Psychiatry is quite distinct from other fields of medicine, in that the disturbances of the mind and the brain that can lead to psychiatric illness, can play havoc especially with the human capacity for a fuller life.

The judgment as to what constitutes a fuller life is not something that is always perfectly apparent.

To some, the issue ends up being a philosophic matter.

For instance, both Plato had a notions of what constituted a successful life. We can also see in other frameworks, that Homer had specific notions of this as well.

Aristotle did not, as his focus was on the enumeration of the varieties of human endevour, without making any relative judgments.

Plato, rather than defining the forms of human action, sought to determine the implications of human action, to vest them with meaning. Aristotle appears to have been interested in the categorization of human events, and avoided addressing meaning.

And yet, despite the fact that meaning does not seem to be the particular subject of medicine, perhaps we can make an exception for psychiatry, in that psychiatry examines emotions, and the sense of whether or not something has meaning is a real emotion.

The sense that something has meaning should have some sort of validity, and the dilemma is, what if a psychiatrist believes that that sense is pathologic ? To that extent, the psychiatrist is caught between making a judgment about validity and the hypothesis that the patient is only going to be able to find meaning for themselves.

And, to that extent, then, finding meaning is a joint effort, one in which the psychiatrist strives to not only help the patient discover who they really are, but also, not to skew that discovery by introducing extraneous judgments.

This is a difficult balance. The psychiatrist is put into a difficult position of helping the patient to discover real meaning, which in and of itself is fraught with peril.

For instance, we may have a patient who is an artist with an obsessional pattern, that reflects and underlying psychiatric illness, and yet, when channeled, becomes part of the artist's expressive work. Does the psychiatrist try to alter the obsessionality ? And if doing so will help the patient in other areas of their life, should they do so ?

It is at that point that we find there is a possible balance -- not between extremes in a given venture, but between separate domains of any given person's life.

In the case of the artist, as mentioned above, we would expect that there would be a balanced outcome for the different portions of the person's life.

One way to speak of achievement is in terms of goals. A goal - oriented practice of psychiatry then, focuses on the patient's goals rather than the normative judgments of the psychaitrist.

In addtion, the patient's goals need to be explored with the patient, to determine how the patient's goals match with reality. In some ways, it might be claimed that "realiity" is not out here -- what might otherwise be posited as epistimological relativism. However, in psychiatry, we are obliged to include the state of reality in the clinical equation.

For instance, if a patient comes to us with a remarkably unrealistic goa ("I want to be married to the Queen of England"), we can certainly explore that goal with the patient, but we should not expect psychiatry to move the patient towards that goal - it is unrealistic, or, if you will, not "in contact with reality".

If a patient states "I want to become an English peer", that is not really a goal -- it is a wish to enter into an identify, a wish to become something other than what we are. It certainly can be explored in psychiatric treatment, as a fantasy. So we see that "becoming" is different from "achieving".

A "becoming" is when a patient that states they wish to become a famous actor. An achievement is a patient that states they wish to learn to the lines in Othello using a certain form of poetic spoken exposition. Quite different --the two items are different things.

Of course, certain things that appear to be forms of becoming are instead fior of achievement. "I want to become a member of my chuirch choir" really means, that one wishes to take the steps neceesary to do so.

Why is the issue of achievement so critical to psychiatry ?

Here is my argument. We live in a society where achievement is devalued. Instead, our children are fed the notion that they have to "become" someone --- that there own current being is somehow devalued, and that the things that they consider important are devalued as well.

This process of devaluing the things that children know is valuable in themselves, occurs not just in schools and in the workplace, but also on the playground, as the imposition of the commerical media enforces a dicatat of how direct human experience should be devalued and replaced with homogenized consumption.

So, despite the failure being most egregious in the schools, it proceeds from the power both ofthe State and of the institutions that carry out the will of the state, especially law, the medical institutions, the police, and the military.

The best step forward that a psychiatrist can take is to allow a patient to develop the inner strengh to overcome these external forces.

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