International Review of Psychiatry

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Outline for a future psychiatry: the transcendent

meaning model (TMM)

James L. Kelley

To cite this article: James L. Kelley (2020) Outline for a future psychiatry: the transcendent
meaning model (TMM), International Review of Psychiatry, 32:7-8, 555-564, DOI:
10.1080/09540261.2020.1713057

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Published online: 28 Jan 2020.

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INTERNATIONAL REVIEW OF PSYCHIATRY
2020, VOL. 32, NOS. 7–8, 555–564
https://doi.org/10.1080/09540261.2020.1713057

ORIGINAL RESEARCH

Outline for a future psychiatry: the transcendent meaning model (TMM)

James L. Kelley
Independent Scholar, Norman, OK, USA

ABSTRACT ARTICLE HISTORY

The now-dominant medical model of psychiatry has recently been challenged by the post- Received 23 November 2019
psychiatry movement. However, the former discounts the agential or subjective aspect of the Accepted 3 January 2020
human being; the latter misses the axiological aspect. A new model is proposed-the
KEYWORDS
Transcendent Meaning Model (TMM)-that nests the individual person within the social (the inter-
Positive Psychology 2.0;
person), and the social within the transcendent or ideological. The study concludes that TMM, fourth industrial revolution;
with its integration of the personal, the social and the religious-ideological with the material, is theory of psychiatry;
a viable blueprint for a future psychiatry that can address some of the current model’s social psychology
vulnerabilities.

The transcendent meaning model (TMM) for
psychiatry: the person, the interperson, and
the transc-person
As psychiatry braces itself to face an uncertain future,
it finds itself caught between two paths: On the one
hand, a medical model that calls into question the
reality of the subject it is supposed to study, i.e. the
agential human (Laing, 1969); on the other hand, a
postpsychiatric model that calls into question the real-
ity of the object of the subject it is supposed to study,
i.e. the values pursued by the agential human.
Though over the last half century psychiatry has
made many advances in understanding how medi-
cines can be used to correct biochemical imbalances
(Eichelbaum, 2003; Vallance & Smart, 2006), doubts
persist as to just how far these treatments go in
reaching the root causes of mental disorders
(Baldessarini, 2014; Smith, 2012; V
azquez, 2014).
While some are unsure that the psychiatric drugs
developed over the last half-century have contributed
to any unambiguous improvement in treatment out-
comes over and above that of the previous array of
medicines (Angell, 2011a, 2011b; Deacon, 2013), other
psychiatric theorists either attempt to strike a balance
between therapy and drugs (Kiesler, 2000; Kramer,
1993, 2011), or hold out hope that mental disorders
will one day be treated by medicine alone
(Psychiatry’s identity crisis, 2012). The latter course
would presumably allow psychiatry to focus less on
therapeutics and more on health management, i.e.
getting the right medicine to the right client in a
timely manner (Detre & McDonald, 1997; Reynolds,
Lewis, Detre, Schatzberg, & Kupfer, 2009).
In light of this variance of opinion as to the rela-
tive importance of medicine and therapeutics to the
psychiatric project, the present writing proposes an
alternative vision of psychiatry grounded in Frankl
(1975, 1986) and Erikson (1968) that pain, limitation,
and suffering are necessary to personal growth in gen-
eral and to overcoming mental and physical illnesses
in particular. The suggested model will in large part
accord with Wong’s formulation of Positive
Psychology 2.0 (PP2.0), which seeks to meet the chal-
lenges of new medical and vocational technology by
reorienting psychiatry towards aiding the individual
self in achieving unity by weathering intra- and inter-
psychic conflicts (Wong, 2014, 2016, 2019).
Growing out of patients’ rights movements such as
Mad Pride, and also out of client-collaborative thera-
pies such as those provided by R.D. Laing’s
Philadelphia Association, post-psychiatry seeks to
head off any possibility of overemphasising pharma-
ceuticals through a re-emphasis on the therapeutic-
evaluative aspect of psychiatric treatment
(Brookbanks, 2014). This would be a welcome change,
except for the fact that a good deal of post-psychiatric
research tries to ground itself in postmodern theory,
specifically a Foucauldian critique of ‘power’ that
defines value as a critical decentring of any existing
sociopolitical hierarchy (Iliopoulos, 2012). Such a

CONTACT James L. Kelley romeosyne@gmail.com

ß 2020 Institute of Psychiatry and Johns Hopkins University
556 J. L. KELLEY
Table 1. The Transcendent Meaning Model (TMM) for psychiatry.
Dimension I. Person
Epistemic domain The self, or ‘what is’
Typical disorder Schizophrenia/anxiety
Perspectival orientation ‘There is something I cannot see’
Mode of ascesis Constitutional/cognitive self-limitation
postmodern post-psychiatry gets us out of the frying
pan of a supposedly value-free scientistic reduction-
ism only to plunge us into the fire of relativism, of
value as a denial of absolute value. Lyotard’s notion
of the self as a site of ‘performativity,’ as a crossroads
through which information circulates, rather than the
traditional self as a conscious, embodied meaning-
maker, is a case in point (Lyotard, 1984, p. 16), since
a number of post-psychiatric texts share Lyotard’s
notion that one can never be certain that one’s per-
spective is value- or truth-bearing; one can only per-
form the self by interlacing it with myriad other
perspectives or epistemic ‘nodes’ (Cilliers, 1998).
In this section, we will outline a third-option the-
oretical template for a future psychiatry that we have
named the Transcendent Meaning Model (TMM)
(Table 1).
TMM’s basic dimension: the person
In order to achieve a coherent understanding of her
role and purpose, today’s psychiatrist must learn to
differentiate three primordial levels of reality: that of
(1) the person, (2) the interperson, and (3) the
transc-person (pronounced: trance-person).
The most basic dimension is that of the person.
The personal sphere is centred upon the self’s proc-
essing of thoughts, sensations and ideations about
what is, that is, about what appears to the sensory
apparatus of the human agent to be processed. Unlike
the medical model of psychiatry (Fulford, 1996, p. 6),
and the methodological reductionism that often
undergirds it (Illich, 1975; Laing, 1960; Szasz, 1961;
Zigmond, 1976, 2018), TMM’s bottom floor consists
not in physical structures that reveal something ‘really
real’ that is assumed to lurk behind the epiphenom-
enal drapery of consciousness and agency. Rather,
TMM’s first level of reality, the personal, is made up
of the single, unified human agent’s conscious yet
mostly pretheoretical functioning. The signal mental
disorder of the personal is schizophrenia, in which
the person’s ability to find meaning in their everyday
activity can be disrupted, involving global and ideo-
logical distortions that filter down to the sufferer’s
individual percepts (Stanghellini, 2001, 2016). For
II. Interperson III. Transc-person
The social, or ‘what should be’ The transcendent, or ‘what is’
Bipolar/affective Paraphrenia/delusional
‘There is something we can see that I cannot see’ ‘There is something we cannot see’
Collaborative/socially normative Radical self-limitation
limitation
example, a schizophrenic can feel that every object
they perceive is disconnected from any purpose rele-
vant to human needs (Maiese, 2011, 2016), but also
think, simultaneously, that an overwhelming yet
inscrutable significance pervades inanimate objects
such as electronic devices (Doherty, 2019, p. 257).
Since the schizophrenic’s status as a person, the
wholeness of the very ‘being of [her] human being’
(Bollas, 2015: 4), is disintegrated in a manner unique
to each individual case (Sullivan, 1962), there is abso-
lutely no way to sidestep emergent levels of being
such as consciousness and spirituality in our treat-
ment of this malady (Mohr & Huguelet, 2014).
Luckily, many psychiatrists today already reject any
kind of dogmatic reductionism in their practice.
Thus, TMM is less a revolution and more an attempt
to formulate a consistent conceptual architecture to
guide today’s practitioners. Future psychiatric thera-
pies must recognise that the sense a person has of her
own wholeness is based upon her ability to construct
modules of meaning out of experiences with other
persons in disparate milieux (Mayer & Flotman, 2017,
p. 62), and to integrate these self-narrated identities
into a psychic unity that, paradoxically, retains its
integrity only to the degree that it becomes precon-
scious and thus accessible as an ‘unthought known’
(Bollas, 1987).
This person-centred baseline of TMM is concerned
with the experiencing of facts as real. How does a per-
son know their experiences are real? Through a ‘vital
enthusiasm’ (Erikson, 1968, p. 92) nourished by an
‘original impetus’ (Bergson, 1911, p. 87) or ‘Nomos’
(Kelley, 2019a, p. 3–4; Schmitt, 2003) within the
unfolding of her experience that goads her towards the
fulfilling of life-purposes. The feeling that experience is
real has to do with being able to relate one’s self to
one’s fielded sensations determinatively by submerging
the appropriate features of conscious experience so
that one may carry through everyday tasks centred
upon focal aspects of reality (Frankl, 1986, p. 51;
Polanyi, 1946, 1962, 1966, 2006, p. 72–75). Bereft of
the requisite sense of living vitality, the schizophrenic
may exhibit ‘cognitive inhibition’ (Williams, 1996),
being unable to render distal certain impertinent fea-
tures of their experience, and thus be detained, for

example, by an interminable counting of branches on
each bough of a tree that they must chop down
(Chadwick, 1997, p. 9). The varied activities that the
average human being has to perform as an integral
member of society require an almost unconscious
sense of what it means to be alive and what it is like to
orient one’s mind and body towards particular situa-
tions (Winnicott, 1945). Schizophrenia is difficult to
understand and to treat precisely because it is a disrup-
tion and a distortion of the individual’s psychobio-
logical ontology at its ineffable base (Beck, Rector,
Stolar, & Grant, 2009, p. 10). This assessment is in
keeping with the consensus among researchers about
schizophrenia’s genetic and social co-basis (Luhrmann,
2016). Other illnesses associated with the personal
include obsessive-compulsive disorder, Asperger
Syndrome, and autism. These maladies certainly have
implications for the social life of the individual; how-
ever, like schizophrenia, they impinge primarily upon
the sufferer’s basic stance as a living being towards
both animate subjects and inanimate objects, even
breaking down the barriers between what is inter-
preted as either living or non-living, either vital or
mechanical (Pepper et al., 2018; Prata, Santos Almeida,
Coelho, & Barbosa, 2017).
TMM’s Meso-Level: the interperson
The second level of reality in TMM is that of the inter-
person, the realm where the person’s internalisation of
cultural mores and natural laws is suffused with the
bizarre glow of the social, or what early sociologists
often called ‘sympathy’ (Kelley, forthcoming). Meeting
someone for the first time can conjure forth a schema
(Carlson, 2010) that combines the familiar with the
distant, an odd sensation psychologists and philoso-
phers have named the uncanny (Freud, 2003; Kristeva,
1980). We may perceive our new acquaintance to be
an absolutely unique and unprecedented interrelation,
and yet we also feel, at some level, that our newly-dis-
covered counterpart is an amalgam of parents, siblings,
former acquaintances, and even characters from films,
myths, and sacred writings (Greenberg & Mitchell,
1985). In a similar manner, we preconsciously link pre-
sent interactions with similar encounters that resemble
the here and now in some respect. This familiar yet
weird relational space is the habitation of the interper-
son, where the human being faces the paradox that, in
order to be herself, she must constantly make connec-
tions not only between persons and situations from
her memories and her present; she must also be able to
self-narrate, or process herself as an interperson: she
INTERNATIONAL REVIEW OF PSYCHIATRY 557
herself is a fragment or aspect of each and every per-
son experienced, all the while remaining an integral
personality that remains permeable without being
‘found’ in the Winnicottian sense (Winnicott, 1963, p.
184–186). That is, the interperson is related to in a
vital and meaningful manner without being fully
revealed and thus totally objectified and de-personal-
ised (Searles, 1960).
While the personal level deals with ‘what is,’ the
realm of the interperson is the realm of axiology, of
‘what should be.’ Aside from his initial insight about
the uncanny, the immanent aspect of Freud’s super-
ego concept can be seen as taking up its abode in the
interpersonal (Hall, 1956, p. 33). Human subjects
internalise the expectations of representative figures
such as parents, teachers, priests, and leaders, and
unconsciously generate a dynamic template for how
they should conduct their lives under such a kaleido-
scopic aegis (Brown, 2006; Freud, 1962). The province
of the interperson is that of vocation, of the product-
ive activity that is the prime conduit through which
an individual becomes a member of a family, a city, a
nation, and, ultimately, a world (Argyle, 1989). Thus,
the role one has in society is related to a notion of
sovereign representation: the interpersonal level is
that of seeing oneself represented by a select group of
persons who embody societal values (or, purposes
that are proper for guiding one towards role fulfill-
ment) that can be revised and approached ambiva-
lently, but which cannot be done away with by a
simple act of will or fiat (Pan, 2019; Schmitt, 1988,
p. 25–26; Schmitt, 2008, p. 59–60).
Following other researchers who have retooled
Kraepelinian nosology (Kraepelin, 1921) to fit current
clinical findings (Bemporad, 1978, p. 13–15;
Stanghellini & Raballo, 2007, p. 14), we can name
bipolar disorder as the prototypical interpersonal ill-
ness, but we should not exclude other related affective
disorders such as depression, paranoia, anxiety and
PTSD. The interperson is faced by a social other who
offers her acceptance and gratification, but who at the
same time threatens her with anxiety stemming from
shame and guilt (Hilgers, 2013); indeed, it seems that
our core emotions, the ones that centre upon our
capacity to co-create meaning socially, can best be
defined as polarities with various positive and nega-
tive sides that interpenetrate and commingle in unex-
pected ways (Mayer & May, 2019). The key is that
the interpersonal must bind together values that
define one’s personality (one’s telos or holistically-
conceived direction in the social world) with one’s
readings of specific authorities, each of whose
558 J. L. KELLEY
relation to the subject retains a sui generis quality
(Vanderheiden & Mayer, 2017). A father is not a
mother, and a biological father is not a priest or a
step-father. Or, to take an authority binary outside
the family circle: A supervisor at the worksite versus
a politician on TV-these project two distinct shades
of authority for which one must prepare a place in
the psyche.
Complicating the interpersonal picture further is
the mysterious relationship of the mother to the infant.
As Melanie Klein and many others have noted, the
mother is the primary relational object for the child,
and the father, siblings, and indeed all other authorities
are mapped onto or seen through the pattern set by
the mother’s original style of interaction (Kelley,
2019b; Spillius, 1988; Stern, 1985, p. 240–241). Thus,
the emotions and the narratives that accompany our
earliest interactions with parental authorities are the
ineluctable portal to personal wholeness and interper-
sonal integration. As social theorist Carl Schmitt once
said apropos of the Roman Catholic Church’s binding
together of patriarchy (God the Father, clergy) and
matriarchy (Mother Church, Mary the Birthgiver of
God): Even when one defies the father, one fails to
evade the mother through whom one addresses the
father: ‘Has there ever been a revolt against the
mother?’ (Schmitt, 1996, p. 8).
In light of the foregoing, a psychiatrist has no right
to intrusively scramble or otherwise disorder a
patient’s interperson; no health care professional
should impose her social ideology on those in her
charge. However, to follow TMM is to realise that
there is no clear-cut division between ideology and
practicality in the therapeutic encounter. While
Viktor Frankl may have been too idealistic in insisting
that psychiatrists can facilitate clients’ self-derived
value-adherence without injecting their own convic-
tions into the situation, he was correct in insisting
upon the client as possessing a subjective relational
space through which personal, social, and spiritual
values can be progressively grasped and incorporated
(Frankl, 2004, p. 172). This subjective space is satu-
rated with the client’s values, and must be taken as
the determining factor by a psychiatrist selecting an
appropriate course of treatment. Indeed, this theme of
patient-psychiatrist collaboration may be the most sal-
vageable aspect of the post-psychiatric perspective,
though certainly it is found also in other strands
of psychological literature such as the Sullivan
and Mitchell influenced intersubjectivity theory of
Stolorow, Atwood, and Orange (Atwood & Stolorow,
2014; Orange, 2011). Thankfully, we are far removed
from the therapeutic milieu of the last century’s
second half, when the most cited psychotherapist in
counselling literature prided himself on talking clients
out of their religious beliefs (Johnson, Digiuseppe, &
Ulven, 1999, p. 310). In place of such a value-corro-
sive approach, it seems that mutual exploration of the
patient’s process of ethic extraction (that is, of their
moving from more raw, unprocessed experiences with
authorities and peers to the formulation of values or
‘oughts’ out of these interactions) should be recog-
nised as the heart of the psychiatric project: collabor-
ation is possible between client and doctor because
every human being lives by values abstracted from
the ‘is’ of a socialisation process that is similar for
every human being.
TMM’s third level: the transc-person
The third, ultimate level of TMM is that of the
transc-person, or transcendence as it relates to the
interperson. What is transcendence? It is the collec-
tion of all of the non-immanent aspects of the super-
ego. For a religious person, transcendence is the
divinity that calls her forth to perfection and sanctity.
For an agnostic person, the transc-personal may be
the inexpressible element experienced in the psyche as
a voice that commands obedience without recourse to
mere earthly wisdom or reasoning. Accordingly, the
typical transc-personal disorder is paraphrenia, in
which the sufferer can hear voices coming from
powerful sentient presences that many religious tradi-
tions identify with demonic possession (Casanova,
2010). In the case of paraphrenia by association, the
personalities of these intermediary beings seem to be
conducted from one psyche to another (Nishihara &
Nakamura, 1993).
As we have stressed, the interpersonal centres
upon the achievement of meaningful social represen-
tation, or what we may call social object relations1,
which can be divided into the symmetrical (the reci-
procity that characterises relations to siblings, co-
workers, and fellow citizens), and the asymmetrical
(the subjection to a teacher, leader, or therapist based
upon mutual pursuit of a more purified embodiment
of socio-cultural value). The transc-personal, being
the realm of self-limitation with no hope of any con-
ventional recompense, dissolves both the symmetrical
and the asymmetrical modes of the interpersonal, just
as the shaman must undergo ‘skeletonization’ and be
re-engineered in order to bring her vision of the
Beyond to bear on society (Hopp
al, 2013, p. 8–10;
Peters, 1989). While the personal level implies

limiting one’s perception so that life-tasks can be per-
formed (Winnicott, 1963, p. 187), and the interper-
sonal level implies limiting one’s claim on meaning
through peer and authoritative collaboration (Leakey
& Lewin, 1978), the transc-personal level involves
radical self-limitation (Kelley, forthcoming).
Other TMM tier interlacings can be enumerated:
The interpersonal level is that of the son who obeys
the parent without identifying his own psyche with
the representative mental object (here the interper-
sonal unfolds the correct context for the personal);
the Roman consul who casts lots to determine when
to go to war is another example of the interpersonal,
which blends hierarchy, uncanniness, and co-efficacy
with an eye to integrating an individual into society
on the basis of shared experience of value (here the
term ‘Roman citizen’ itself reflects the distinction-in-
unity of the interpersonal-personal, for one cannot be
a citizen alone, nor can one be a Roman without alle-
giance to Roman deities). Moreover, the personal level
reflects the transc-personal in its reliance on meaning
as the experiential atom beneath which no human
reality worth the name exists.
TMM’s ensconcing of the transc-personal at the
apex of human psychic life is, among other things, a
repudiation of scientism, which is the notion that,
since there are no agents or subjects in the world, but
only objects, mathematical physics not only explains
the whole of reality, but also explains and interprets
itself (Capaldi, 1998, p. 44). But what would a consist-
ently scientistic psychiatry look like? It would require
no personal interaction, only a re-engineering of
physical particles and their forces in the hopes of
infusing more integrity into the objectified patient’s
material structure. In theory, such a job would be
best performed by an algorithm written onto a com-
puter chip, and so, if we follow scientism to its inex-
orable conclusion, this quaint pastime we call
psychiatry gracefully bows out in favour of a com-
puter-driven biophysics. However, it would be remiss
to equate science with scientism (Voegelin, 1948). A
properly conceived science is the only hope for TMM,
which will continue to depend upon psychiatry’s
ever-expanding knowledge of medicine to provide its
therapies with a dependable empirical grounding.
Implications of TMM: how do the TMM levels
interrelate, and what is TMM’s relevance to a
future psychiatry?
Each of the three tiers of TMM is a value conception
that speaks to its correlative dyad only in the context
INTERNATIONAL REVIEW OF PSYCHIATRY 559
of the individual human being who embodies the
whole triad and climbs its ascending value-ladder
throughout a lifetime. It may help to describe the
TMM hierarchy from two complementary vantage
points: (1) From bottom to top: The meaning of the
personal level’s basic experience of vital living is
found in the interpersonal level’s critical formation
and sustenance of shared value; the meaning of the
interpersonal is found in the transc-personal, where
social norms are both validated and ‘beyonded.’ (2)
From top to bottom: The basis of transcendence is
found in the social object relations of the interperson,
and the interperson can have no integrity outside of
the skin, musculature, bones, blood, nerves, and brain
that make up the human body.
A final word on ascesis and religion will round out
this section on the implications of TMM. A father ful-
fils the interpersonal by limiting his own desires for
the sake of his children, by making one-way transfers
of resources and time to ensure their sustenance and
development (Kelley, 2019b); however, transc-personal
life points towards radical self-limitation: the martyr
or the ‘holy fool’ turns all social mores inside-out by
revealing that, while necessary to sustain both bio-
logical life (personal) and social meaning (interper-
sonal), human values are provisional time-buying
measures that do not exist for their own sakes, but
rather as a middle-level between the biological and
the transcendent. In other words, sociality is both for
species perpetuation (interpersonal goal) and for the
species’ telic completion (transc-personal goal). We
must take seriously the fact that the overwhelming
majority of people who have ever been born have
believed that human existence’s immanent value is
connected to either a transcendent deity or to a pan-
theon of deities (Frankl, 1975, p. 140). Any psych-
iatrist who lacks both religious faith and agnostic
tolerance must cultivate a vicarious reverence towards
their charges’ transc-personal dimension (Bhugra,
1996); failure to do so may hamper clients’ meaning-
making capacities, and thus worsen their condition
(Bhugra & Bhui, 2001, p. 15–16). These insights that
TMM shares with other approaches will aid psych-
iatry by providing the anthropological context within
which medical technology can help to preserve and
develop human agential meaning.
Conclusion: implications and limitations of

TMM vis-A-vis pp2.0 and 4ir
TMM may assist in leading PP2.0 beyond the natural-
istic framework of most PP1.0 studies. Major PP1.0
560 J. L. KELLEY
research programmes such as those conducted by
Taylor and Seligman take no account of religious or
ideological ‘culture systems’ (Williams, 1996, p. 371),
instead defining positivity as standing ‘without any
relationship to something outside of the natural,
material order’ (Nelson & Slife, 2016, p. 3). Flowing
naturally from this methodological reductionism is
PP1.0’s tendency to zero in on ‘specific emotions,
thoughts, and behaviours rather than the whole per-
son’ (Wong & Roy, 2018, p. 145), a penchant that is
remedied by TMM’s personalistic holism, which
respects the integrity of the three primordial catego-
ries-persons, collectives, and ideologies-and yet ultim-
ately sees all three together as a perichoretic whole,
each dimension completing, interpenetrating, or
‘running around’ the others (On perichoresis or
‘mutual indwelling,’ cf. Norris, 2009; John of
Damascus, 1989: §1.8, §1.14, §4.18).
On the 4IR front, we can use TMM to cross-exam-
ine new technologies that might otherwise pass psy-
chiatric muster unquestioned. For instance, a
Canadian company has developed a ‘plush seal’ robot
companion called Paro intended as a companion for
the elderly. Paro’s computer-linked sensors learn what
actions-such as blinking, making eye contact, and
cuddling-elicit a favourable reaction, and increase the
frequency of the desired stimuli. Liang et al. (2017)
studied the effect of Paro on dementia sufferers both
in a care centre and at home, concluding that
Paro significantly improved facial expressions (affect)
and communication with staff (social interaction) at
the day care centre (Liu, 2018, p. 278–279).
The Paro study, valuable as far as it goes, stops at
the quantitative, presupposing that a more communi-
cative patient is a more content, more flourishing
patient. But what are the qualitative aspects of these
communications? In the paper’s ethical considerations
section we are informed that many of the study’s par-
ticipants, in the grip of dementia, were unable to give
consent to have Paro as their assistant rather than a
real animal companion (Liang et al., 2017, p. 3).
Thus, it is probable these individuals were not able to
determine whether or not this furry mass with eyes
that was foisted upon them was a living being. The
study reports lowered blood pressure and other signs
of stress relief in the participants, but is it not a tres-
pass against the interpersonal (and thus against the
transc-personal) to give a client a false impression of
sociality and transcendence? Liang et al. are quite
proud that automated pets such as Paro relieve both
institutions’ boards and sufferers’ families of financial
burdens (Liang et al., 2017, p. 3), but does this type
of robot health care not also have the unintended
result of severing links between clients and potential
visitors whose consciences may be falsely set at rest
knowing Paro will visit the sick for them? Moreover,
Laing et al. does not take the religious beliefs of the
participants into consideration. What would a
patient’s Orthodox priest advise on the question of
whether or not their spiritual child should spend their
last days holding a robot paw under pretences that
can only be called false?
As the Paro case indicates, the psychiatric implica-
tions of loneliness are far from straightforward
(Collins, 2018), and a 4IR future seems to promise
even more complications in this area. A major theme
in 4IR research is vocation: The workspace of the near
future is projected to overlap increasingly with domes-
tic space (Lynch, 2017; Schwab, 2016). This develop-
ment will not be a return to the ‘domestic economy’
of home crafts (Zaretsky, 1975, 2004), however, since
work will be almost completely computerised and will
not require one to be outside of the home.
What are some prospective issues that could result
from a future workspace that becomes more and
more difficult to distinguish from ‘me time’? A new
type of loneliness or solitude is likely to take hold in
a 4IR world in which human contact is being replaced
by virtual reality and computer-to-human communi-
cation. Virtual conferences are replacing face-to-face
interaction in the business world, and computer-gen-
erated communiques are becoming more common,
with ‘natural language’ technology obviating the need
to compose responses to emails beyond scanning the
program’s suggested response before pressing ‘send’
(McCarthy, 2019). Most research on the correlation
between screen time and psychiatric health has
focussed on children and adolescents, but it has con-
sistently shown that an increased exposure to com-
puter screens is
associated with lower psychological well-being,
including less curiosity, lower self-control, more
distractibility, more difficulty making friends, less
emotional stability, being more difficult to care for,
and inability to finish tasks (Twenge &
Campbell, 2018).
What happens to the subjective space of agential
values when most interactions and decisions become
directly mediated by smart-tech? It is likely that the
human interpersonal sphere, both inside and outside
the workplace, will become increasingly polluted by
computer-generated predictive suggestions. Will the
‘smart assistant’ or mental health app (MHapp)
become the 4IR superego, interfering even with the

disembodied voices of parents, culture, and the Deity?
We already wear wrist watches that record emotional
outbursts and instances of supposedly hostile verbi-
age; if and when necessary, these computerised
helpers offer personalised self-affirmations and even
auto-book appointments with therapists (Mesk
o,
2019). However, privacy rights are severely threatened
by these information-driven technologies (Yaphe,
2016). Third-party companies are receiving both
gene-based and real-time updated health records
about millions of people even as I type this sentence.
Will tomorrow’s employer be able to do a background
check that tracks how often I have become angry over
the last year? If so, would such information not be
misleading, since smart watches and other devices
often monitor a single isolated factor, such as heart
rate, and are preset with arbitrary thresholds for clas-
sifying emotions? After all, if I am afraid, focussed or
ecstatic, my heart rate can spike, with little or no
aggression being involved (Cunningham, Snyder, &
Kang, 2019). According to the TMM model we have
been outlining, it would be unjust for an employer to
deny a prospective employee a position based upon a
computerised program’s auto-booking feature, at least
without a health care professional or other authorita-
tive voice to evaluate the situation.
Woebot, one of the MHapp assistants on the mar-
ket at present, inadvertently alerts us to the danger of
assuming that robots are non-intrusive and value-free
in their interventions. In Woebot’s credo, available on
its website, the app claims that it
completely accept[s] a person’s choice to change or
not. I try to never assume that someone wants help,
so I’ll always issue an invitation … . (Woebot, n.d.).
This ostensibly non-coercive stance is called ‘sitting
with open hands’ by Woebot’s creators (Woebot,
n.d.), but we could just as easily call it ‘gentle, persist-
ent nagging,’ or ‘leaning in with a constant, gentle
shoulder-tap.’ In other words, we should direct
research towards understanding just how these com-
puterised suggestion-givers effect the mental health of
their human users (Bakker, Kazantzis, Rickwood, &
Rickard, 2016). Psychologists have recently gained
considerable insight into how interpersonal relations
can be subtly directed through offhand comments,
facial expressions, and other gestures that normally
come and go without being direct enough to call forth
a fully-fledged response (Sue, 2010). Perhaps psychi-
atric theory should follow this line of research by
examining how clients’ behaviours are effected by
app-generated directives that often are not overseen
INTERNATIONAL REVIEW OF PSYCHIATRY 561
or designed by the credentialed (Israelson-
Hartley, 2019).
In light both of our outline of the proposed psychi-
atric model, and of our discussion of the model’s
feasibility vis-a-vis new vocational and health care
technologies, we conclude that TMM, as an integra-
tion of the personal, the social and the religious-ideo-
logical with the material, is a viable blueprint for a
future psychiatry that will continue to negotiate the
relationship between medicine, therapy, and public
health concerns. What is more, as we have indicated
in our consideration both of robot assistants and
MHapps, TMM provides a person-centred perspective
from which any proposed Positive Psychology for the
4IR can be adequately vetted.
Note
1. For a Bourdieuian notion of ‘social object relations,’
which differs from the TMM version of the term
presented here, cf. Ruiz (2017).
Disclosure statement
No potential conflict of interest was reported by the author.
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