Philosophizing about mental health is a challenging thing to do. One does not want to risk denying the reality of suffering that comes to be labelled as ‘mental illness’ or ‘mental health struggles,’ whether this take the form of depression, anxiety, psychosis, or a behavioural issue. However, there are real problems with the way mental illness and its supposed inverse are handled conceptually that ought to be addressed both for intellectual consistency and so that care for those struggling can improve based on a better understanding of the nature of the struggles at hand. I argue that the disciplines presently named psychiatry and clinical psychology ought to develop into two equally valued branches of medicine and existential psychotherapy, the former dealing with physical diseases that have neurobiological correlates, the latter dealing with the phenomenological experiences of persons struggling with all manner of problems aptly called ‘psychological’ in the non-scientific signification of ‘psyche’ (from Greek psukhē meaning breath, mind, spirit, or the animating principle in the physical body (“Psyche (n.),” Online Etymology Dictionary)). I contend that the attempt to collapse these two fundamentally distinct domains into one another is problematic and far less fruitful than a framework that keeps them separate. I will complement this deliberation by discussing some cultural impacts of medicalized mental life, in particular the contagion effect and issues of personal responsibility. The goal is to show how the medical model is inadequate for addressing psychological difficulty in its many manifestations, and that this is chiefly owing to the flawed concept of ‘mental illness’ at its base.
It is hardly contestable to claim that all of mental life—everything about what we experience, think about, or believe—cannot be cleanly separated out into categories of ‘healthy’ or ‘unhealthy,’ ‘normal’ or ‘abnormal,’ ‘functional’ or ‘dysfunctional’. Neither, then, should it be contestable to assert that a project that aims to contrive categories of ‘mental illness’ that are determined to be both a) definitely dysfunctional according to some acceptable standard of normalcy and b) discrete categories that reflect real phenomena in nature, is bound to fail from the start. Mental life is just too all-encompassing, complex, and not nearly well understood enough for such a project to be feasible. Nevertheless, such a project is what is attempted in the Diagnostic and Statistical Manual of Mental Disorders (currently in its fifth edition). This is a project we can assume is ongoing given the fairly regular release of new editions with modifications made to existing diagnoses, the addition of new diagnostic categories, and the erasure of old ones. Our framework for understanding ‘mental illness’ is still evolving and is by no means an exact science. This does not by itself indicate that attempting to study the phenomena delineated by the term ‘mental illness’ in a scientific manner is an illegitimate endeavour, but it does mean that this is a question we are not unjustified in raising.
What I would like to call into question in this paper is the concept of ‘mental illness’ itself rather than the issues to do with psychiatry or clinical psychology as scientific enterprises, though of course an attack on the very concept that underpins what these disciplines aim to investigate has radical implications for them, if successful. I take Thomas Szasz’ argument that there is no such thing as an illness of the mind seriously, based on a fundamental difference in kind separating the mind from the body, and our consequent inability to ascribe anything like a disease to the mind when it is properly understood. Szasz maintains in his 1961 book The Myth of Mental Illness that nothing we presently have any knowledge about can be said to belong to the category of ‘mental illness,’ since a condition either corresponds to a disease in bodily tissue, in which case it is a disease properly understood and not a phenomenon of the mind, or it does not qualify as a medical condition, in which case it is either a ‘mental’ phenomenon (what he calls a ‘problem in living’) or it is a disease that modern medicine does not have the tools to detect and evaluate. This position does not assume that the mind and the body, or more specifically the brain, have no correlation with one another, but it does suggest that starting with the assumption that any pervasive problem an individual has must have a basis in the brain, whether or not we know about or can detect it with any current tool of measurement, is unfounded.
To be clear, I am not arguing that those conditions generally referred to as mental illnesses are nonexistent or don’t count as genuine problems, often with biological correlates, which cause individuals great difficulty. What I am contesting is the idea that anything rightly called an illness can be attributed to or localized in the mind; therefore, I am calling into question the concept of mental illness as such, as encapsulating illness of the mind, rather than either a) illness of the body/brain which affects mental functioning broadly, or b) problems in living that are circumstantially or experientially based rather than biologically based. The mind-body problem is of inextricable relevance to this discussion, as is the problem of objectivity that comes up in any science. Science is an empirical endeavour, which means it looks to the physical world for information and uses this information to build an understanding of what is ‘true’. Since the mind does not belong to the physical world in the same way that objects do, it seems perfectly clear from the start that a science (in the modern sense of the word) of mental phenomena is not possible. The mind is not a material object available for sense perception and data collection; it is that very entity which does such perceiving of other entities and which collects and analyzes data about them. The pertinent question then presents itself of whether human beings are the kind of beings that can study themselves (or their kind of being/ category of entity) in the same manner that they can study other entities, such as the body or physical elements of the natural environment. By ‘itself’ I mean the inner experience; subjectivity; the ‘mind’ as a general category, not to be equated to the individualized ‘subject;’ that same thing which engages in scientific research, poses the questions, decides how to answer them, and thinks about what the proposed answers mean. Can we engage in scientific study of that which we are ourselves? Phenomenology, at least as offered by Martin Heidegger, would answer in the negative, at least until an ontological hermeneutic of the kind of Being that human beings are (Dasein) has been given. This Heideggerian critique of science has been taken up by many scholars exploring these questions around psychiatry and phenomenology, and we will look at some of their arguments now.
In a paper entitled “Neuroscience Cannot Reach Existence,” Patrick Whitehead criticizes the neurosciences for conflating measurements with their intended objects of measurement. He argues that quantifications of neural activity and brain states may be correlated with certain mental states, but they do not tell us anything about the experiential quality of those states, which is absolutely essential to understanding them (Whitehead 162). He claims that ‘problems of existence’ have been obscured in modern forms of psychiatry and clinical psychology that overemphasize the neuroscientific side of things (Ibid.). Critical is a distinction he then draws between ‘disease’ and ‘illness’, clarifying that “[d]iseases occur at the level of objective physical reality and are discovered by the tools of experimental science (e.g., microscope). An illness is the subjective and disorienting experience of falling out of one’s normal routine and well-being” (163). Whitehead proceeds to illustrate this difference with several examples so as to reveal that science is valuable in uncovering facts about pieces of the natural world when viewed as objects, but that the meaningfulness of experiences and these same objects when viewed from the everyday human point of view, rather than through the scientist’s object-making gaze, is not disclosed in any way by scientific investigations (164-6). He writes, “[w]hen neuroscientists and others mine the nervous system in an attempt to understand existence, what they are in search of has already been lost,” alluding to how a difference in kind separates the objects of nature, including the human body and the brain contained within it, from the problems of existing which can only be characterized or understood phenomenologically (166). States of being cannot be equated with brain states. To do so is an error in understanding that tries to bridge the gap between material reality and conscious experience. Drawing from Heidegger’s criticism of psychiatry and psychological science, Whitehead asserts that we must understand psychological phenomena as psychological, as occurring within the psyche, and avoid conflating them with measurable activities of the brain (173-4).
Kevin Aho similarly critiques the medical model of mental illness through a phenomenological or existentialist lens in his 2008 paper “Medicalizing Mental Health: A Phenomenological Alternative.” Aho advocates for ‘postpsychiatry,’ an approach opposed to monolithic biological explanations for mental phenomena but which still regards psychiatry as a worthwhile enterprise (Aho 244). He cites Nietzsche in stating that human suffering is multifaceted and cannot be explained by any single framework of explanation; it can only be understood through interpretation since it lacks discoverable objective properties (Ibid.). Aho thinks that the first priority of psychiatry should not be to “identify an observable pathology that fits neatly into the ready-made diagnostic categories of the DSM”; rather, it should be “to suspend the prejudices that come with being a scientist or medical doctor in order to hear the patient describing her/his own experience” (244-45). Such a phenomenological approach to dealing with problems puts the patient’s experience first rather than attempting to convert their experience into data and filter it through the prevailing scientific model of mental illness and its categories. Instead of asking a patient questions and seeing if they tick all the boxes for a particular diagnosis, a phenomenological approach such as the one described here advocates confronting the existential problems at play head-on before jumping to any ready-made conclusions.
Reporting on the process of medicalization of psychological phenomena that has occurred over the past several decades in psychiatry, Aho is critical of the manner in which psychiatry has come to regard a wide range of unpleasant or undesirable experiences as potential indicators of abnormality warranting medical intervention (247). We might take this further and contend that it is not only the psychiatric profession that engages in this medicalization process: popular awareness of the different diagnoses that people can be given presumably gives the average individual a sense that many of her own experiences might qualify as clinically relevant or ‘pathological’, thus altering the way she experiences herself and her life. The well-documented phenomenon of social contagion lends credibility to this idea: it is commonplace to observe an increased prevalence of certain psychiatric symptoms and even diagnoses in the social networks and environments of individuals who have received some such diagnosis (Keyes 2022). This will be discussed in more depth later on.
After arguing that the mechanistic approach to psychology is unconvincing due to the nature of mental phenomena as fundamentally distinct from those of the material world, Aho forwards phenomenology as a promising methodology for building an appropriate understanding of mental life and its problems. It shows that the nature of human experience is not that of an object that lends itself to measurement, but is “always actively directed towards the world” as “an intentional directedness” that procures a world of meaning for itself (250). Heideggerian phenomenology in particular (by contrast to Husserl’s) emphasizes the importance of the world around us in defining the kind of Being that we are —what Heidegger terms “being-in-the-world” (251). We are always already involved and concerned with a world, Heidegger says, and it is only within the framework of such a world that the phenomenon of Being itself becomes intelligible (Ibid.). The world of ‘concernful involvement’ is not the same thing as the physical world of objects, but is something akin to the subjective network of meanings within which we operate as psychological beings. In this network, a pencil is not a thin piece of wood with a stick of graphite in the centre, but a tool for writing. Subjective meaning-structures are the ‘world’ within which we operate, and is the only place where the ‘mental’ can be honestly said to reside. Conflating this world with the material world is simply a mistake; it neglects to consider the kind of being that human beings are. This kind of being is named ‘Dasein’ in Heidegger’s philosophy, meaning ‘being-there’ in German, but we might also recognize it by the names of consciousness, intentionality, or subjectivity, at least for our purposes here.
Understanding the mental in this specific phenomenological sense renders the concept of ‘mental illness’ somewhat incoherent. It more or less pulls the ground of assumed objectivism in psychiatric science out from under us and forces us to consider that the mental is not a realm in which something can be ‘right’ or ‘wrong,’ ‘healthy’ or ‘sick,’ but is simply a place where interpretation occurs, things are infused with significance, and human beings operate in a directed, ‘concernful’ manner. A person’s suffering, then, becomes something that is “situated and made intelligible by her/his involvement in the world” (Aho 251). It is not the task of psychiatry to uncover ‘the truth’ about conditions called mental illnesses, because such a truth does not really exist. Rather, psychiatry should reorient itself in a manner that recognizes the sociohistorical factors that exert strong influence on its diagnostic categories, while focusing on the contextualized experience of suffering of patients (Ibid.). In similar manner to Whitehead, Aho distinguishes ‘disease’ from ‘illness’ where the former designates a biophysical phenomenon that would respond to medical treatment, and the latter describes the experiential dimension of something we might call a disorder (Ibid.). By adopting a stance more amenable to this truly psychological understanding, psychiatry could save itself from the reductionism that ails its current path and leads to undue input from the psychiatrist in shaping the way a given form of suffering is interpreted and understood. Aho remarks,
Scientific evidence is itself grounded in the embodied social experiences of a finite human life, which represent the evidence that is most familiar to us, yet it is this evidence that psychiatry increasingly overlooks. The phenomenological account of the lived-body reminds us that whatever neuroimaging reveals as a brain abnormality is experienced and understood in different ways through the ongoing, situated life of the patient (251).
Phenomenology is a crucial piece of the psychiatric puzzle, then, because it not only shows us the domain in which actual suffering occurs, but also informs us about how science itself is conducted, namely by the same kind of being which is its object of study in the case of ‘human sciences.’
Aho advocates for a kind of existential psychotherapy that allows patients to confront the “contingency and uncertainty of the human condition” rather than indiscriminately seeking to resolve discomfort with prescription drugs (Aho 252). Importantly, and in line with the aforementioned ‘postpsychiatry’ position, he does not oppose psychiatric medication altogether, but opposes its widespread and often scientifically unsupported use for any and all forms of suffering (248). Instead, the ‘life story’ must be brought back as the ‘horizon’ or framework through which patients can build an understanding of their suffering (253). Psychiatrists and patients should engage in open dialogue that seeks to determine the meaning of mental suffering, withholding all presuppositions that its meaning is predetermined or objectively existing and merely needs to be ‘discovered’ (Ibid.). On this account, the problem of objectivity in a science that takes humanity as its object is surmounted by implementing a hermeneutical phenomenological approach. This approach pairs a more fitting understanding of the kind of being that human beings are, and of the plane on which suffering occurs, with existing scientific understandings of brain activity, cognitive processes, and neurochemistry, reserving medical interventions for cases where a cause at the associated level of analysis has been identified.
I will now turn to a discussion of some of the downstream cultural consequences of medicalized mental life in an attempt to further demonstrate the need for a more phenomenologically based approach. Firstly, the widespread implementation of medical language in discussing mental life yields some troubling effects. Buzzwords related to mental health and DSM diagnoses are ubiquitous in the modern age, largely due to growing awareness and acceptance of mental illness as a real phenomenon and major source of suffering for which help is available. This may not be a negative development, of course, as a cultural shift in this direction certainly encourages those struggling to get help. Yet I believe there is a danger in allowing ourselves, as individuals and as a society, to begin conceiving of all of mental life (which really designates absolutely everything insofar as we assume a human stance, which of course we cannot help but do) in terms of ‘health’ and ‘sickness’. Suffering is a dimension of life that is real and irreducible, but this does not correspond to the medical language that seems to be applied with less and less hesitation to ‘ordinary’ problems in living as time goes on. To clarify: calling problems ‘ordinary’ does not overwrite the suffering they cause, perhaps contrary to popular belief. Whether thirty or three thousand or fifty million people suffer from something does not affect the degree of suffering that each individual undergoes, except insofar as loneliness or statistical minority makes something more difficult to overcome or deal with. But returning to my previous point—the medical model of mental illness does not only determine the ways in which conditions are researched and talked about in academia; it also affects how people in the general population think about their own mental lives, and I think there is good reason to believe that these effects are largely negative.
One such effect at the individual level is the tendency to automatically classify increases in negative emotion as a sign of ‘mental illness,’ which signifies that something is wrong with someone for experiencing a period of heightened anxiety or depressed mood, without regard for the large number of potential reasons for this emotional shift. Suspecting that one has a disorder of some kind instead of interpreting the same experiences as pointing to a problem in living in the face of which their reaction is completely normal and ‘healthy’, produces an unnecessary degree of neuroticism and mental hypochondriasis that in itself could damage a person’s functioning and even be a causal factor in their meeting criteria for a DSM diagnosis. The irony of medicalized mental life is that it may well make us psychologically ‘sicker’ by offering up a multitude of categories of pathology into which we can easily slot ourselves whenever we experience normal variations in mood and personality that accompany the ebb and flow of life. By making these categories of pathology available to the popular understanding, we become collectively ‘sicker’ by coming to identify with diagnostic categories that do not necessarily point out a problem with one’s mental or neurological functioning.
As was previously mentioned, the contagion effect in psychopathology is at this point fairly well documented, so it ought not to be ignored when discussing the cultural impacts of psychiatry. Horesh et al. (2022) found the effect to be more prominent for some disorders (PTSD, MDD) than others (psychosis, OCD), perhaps suggesting that the phenomenon at play is emotional contagion rather than behavioural mimicking (Horesh 2022). Nevertheless a huge body of social science research shows social contagion to be an empirically well-supported phenomenon, and this is worth noting when critiquing the medical model and the DSM in particular. It supports the argument, discussed previously, that medicalizing mental life encourages the interpretation of normal experiences as abnormal and pathological and that this could damage an individual’s ability to cope with the experience, since they are viewing it through the lens of something being wrong with their mind or brain rather than through the lens of a challenging event taking place in their life. A phenomenological therapeutic approach overcomes this effect by operating within the framework of assumed ‘normalcy’ rather than disorder, not reducing the fact of suffering in the process, but implicitly and explicitly helping individuals to cope with problems in living by helping them on a road to self-understanding; a road which is only ever travelled through interpretation of the ‘life story’ as Aho puts it. Mental suffering is internal and subjective and does not lend itself to objective analysis by its very nature.
Another potential cultural impact of medicalized mental life is the alteration of views of personal agency and responsibility. If something in the mind is conceived of as a disease, then the individual with the disease (or disorder) is not responsible for the downstream effects of this ‘disease,’ i.e. any behaviours that might be attributed to it. This is a point that Szasz makes throughout The Myth of Mental Illness. In medicalizing the mind through the language we use to talk about it, and in only validating empirical research that aims to uncover causal structures as an acceptable means of studying it, free will is negated partially or totally. In some sense, one is not responsible for what one does if one’s actions are deemed to be a consequence of some biological correlate or some pattern of thought that meets the DSM criteria for a disorder. Of course, in some cases this is an understandable and seemingly appropriate interpretation with mostly positive cultural consequences. For example, learning that someone has autism may lead one to interpret certain behaviours differently: a social cue that might have been taken as impolite will be attributed to their autism, which is not their fault, and so no personal grudge will be held towards the individual where it might have been otherwise. Discovering that a student has a learning disability allows teachers and school administrators to offer the necessary accommodations rather than punishing the student for struggling in school. These categories, assuming they are ‘real,’ allow for healthy sociocultural adaptations regarding personal responsibility and illness. Importantly, though, these exceptions to the usual standards of personal responsibility depend upon the diagnosis in question being a demonstrably valid explanation for the behaviour in question (the autistic person’s poor social skills; the student’s poor grades), and the exception granted must correspond to the affliction.
Even with well-supported diagnoses, people may not feel inclined to write off behaviour as a consequence of an illness because the interpersonal effects are too significant for that to be acceptable. A good example is personality disorders, particularly Borderline (BPD) and Antisocial (APD). This DSM category of disorders is particularly problematic for many reasons, and brings the issue of personal responsibility to the fore. A parent with BPD might neglect and even emotionally abuse their child, and society would not excuse this behaviour “because they have BPD”—nor should they. Yet the medicalized language for mental life would seem to lead us directly into such an implication of irresponsibility. Antisocial Personality Disorder is even more challenging, especially in those who are psychopathic. Even if a perfect causal explanation were reached for psychopathy, telling us that it is caused by a combination of interrupted development of a certain neural network during gestation and early childhood abuse, we would not for the most part be prepared to excuse psychopathic behaviour or to write it off as ‘not the person’s fault’ —our moral inclinations go too deep for this.
I am not claiming here that mental health workers or people receiving diagnoses themselves actually consciously believe that their patients/they are not responsible for themselves; I am arguing that for there to be consistency between the medical language we use and the cultural attitudes we hold toward illness, we would have to assert this. The fact that we don’t always adjust our views on a person’s responsibility for themselves indicates that mental illness is a more complicated phenomenon than physical illness, one with nuanced social impacts which strike a unique chord when it comes to interpersonal dynamics. This is a very important cultural effect of the concept of ‘mental illness’ that cannot go undiscussed. Admittedly, it is a sensitive subject, but this does not excuse us from addressing it. Again, making a pragmatic case for diagnostic categories in assessing and helping (‘treating’) people is different from the conceptual issue of whether or not such categories are real. I think there is some legitimacy to this pragmatic case, but am still inclined to believe that our ability to help people will always be hindered in the end by an approach that isn’t expressly and rigorously concerned with accurately understanding the subject matter it deals with. Medicalized mental life throws us in the deep end of the issue of free will versus determinism, forcing us to play out in real time which side of this debate we favour. Determinism at the institutional level inevitably produces downstream cultural and psychological impacts, whether these are intended or not. It is the responsibility of psychiatric professionals to be mindful of these consequences and to consider whether something might be learned from any potential harms that result (namely, that phenomenological light deserves to be shed on any and all discussions of experienced mental difficulty).
Empirical clinical psychology has abandoned anything resembling psychoanalysis on the basis that it has gained no empirical support in treating DSM diagnoses of any kind. Fearful of anything not empirically supported, psychotherapy nowadays is effectively reduced to different forms of Cognitive Behavioural Therapy (CBT). The actual psychology behind CBT (language of “core beliefs”, “negative reinforcement”, “stimulus pairing”, and so on), while seemingly quite valid and helpful, can still be viewed as a massive oversimplification of the almost incomprehensible complexity of human experience. While it is laudable to focus on “what works”, demonstrably and for most people (and this approach almost certainly reduces a huge amount of suffering by offering pre-formulated solutions to problems that have been standardized or categorized well enough to be studied scientifically), there is something to be said for continuing to confront the more complex dynamics at play in any ‘psychopathology’. Of course this is a daunting task, but that doesn’t mean it is one on which we are incapable of making progress. By safely sticking to ‘empirically supported treatments’, scientific psychology avoids addressing most of human psychology in my opinion because it is frightened of anything not backed by empirical evidence. As previously stated, this is understandable and I do not wish to write off all the work done on scientifically supported psychotherapies and the positive effects these therapies have had on people’s lives. I am simply pointing out the important fact that in totally sidestepping anything psychoanalysis-adjacent (meaning therapeutic approaches that have their grounding in the life story, in the individual’s direct experience of life), we miss out on a huge amount of untapped potential for both understanding ourselves and helping people address their most profound personal issues. This is where ‘non-traditional’ psychotherapy departs from empirical psychology, and we are left with a deep schism in the present day between scientific and nonscientific approaches to ‘curing’ the human mind. Reconciling this schism is important for the future of mental health care, and if they cannot be reconciled, allowing the two parallel fields to flourish in equal measure may be a happy solution. The details of this resolution have yet to be configured.
This paper has examined the tension between biomedical psychiatry and phenomenological approaches to mental wellbeing. We explored the concept of mental illness as forwarded by scientific psychiatry and demonstrated that it is problematic on the basis of the mental being the proper domain of phenomenology rather than psychological (or any) science. Further, we argued that difficulties occurring in the mental domain are not successfully dealt with by medical interventions owing to the different levels of analyses at play: one physical and object-focused, the other experiential and intrinsically subjective. Finally, we discussed some of the pertinent cultural consequences of the current psychiatric paradigm with an eye to demonstrating that phenomenology is a necessary supplement to psychological sciences in dealing with problems typically placed under the umbrella of mental illness or disorder.
Works Cited - Bibliography
Aho, Kevin. “Medicalizing Mental Health: A Phenomenological Alternative.” Journal of Medical Humanities, Vol. 29, (July 2008), pp. 243–259. Springer Link, https://doi.org/10.1007/s10912-008-9065-1. Accessed 14 April 2022.
Creegan, Robert F. “A Phenomenological Critique of Psychology.” Philosophy and Phenomenological Research, Vol. 9, No. 2 (Dec., 1948), pp. 309-315. JSTOR, https://www.jstor.org/stable/2103399. Accessed 14 April 2022.
Horesh, Danny, Ilanit Hasson-Ohayon, and Anna Harwood-Gross. 2022. "The Contagion of Psychopathology across Different Psychiatric Disorders: A Comparative Theoretical Analysis" Brain Sciences 12, no. 1: 67. https://doi.org/10.3390/brainsci12010067
Keyes KM, Shaman J. Contagion and Psychiatric Disorders: The Social Epidemiology of Risk (Comment on “The Epidemic of Mental Disorders in Business”). Administrative Science Quarterly. 2022;67(1):49-55. doi:10.1177/00018392211067693
“Psyche (n.).” Online Etymology Dictionary, 14 Oct. 2021, https://www.etymonline.com/
/word/psyche.
Szasz, Thomas. The Myth of Mental Illness. Harper Perennial, 2010.
Whitehead, Patrick. “Neuroscience Cannot Reach Existence.” Phainomena, Vol. 29, (June 2020), pp. 161-174. Phainomena, http://www.phainomena.com/wp-content/uploads/2020/07/7_E-PHI_29_112-113-Whitehead.pdf. Accessed 20 April 2022.
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