talked further about the paper in various forums such as here , and has discussed this media and online reaction.

I know How Journalism Works. I know that the headline is chosen by a subeditor, not the author of the article. I know that “Doctors write nuanced article on changes in how psychiatrists see vampires over time” is not a headline.

In a way, this coverage illustrates that for the media as well as in day to day a life, a psychiatrist is character with a somewhat predetermined role and that, if a psychiatrist is writing about vampirism, it must be through the prism of mental illness and of treatment. Even in cases where the psychiatrist is trying to do the direct opposite. Alasdair MacIntyre wrote (quoted in the blog post linked immediately above):

Contrast the quite different way in which a certain type of social role may embody beliefs so that the ideas, theories and doctrines expressed in and presupposed by the role may at least on some occasions be quite other than the ideas, theories and doctrines believed by the individual who inhabits the role.



What makes “a new mental illness”?: The cases of solastalgia and hubris syndrome. Cosmos and History, 2009. Part 3

Solastalgia and hubris syndrome considered through the prism of the contesting definitions of mental illness

Analogies can be drawn between solastalgia and post-traumatic stress disorder. Post traumatic stress disorder is a contested diagnosis within psychiatry. Many argue that it is simply a new name for a condition described by Homer (Shay 1995) and recognised by military physicians and psychiatrists under a variety of names (Shepherd 1994). Others argue that is has been “invented” for political reasons (Summerfield 1999) and reflects the subjugation of psychiatry to socio-political imperatives. Uniquely among conditions described in both DSM-IV and ICD, in its definition the cause is specified.Solastalgia would share this quality. Indeed, online commentators from the environmental movement have criticised Albrecht for the perceived narrowness of the focus and his adoption of a medical model of harm induced by environmental change.

It is of course invidious to try and predict what individual thinkers might “make of” solastalgia and Albrecht’s contention that it is a “new mental illness, ” or of Owen’s identification of hubris syndrome as potentially causing more death and disability than any other illness worldwide. However, it seems reasonable to assume that Thomas Szasz would dismiss the idea of both being “new mental illnesses” because he views mental illness itself as a myth. The problem of adjusting to an environment made strange around one is a “problem of living”, and the problem of leaders growing out of control is a political one. The use of the concept of disease in these two settings is simply an error.

Using Boorse’s framework to analyse these entities also leads to interesting considerations. One of Boorse’s initial arguments in his 1975 paper is that what gives rise to ambiguity and difficulty with mental illness is the “territorial ambitions” it has. Psychiatry is laying claim to more of life’s problems, leading to a “medicalisation of morals.” This,rather than basic definitional issues of what is a mental illness, leads to problems. In a sense Boorse partly agrees with Szasz about “problems of living” being the root of at least some “mental illnesses”—the difference being that Szasz would deem all mental mental illnesses so. This would suggest that Boorse would be sympathetic to the view that the concept of solastalgia and hubris syndrome represents medicalisation of the moral fault of man-made environmental change and of overweening power. Boorse’s 1975 argument came in two parts—by positing disease as dysfunction, it preserved a value-free status for medical and psychiatric practice and decision making, while by describing the social components of illness, it acknowledged the degree to which social practices and behaviours within a social context define illness. In the case of solastalgia, what “dysfunction” may be said to underlie the “disease process?” It is not clear, although perhaps the development of psychological assessments of Environmental Distress may aim at identifying specific thought processes. It is noteworthy that Albrecht and colleagues do not propose a “treatment” for solastalgia, but propose further research. It is not suggested that the interviewees reactions are in any way pathological, or that other reactions and emotions are more appropriate or more “functional.”

Canguilhemian notions of illness as a loss of normativity, a loss of the ability to adapt, are consonant with solastalgia’s emphasis on the distress caused by change. Canguilhem’s other emphasis on an understanding of disease that must move beyond the laboratory and detached “scientific” considerations to the setting where distress is experienced is also echoed in the solastalgia literature. Yet the use of a rating scale, with the inevitable emphasis on scores and purported norms, suggests an approach ultimately very different from that of Canguilhem.

Using Fulford’s “full field” model of mental illness, which incorporates both a “value-laden” pole of failure-of-action/illness and a “value free” or “factual” failure-of-function/disease pole, we again hit the difficulty of which, if any, failure of function is being described.There is a similarity between the approaches of Locker and Albrecht in terms of their use of interviews to discover themes in subjective experience. Using the four features identified by Locker, clearly the experiences described by Albrecht’s interviewees are negatively evaluated. They have an ongoing duration and intensity. The experience is not “done by the person experiencing it.” The “sense of injustice and powerlessness” described by Albrecht et al in their paper as characteristic of solastalgia reinforces this. However, one could observe that that the experience could be said to be due to the actions of another—for instance the mining companies. Using this approach, solastalgia describes distress rather than disease.

As for hubris syndrome, Owen suggests neurochemical imbalances that may underly the phenomenon. These are very much suggestions, however, without any definite suggestions as to what neurological circuitry is involved, for instance. Owen also writes that

Hubris syndrome is not yet a diagnostic category of accepted mental illness but it probably stems from a set of genetically codetermined predisposed personality traits. To the psychiatrist any potential new syndrome is likely to be an interaction between genes and environment or nature and nurture. Early biology and upbringing provide the basis of personality which can then be expressed, or not, depends on constraints or opportunities. (Owen, 2008b, p. 431)

While this statement is accurate, it is also extremely generalised and does not point to which aspects of “early biology and upbringing” might contribute to later hubris syndrome.

Owen locates hubris syndrome as stemming from personality traits. The implications of Canguilhem’s thinking on the normal and the pathological for the diagnosis of personality disorders has been discussed by Buchanan (2007), in particular intolerance of “the inconsistencies of the environment.” Buchanan suggests that “one testable hypothesis arising from Canguilhem’s work is that a failure actively to adapt to one’s surroundings represents the final common pathway by which narcissistic, borderline, schizoid, or other traits prevent someone from achieving his or her potential in a range of social and occupational spheres.” Owen describes a rigidity and unwillingness to reverse decisions as being among the criteria for hubris syndrome.

The distress experienced by Albrecht’s interview subjects is real. Is what they are having a “new mental illness”? While there is clearly some journalistic hyperbole at play here, and in their published papers Albrecht and his co-authors are careful to emphasise the preliminary nature of their work, solastalgia serves as a good example of how the concept of “mental illness” is discussed in the public domain. Albrecht is describing a psychological phenomenon and making a link with environmental change.

From the philosophical point of view, solastalgia is extremely broadly defined and seems synonymous with distress due to environmental changes. Albrecht et al powerfully illustrate the distress of their interviewees, but have not shown this is distress to be a mental illness. The weakness of Robins and Guze’s model of defining mental illness is illustrated by this. Essentially it depends on consensus and the acceptance of a phenomenon as an illness by the body of psychiatrists. Solastalgia, especially since the creation of a relevant and reliable rating scale, may in fact suit this definition more readily that any definition rooted in more philosophical rigour.

Similarly Owen provides a checklist of “symptoms” of hubris syndrome. Unlike what is the case with solastalgia, there is no evidence that the individuals purportedly “suffering from” hubris syndrome are experiencing any distress. The threat is more to society in general. Using Locker’s framework, the experience is not negatively evaluated by the person, or experienced as necessarily inflicted from outside on the person. Furthermore there a sense of powerlessness is not (though possibly one of injustice is) associated with the experience. Overall, then, what Owen is described is not pathological for individual but for wider society.


One could surmise that one of the motivations for developing the concept of solastalgia is to try and quantify the immediate health costs due to environmental change and further influence the arguments about environmental policy (a particular issue in Australia, which has a strong mining lobby) in the context of often rancorous debate, rather than to identify a new mental illness per se. Similarly, Owen’s identification of hubris syndrome can be seen as a plea for rule by cabinet and parliament rather than individuals, for oversight over leaders and for mechanisms to avoid the isolation and insularity that can accompany great power.

The language of psychiatry, as seen with Robins and Guze’s approach to defining schizophrenia as an entity, tends to circularity. Mental illness is treated by psychiatrists, and who are psychiatrists? They treat mental illness. This allows the language of psychiatry to be adopted as a form of rhetoric. What both Albrecht and Owen have identified are serious social problems, ones which in different ways can affect the continuance of human life on this planet. Both raise issues that are worthy of consideration by any thinking person. The rhetoric of mental illness, which of course is related to the rhetoric of illness and disease overall, is a powerful tool to raise awareness and to agitate for change. However we should be cautious of identifying new mental illnesses based purely on the laudable motivations of those who expound them.

Special Lecturer and Senior Registrar in Psychiatry
at the Department of Psychiatry and Mental Health Research,
St Vincent’s University Hospital/University College Dublin,
Elm Park, Dublin 4, Ireland.


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