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Medicalizing Mental Health: A Phenomenological Alternative

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Abstract

With the increasingly close relationship between the pharmaceutical industry and the American Psychiatric Association (APA) there has been a growing tendency in the mental health professions to interpret everyday emotional suffering and behavior as a medical condition that can be treated with a particular drug. In this paper, I suggest that hermeneutic phenomenology is uniquely suited to challenge the core assumptions of medicalization by expanding psychiatry’s narrow conception of the self as an enclosed, biological individual and recognizing the ways in which our experience of things—including mental illness—is shaped by the socio-historical situation in which we grow. Informed by hermeneutic phenomenology, psychiatry’s first priority is to suspend the prejudices that come with being a medical doctor in order to hear what the patient is saying. To this end, psychiatry can begin to understand the patient not as a static, material body with a clearly defined brain dysfunction but as an unfolding, situated existence already involved in an irreducibly complex social world, an involvement that allows the patient to experience, feel, and make sense of their emotional suffering.

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Notes

  1. An earlier draft of this paper was presented to the American Society for Philosophy, Counseling, and Psychotherapy (ASPCP) at the American Philosophical Association (APA) Eastern Division Meetings in Washington DC, December 2006.

  2. P Bracken and P Thomas, Postpsychiatry: Mental Health in the Postmodern World (Oxford: Oxford University Press, 2005), p. 179.

  3. Although managed care can mean a number of things, I am using the term managed care organization (MCO) and health maintenance organization (HMO) as a reference to any large, for-profit corporations that specialize in the management and control of health care delivery through a variety of regulatory bureaucratic processes and financial strategies to solve the problems of recent health care cost escalation. See I. Miller, “Managed Care is Harmful to Outpatient Mental Health Services: A Call for Accountability,” Professional Psychology: Research and Practice 27, no. 4 (1996): 349–363 and P Cushman and P Gilford, “Will Managed Care Change Our Way of Being?,” American Psychologist 55, no. 9 (2000): 985–996.

  4. See RD Laing, The Divided Self: A Study of Sanity and Madness (London: Tavistock Press, 1960); E Goffman, Asylums: Essays on the Social Situations of Mental Patients and Other Inmates (New York: Doubleday, 1961); and M Foucault, Madness and Civilization: A History of Insanity in the Age of Reason (New York: Vintage Books).

  5. T Szasz, The Myth of Mental Illness (New York: Harper and Row, 1974), p xiii.

  6. Bracken and Thomas, p 95.

  7. F Nietzche, The Gay Science, trans. W Kaufmann (New York: Vintage Books, 1974), p. 336.

  8. To this end, I am following in a long line of criticism of mainstream psychology and psychiatry that draws on the philosophical methods of hermeneutic phenomenology. See H Dreyfus and J Wakefield, “From Depth Psychology to Breadth Psychology: A Phenomenological Approach to Psychopathology,” in Hermeneutics and Psychological Theory: Interpretive Perspectives on Personality, eds. S Messer, L Sass, and R Woolfold (New York: Rutgers U Press, 1988); R Askey “Heidegger’s Philosophy and Its Implications for Psychology, Freud, and Existential Psychoanalysis,” in Zollikon Seminars: Protocols, Conversations, Letters (Evanston: Northwestern University Press, 2001), pp 301–315; C Guignon, “Hermeneutics, Authenticity, and the Aims of Psychology,” Journal of Theoretical and Philosophical Psychology 22 (2002): 83–102; and K Aho, “Acceleration and Time Pathologies: The Critique of Psychology in Heidegger’s Beitrage,” Time and Society 16, no 1 (2007): 25–72.

  9. See P Cushman, “How Psychology Erodes Personhood,” Journal of Theoretical and Philosophical Psychology 22, no. 2 (2003): 103–113 and Cushman and Gilford.

  10. Cushman, pp 108–109.

  11. Consider the 1949 study by the psychologist Philip Ash which showed that three psychoanalysts faced with a single patient, and given identical information at the same moment, were able to reach the same diagnostic conclusion only 20% of the time. P Ash, “The Reliability of Psychiatric Diagnosis,” Journal of Abnormal and Social Psychology 44 (1949): 272–276. Cited in A Spiegel, “The Dictionary of Disorder,” The New Yorker (3 January 2005): 56–63.

  12. E Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (New York: John Wiley & Sons, 1997), p. 303, 313; P. May and H. Tuma, “The Effect of Psychotherapy and Stelazine on Length of Hospital Stay, Release Rate and Supplemental Treatment of Schizophrenic Patients.” Journal of Nervous and Mental Disease 139 (1964): 362–369.

  13. B Lewis, Moving Beyond Prozac, DSM and the New Psychiatry: The Birth of Postpsychiatry (Ann Arbor: Michigan U Press, 2006), 4

  14. H Kutchins and S Kirk, Making Us Crazy: DSM, the Psychiatric Bible and the Creation of Mental Disorders. (New York: Free Press, 1997), p. 31.

  15. The italicized words are the only changes made between the DSM-III-R and the DSM-IV. See Kutchins and Kirk, p. 268.

  16. Cushman, p. 10.

  17. Lewis, p. 4

  18. Ibid, p. 5.

  19. Shorter, p. 303. See also Kutchins and Kirk, p. 15.

  20. P Chodoff, “The Medicalization of the Human Condition,” Psychiatric Services 53, no. 5 (2002), p. 662.

  21. M Talbot, “The Shyness Syndrome,” New York Times Magazine (4 June 2001):11–12. See also Chodoff, p. 268.

  22. Kutchins and Kirk, p. 23.

  23. G Harris, “Proof is Scant on Psychiatric Drug Mix For Young,” The New York Times (23 November 2006).

  24. Ibid. See also C Benedict, “What’s Wrong with a Child? Psychiatrists Often Disagree,”The New York Times (11 November 2006).

  25. Chodoff, p. 628.

  26. Ibid.

  27. E Husserl, “Introduction to the Logical Investigations,” in The Phenomenology Reader, ed. D Moran (New York: Routledge, 2002): p. 75.

  28. E Husserl, “Phenomenology,” in The Continental Philosophy, eds. R Kearney and M Rainwater (New York: Routledge, 1996): p. 15.

  29. Cited in Bracken and Thomas, pp 118–119.

  30. Ibid, p. 119.

  31. Cited in Lewis, p. 5 (my emphasis).

  32. Bracken and Thomas, pp 108–111.

  33. F Richardson, B Fowers and C Guignon, Re-envisioning Psychology: Moral Dimensions of Theory and Practice (San Francisco: Jossey-Bass, 1999), pp. 199–236 and 290–291.

  34. M Merleau-Ponty, Phenomenology of Perception, trans. C Smith (New York: Routledge, 1962), p 73.

  35. Cushman, pp. 108.

  36. See Husserl, “Introduction to the Logical Investigations,” p. 76.

  37. It can be argued that Husserl jettisons his Cartesian view and the world-constituting role of the transcendental ego when he turns his attention to the foundational role of the “life-world” (Lebenswelt) with the 1936 publication of his Crisis of the European Sciences. See Moran, p 179 and 183.

  38. M Heidegger, Basic Problems of Phenomenology, trans. A Hofstadter (Bloomington: Indiana University Press, 1988), p. 64.

  39. M Heidegger, On Time and Being, trans. J Stambaugh (New York: Harper and Row, 1972), p. 74.

  40. M Heidegger, Being and Time, trans J Macquarrie and E Robinson (New York: Harper and Row, 1962), p. 5.

  41. In his preface to The Phenomenology of Perception, Merleau-Ponty makes this point when he says, “Truth does not ‘inhabit’ only the ‘inner man’ or more accurately, there is no inner man, man is in the world, and only in the world does he know himself. When I return to myself from an excursion into the realm of dogmatic common sense or of science, I find, not a source of intrinsic truth, but a subject destined to the world.” (1962, xi)

  42. Heidegger, Being and Time, p. 274.

  43. HG Gadamer, Truth and Method, trans. J Weinsheimer and D Marshall (New York: Continuum Press, 1994), p. 270.

  44. Bracken and Thomas explain how psychiatry objectifies the patient’s personal experience of suffering in the following way: “In psychiatry, a person might complain of feeling ‘empty’, ‘without direction’, ‘fed up’, or simply ‘miserable’. These feelings are often bound up with such things as unhappy relationships, difficult work situations or physical ill health. In the psychiatrist’s formulation, these feelings become ‘dysphoric mood’ or ‘symptoms of depression’. Painful thoughts about the possibility of ending one’s life, with all the cultural, religious, personal and family implications and nuances that such thoughts invariably bring to the fore, become simply ‘suicidal ideation’.” (2005, 108)

  45. See P Freund, M McGuire, and L Popdhurst, Health, Illness and the Body (Upper Saddle River, NJ: Prentice-Hall, 2003), pp. 147–167; SK Toombs, "The Body in Multiple Sclerosis: A Patient’s Perspective," in The Body in Medical Thought and Practice, ed. D Leder (London: Kluwer, 1992): 134; and S Nettleton, "The Sociology of the Body," in The Blackwell Companion to Medical Sociology, ed. W Cocherham (Oxford: Blackwell Publishing, 2001): 52–54.

  46. See E Husserl, The Crisis of the European Sciences and Transcendental Phenomenology: An Introduction to Phenomenological Philosophy, trans. D Carr (Evanston: Northwestern University Press, 1970), p 107, where he explains this distinction; see also K Aho, “The Missing Dialogue between Heidegger and Merleau-Ponty: On the Importance of the Zollikon Seminars,” Body and Society 11, no. 2 (2005): 1–23.

  47. M Heidegger, Zollikon Seminars, trans. F Mayr and R Askay (Evanston: Northwestern University Press, 2001), p 86, 91. See also HG Gadamer, The Enigma of Health, trans. J Gaiger and N Walker (Stanford: Stanford University Press, 1996), p. 134.

  48. It also reveals the way mental distress is embodied differently in particular cultures and historical periods. The psychiatrist Thomas Fuchs, drawing on the methods of phenomenology, has pointed out that in some cultures, depression is not experienced as an “affective or mood disorder” as the DSM claims. Rather, it is experienced solely in terms of somatic complaints of fatigue and exhaustion with little or no awareness of sadness, guilt, or anxiety that accompany the Western experience of depression.

  49. M Heidegger, The Fundamental Concepts of Metaphysics: World, Finitude, Solitude, trans. W McNeill (Bloomington: Indiana University Press, 1995), p. 67.

  50. Although Langeweile is the German word for boredom, for Heidegger (1995), the word captures many of the characteristics of depression, including feelings of emptiness, emotional flatness, and indifference to the world.

  51. Heidegger, Being and Time, p. 153.

  52. Gadamer, The Enigma of Health, p. 77.

  53. C Guignon, On Being Authentic (New York: Routledge, 2004), pp. 126–145.

  54. See Richardson, Fowers and Guignon, pp. 260–276.

  55. Gadamer, Truth and Method, p. 269.

  56. Ibid, p. 268.

  57. Ibid, p. 254. See also Moran, pp 276–77.

  58. Ibid, p. 180.

  59. Ibid, p. 375.

  60. Ibid, p. 316.

  61. Gadamer, The Enigma of Health, p. 98.

  62. Gadamer, Truth and Method, p. 109.

  63. See Cushman and Gilman, p. 986.

  64. Ibid, p. 994.

  65. Gadamer, The Engima of Health, p. 138.

  66. Heidegger, Zollikon Seminars, p. 134.

  67. Gadamer, Truth and Method, p xxii.

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Acknowledgements

I am thankful to Charles Guignon, Phil Sinaikin, and Philip Cushman for recommendations and advice regarding this paper and to two anonymous referees for helpful comments and criticisms.

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    Kevin Aho

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Aho, K. Medicalizing Mental Health: A Phenomenological Alternative. J Med Humanit 29, 243–259 (2008). https://doi.org/10.1007/s10912-008-9065-1

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