Second Reader: Aukje van Rooden Date: 18-08-2020
The Problem of Personhood
An Existential Approach to Self-Ambiguity in the Context of Psychiatric Disorder
Research Master in Philosophy Faculty of the Humanities University of Amsterdam
Acknowledgements
First and foremost I want to thank my supervisor Maarten Coolen. Your conscientious feedback and attention to detail were of tremendous help in writing this thesis. Moreover, I want to thank Aukje van Rooden for being such an important source of inspiration and support over the course of this master program. Sanneke de Haan, thank you for our inspiring and encouraging conversation on this topic. Hopefully, there will be many more to come. A special thanks goes out to my mother. Thank you for so bravely sharing your feelings and experiences with me and for inspiring me to write this thesis.
Table of Contents
Introduction 5
1. Fathoming the Problem of Self-Illness Ambiguity 10
1.1. What is Self-Illness Ambiguity? 10
1.2. The Frailties of Medical Discourse in Psychiatry 18
1.3. Phenomenology: A Promising Alternative 26
2. From Selfhood to Personhood 37
2.1. Rephrasing the Issue: Beyond the Dichotomy of Disease 37 2.2. On the Shortcomings of the Notion of the Self 44
2.3. On the Significance of Personhood 52
3. Regarding the Vulnerable Human Being 61
3.1. On the Ontological Fragility of Personhood 68
3.2. Personhood in Psychopathology 70
3.3. Self-Illness Ambiguity: In-Between Acting and Suffering 75
Conclusion 82
Literature 85
Introduction
Eternal tourists of ourselves,
there is no landscape but what we are. 1
- Fernando Pessoa, The Book of Disquiet
As a daughter of a loving mother with bipolar disease, the question of the relation between her illness and who she is, emerged on numerous occasions throughout my childhood. Growing up, my mother was always by my side and for a long time, my relationship with her was the most intimate thing I knew. Yet, despite our closeness, I struggled to understand who my mother actually was. In moments, the intimacy of our relationship was troubled by the alienating experience of not being able to recognize her in her thoughts and actions; they could be in complete discordance with the woman I held her to be. Was it really she in the moments that she could only talk downheartedly and lost her interests in the things and people she usually cared for so deeply? Was it really she in these manic moments when her conscientious way of doing things made way for impulsive decisions? These alienating moments I could understand only in terms of the mental illness that burdened my mother’s day-to-day existence. Yet, simultaneously I was unable to draw a line between where my mother stopped and the illness began.
The ambiguous relation between a person and her mental illness is a problem deeply affecting the mentally ill person and her loved ones. As psychiatric disorders pertain to how a person thinks, feels or acts, it is no longer clear which thoughts and feelings are genuine expressions of who one is, and which are expressions of one’s disorder. In 2007, this problem between distinguishing oneself and one’s illness was brought to the fore by psychiatrist John Sadler, who labelled it ‘self-illness ambiguity’. Since then, this problematic has sparked
increasing interests within the psychiatric field. It is considered a key problem to patients, since being able to reconceptualize one’s self, to define who one is in the context of a mental health condition, is a core component of recovery and a non-ambiguous self-experience and self-understanding is crucial for attaining a sense of authenticity. As such, an ambiguous 2 self-illness relation is thought to severely contribute to the complexity and vulnerability of the lives of people with mental disorders. Simultaneously the question of the self-illness relation is a question crucial to the field of psychopathology and psychiatry as a whole. The 3 questions raised within the intimate sphere of someone coping with mental illness essentially come down to an interrogation of the fundamentals of psychopathology. They relate to complex conceptual issues such as: “What is an illness?” “And what does it mean to ‘be oneself’?”
In this thesis, my concern lies primarily with the people suffering from mental illness, who find themselves in the predicament of having to live a meaningful life while a lasting and arduous kind of self-ambiguity seems inescapable. My project commences from the basic assertion that t he experience of a fundamental puzzlement that people with mental illness go through, relates to a deficiency of high-quality care for their self-understanding on an existential level. People with mental illness struggle in defining their self-illness relation, as this relation is necessarily ambivalent: while mental illness is alien in some aspects, it
simultaneously belongs to a person in others. In this thesis, I will indicate that existing approaches addressing the problem of self-illness ambiguity have not paid sufficient attention to the dialectical relation of selfhood and otherness constitutive of our personal identity. As such, they are unable to comprehend the ambivalent nature of mental illness as both belonging and alien.
2 See: Beate Schrank and Mike Slade, “Recovery in Psychiatry,” Psychiatric Bulletin 31, no. 9 (2007): 321–25;
Alexandre Erler and Tony Hope, "Mental Disorder and the Concept of Authenticity," Philosophy, Psychiatry &
Psychology 21, no. 3 (2014): 219-32.
3
For this reason, I will construct an alternative approach to the problem of self-illness ambiguity based on the notion of ‘personhood’. So far, the concept of personhood has received very little attention in contemporary psychopathology. Yet, I believe that a full-fledged account of what it means to be a person will provide a deeper understanding of what it means to cope with mental illness and can uncover the different aspects contributing to the fundamental existential fragility of mentally ill persons. My approach will be based primarily on the theory of personhood offered by the French philosopher Paul Ricoeur. Ricoeur’s philosophical efforts lie in dismantling the illusion of an autonomous, self-transparent self. Human selfhood is, according to Ricoeur, fundamentally fragile and opaque due to the continuous eruption of otherness in the heart of the self. The notion of ‘personhood’ pertains to the task of coping with this fragility; it denotes the existential project of reappropriating the self through this dialectic of selfhood and otherness constitutive of our personal identity. Ricoeur’s understanding of the fragility of personhood, I
will argue, must be considered as the point of departure for understanding mental suffering more generally and the problem of self-illness ambiguity in particular.
The structure of my thesis will be the following: in the first chapter I will introduce ‘self-illness ambiguity’ and consider existing approaches to this problem. I will start by looking at the conclusions of qualitative, empirical research and testimonies of persons with mental illness to give an account of the experience of self-illness ambiguity. Subsequently, I will assess two dominant approaches, medical psychiatry and contemporary phenomenological psychopathology, for their capacity to address this intricate issue. Here, I conclude that while the predominant medical discourse even seems to contribute to this problem, the phenomenological approach offers a more promising outlook as it stresses the value of subjective experience. However, due to an Husserlian idealist tendency in the
contemporary debate, it struggles to incorporate the more explicit self-relating aspects of mental suffering.
In the second chapter, I will delve into the subject more deeply by considering the existing research in phenomenology on ‘self-illness ambiguity’. Here, I will reveal that many phenomenological contributions to psychopathology revolve around one central notion: the ‘self’. This notion however, comes with limitations in relation to the problematic of self-illness ambiguity. Particularly, it might obstruct an understanding of the ambivalent status of mental disorder as both belonging and alien, as it struggles to recognize our sense of self as the outcome of a dialectic of selfhood and otherness. Therefore, I argue that doing justice to both the intimate and alien nature of mental illness and thereby of the very structure of personal identity itself, means going beyond the notion of selfhood and towards the notion of personhood.
In the third and final part of the thesis, I will construe how the concept of personhood offers a fruitful basis for an existential approach to the problem of an ambiguous self-illness relation. I will underscore the importance of Ricoeur’s ontological view of the human being as fundamentally broken or shattered. His view of personhood allows us to explore the ways that our experience of being a self is troubled by an otherness that challenges our understanding of who we are. Importantly, Ricoeur’s understanding of personhood is rooted in the various ways in which our biology challenges our experience of being an autonomous self. Furthermore, as personhood is a normative notion based on an act of recognition, the notion reveals that our own identity forms a ceaseless task. Thirdly and finally, Ricoeur’s account of personhood helps in our understanding of the suffering in mental illness by conceiving it as an integral and highly personal aspect of human existence.
Finally, I wish to remark that mental illnesses can, on the basis of their severity, chronicity, and other features, vary in their perturbation of the personal self. In this thesis, I will limit myself to discussing examples of either unipolar or bipolar depression. This is first of all, since most of the existing research on this topic involves either one of these types of mood disorders. The second reason is more fundamental; both unipolar and bipolar depression prove suitable for this inquiry into the problem as self-illness ambiguity, as they are affective disorders that present themselves as life-long, chronic conditions, with severe alterations that can happen gradually. As such, these affective disorders are exemplary for the ways in which severe mental illness can pose an alarming threat to the self.
1. Fathoming the Problem of Self-Illness Ambiguity
In this chapter I will outline the general problematics of self-illness ambiguity and assess two dominant approaches to psychiatry, the medical and phenomenological model, for their capacity to address this intricate issue. In the first section, I will try to establish an account of what self-illness ambiguity is, and more specifically, what it means to a person who regularly experiences this form of ambiguity. Self-illness ambiguity, in this context, arises as an existential problem that shapes and conditions the life of a person with mental illness. In the second section of this chapter, I will explain how the medical approach to psychiatry presents a normative and productive discourse, based on the concept of disease, that severely contributes to the problematics of self-illness ambiguity. Finally, the phenomenological approach to psychiatry will be discussed as an alternative to the preeminence of this medical model. Phenomenology, I argue, offers a very valuable perspective on psychiatric issues as it takes the subjective experience of patients as its primary concern. Nevertheless, I will show that the predicament of self-illness ambiguity still forms a profound challenge to the phenomenological method, as it struggles to integrate some central, more reflective aspects of our personal identity.
1.1. What is Self-Illness Ambiguity?
Mentally ill people face a lifelong task: to make sense of who one is in the context of one’s mental disorder. This task proves extremely difficult: people with mental illness cannot “accept at face value their knowledge of their self and knowledge of the world”. Self-illness 4 ambiguity is the name identifying a large portion of the ambiguities a mentally ill person is confronted with. Yet, it does not refer to a univocal problem. Self-illness ambiguity concerns the ever-shifting relation between oneself and one’s illness. As such, it refers to an intricate problem in which many aspects of one’s self and of one’s relation to the world are involved.
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The question of ‘who one is’ in relation to one’s illness is tied up with a lot of questions concerning among others central notions to our identity such as autonomy, responsibility and authenticity. Furthermore, there are numerous factors, conceptual, epistemological and contextual, complicating this question. In this section, I will limit myself to giving a general outline of the lived experience of self-illness ambiguity. As my effort in this thesis lies in a better apprehension and better support for people experiencing self-illness ambiguity, its success depends largely on providing a clear account of the meaning of this experience. It is for this reason, that I have established a general definition, based on different testimonies in qualitative research, comprising four central aspects of this experience:
Self-illness ambiguity is (1) a form of alienation, which (2) manifests itself explicitly on a conceptual level, resulting (3) in a lifelong existential predicament in which (4) the question of the relation between one’s self and one’s illness presents itself repeatedly in normative contexts.
While this definition is not exhaustive in describing a very complex existential condition, I think the four aspects I have mentioned serve in providing a rather integrated account of the experience of people with mental illness. In the following sections, I will consider the meaning of these aspects thoroughly.
Self-Alienation
Bipolar disorder is a disease that for me, literally steals me from myself, a disease that executes me and then forces me to stand and look down at my corpse. It is what the criminal lawyer in me calls a medical examiner’s antithesis: life by strangulation. 5
5 Jennifer P. Wisdom et al., “‘Stealing Me From Myself ’: Identity and Recovery in Personal Accounts of Mental Illness,”
These words, uttered by a middle-aged man, a criminal lawyer, suffering from bipolar disease, bring out the troubling experience of being bereaved from who you are by one’s disease. In different qualitative researches, it has been shown that people with bipolar depression or unipolar depression, experience on a regular basis feelings of confusion, contradiction, and self-doubt, which obstruct them in establishing any continuity in their sense of self. A participant of a research conducted by Maree Inder with bipolar patients on 6 the continuity of the self, stated for example: “Like I actually don’t know who I am. There’s a few kinds of core things, but it’s almost like my personality was grappling with my mood.” 7
These feelings of a loss of self, or self-alienation can be better understood by considering the philosophical account of self-ambiguity given by Roy Dings. Self-ambiguity, according to Dings, is concerned with how a person experiences something “in terms of how this relates to oneself or ‘who one is’”. Self-ambiguity thus concerns the sense in which some action or 8 feeling seems to ‘belong’ to the individual. For every person, this sense of belonging, according to Dings, can differ greatly: “For instance, writing papers might be typically felt as being internal to me, but might become less internal if I am mourning a loss or if I am moving houses.” The sense of belonging can change when either our ‘self’ becomes 9 ambiguous (this happens for example, when we experience big life events, such as that we fall in love or lose a loved one) or when that to which we relate is ambiguous (for instance in the case of a complicated friendship). In these cases, we speak of a loss of ‘mineness’, a loss of a feeling of familiarity and of things ‘making sense’. Importantly, Dings stresses that usually we experience an action or feeling, neither as fully belonging to us nor as completely alien,
6
Maree L. Inder, ""I Actually Don't Know Who I Am": The Impact of Bipolar Disorder on the Development of Self,"
Psychiatry 71, no. 2 (2008): 123.
7 Inder, “I Actually Don’t Know Who I Am,” 128.
8 Roy Dings, “Not being oneself? Self-ambiguity in the Context of Mental Disorder,” (PhD Diss, Radboud University,
2020): 45.
9
but as somewhat in-between these two states. Consequently, self-ambiguity is a familiar experience to everyone: it forms an inevitable part of a person’s day-to-day existence.
As self-ambiguity, which is accompanied by feelings of self-alienation, depends on both the ambiguity of a person’s selfhood, and that to which the self relates, we can fathom why people with mental illness are especially prone to this experience. For people with mental illness, their self-understanding as well as their relationship to the world can be radically altered. Their sense of self can be thoroughly interfered with by changes of mood. Furthermore, the things to which they relate can appear more frequently ambiguous as well, because the things people with mental illness relate to are either inherently more complex (such as their diagnosis) or become more complex due to their illness (such as their intimate relationships with others). Finally, people with mental illness experience collateral forms of self-alienation as a result from dealing with their illness. Psychiatrist David Karp mentions “a usually lifelong career of finding fitting medical experts” and “mind-altering medication” as important sources of alienation in the lives of people with mental illness. 10
Conceptual Confusion
I suffer from depression. So the doctor said. So he continues to say.. These days it's getting easier to believe him and take the medicine I have, but it's taken a while to get here. When the doctor first told me I was depressed, I was puzzled. Of course I was depressed. I was often depressed, loads of times, ever since I first learned the word. But I certainly wasn't depressed.
11
This woman, who writes under the name of Ruth Henry, is trying to come to terms with her diagnosis in a beautifully written personal account of her illness. She struggles to align her diagnosis, and the accompanying descriptions of depression in the DSM, with her
10 David Karp, “Illness Ambiguity and the Search for Meaning: A Case Study of a Self-Help Group for Affective
Disorders,” Journal of Contemporary Ethnography 22, no. 1. (1992): 148.
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self-understanding. The woman clearly doubts about what a depression is, about who she herself is, and she switches in her text between various conceptualizations of both. Hence, the woman's testimony exposes the conceptual problems at work in the condition of self-illness ambiguity.
Generally, self-illness ambiguity is thought to occur on two ‘levels’, resulting in two types of
self-ambiguity. Firstly, a person experiences on an experiential, phenomenological level12 some form of estrangement: a person might feel lost, or not like herself. Importantly, nearly all patients respond to these feelings of alienation or inauthenticity, by trying to make sense of them. Now, the self-illness ambiguity will occur on a reflective, conceptual level: a person feels prompted to ask questions about who she is, and in what way she relates to her illness. In the text by Henry for example, the woman wonders whether to consider her depression as a disease entity coming from the outside, or rather as something intimate that permeates the very core of her being.
Dings underlines that the self-illness relation is generally considered a diachronic process: a person experiences different phases in which her understanding of the self is continuously revised. Usually, the moment of diagnosis is deemed to mark a critical moment in the13 person’s process of trying to identify and interpret the meaning of one’s own experience. 14 Yet, it never stops there. A remark of a person with bipolar disease in a self-help group, indicates that coping with an ambiguous self-illness relation involves an ongoing interpretation: “I'm trying to discover my basic personality aside from the disease. That's why I'm at these meetings, to discover which is which.” While self-illness ambiguity always comprises 15 experiences of alienation on an experiential level, it is on the conceptual level that the
12
Dings, “Not Being Oneself,” 16.
13 Dings, 65.
14 David Karp, “Living with Depression: Illness and Identity Turning Points,” Qualitative Health Research 4, no. 1.
(1994): 6.
15
problem of the coherence of personal identity takes on an explicit form. These conceptual complications (the impossibility to distinguish between who one is and the illness, the difficult question of what ‘mental illness’ or ‘identity’ actually is) are largely responsible for making the predicament of people with mental illness so highly complex.
Existential Predicament
Because you think you know who you are and you think you have an identity and the identity has been molded from your depression which you’ve had for over a year. 16
In a research conducted by Inder, a participant suffering from depression expresses how his identity seemed to have become indissoluble from his depression. This intertwinement of one’s personal identity with his mental illness points to the profound existential dimension of self-illness ambiguity. In the previous section I have stated that the self-illness relation forms a diachronic process; self-illness ambiguity means a lifelong questioning of the relation between oneself and one’s illness. The research of David Karp has been pivotal in showing not merely the diachronicity of this process, but also the entanglement of the questioning of this relation between oneself and one’s illness to fundamental, existential issues.
The existential dimension of self-illness ambiguity is illustrated by a research David Karp conducted, in which he participated in and reported on the sessions of a self-help group for people suffering from unipolar and bipolar depression. As the title of his paper “In Search for Meaning” suggests, the central object of his inquiry is the participants’ quest to find ways to live a meaningful life despite the “uncertainty, ambiguity and lack of clarity” of their predicament. Regularly suffering from depression himself, Karp carefully investigates the17
16 Inder, “I Actually Don’t Know Who I Am,” 129. 17
ways in which the participants are collectively creating explanations, understandings and common "illness ideologies" in order to impose some order onto a hazy and ill-understood life condition.” 18
Karp’s research therefore exhibits how self-illness ambiguity is a predicament with a profound existential dimension. People with mental illness are bewildered in their existential orientation: their sense of the reality of the world, and of their situation in the world is put at serious risk by their illness. They have life situations that require far more definitional 19 efforts than others. While every human being contemplates her own sense of identity and 20 her place in the world, the answers to these questions are less self-evident in the context of mental illness. Accordingly, for people with mental illness contemplating these questions becomes a ceaseless task.
Normative Question
You do feel like you’re actually yourself finally and the self you are on that day is just amazing, you can do anything you want and it’s great. 21
But it’s not me. It’s not who I want to be or anything of the sort. 22
These two testimonies, from different participants in a research conducted by Inder, present an elementary form of identification: one person positively affirms her state of being, stating that she finally feels herself, while the other disassociates herself from a negative experience saying ‘it’s not me’. “That’s me” or “that’s not me” are mundane and simple assertions we make implicitly or explicitly on an almost daily basis. Saying “that’s me” or rather “that’s not me”, in regard to your own actions or feelings is not a descriptive act: how could your actions
18
Karp, “Illness Ambiguity,” 140.
19
See: Matthew Ratcliffe, Feelings of Being: Phenomenology, Psychiatry and the Sense of Reality (Oxford: Oxford University Press, 2008).
20 Karp, “Illness Ambiguity,” 166.
21 Inder, “I Actually Don’t Know Who I Am,” 129. 22
- in a descriptive sense - not be your own? Instead, these statements reveal that personal identity is a normatively loaded issue.
People with mental illness struggle more than others in upholding a positive sense of self, as their illness brings upon them a lot of stigma. There are all kinds of stigma associated with 23 mental illness, and both unipolar and bipolar depression are met with different biases. In her book Bipolar Expeditions, Emily Martin interrogates the forms of stigma associated with bipolar disease. Most importantly, she notes how being known as a manic-depressive person “throws one’s rationality into question”. Here, Martin addresses perhaps the most relentless 24 form of stigma against all of the mentally ill: while the ontological and legal status of the mentally ill has shifted over the years, there is still a powerful divide that demarcates the “irrational people” from the rational. In addition, people with mental illness have - more 25 often than others -“biographies littered with failures.” People suffering from mental illness 26 often have stories of failed marriages, alienation from family and friends, or broken work histories. These negative experiences of the past can hinder a person in maintaining a positive self-image.
This struggle in upholding a positive sense of self is reflected in a person’s coping with an ambiguous self-illness relation. In his research conducted with the self-help group, Karp notes how people adopted different strategies in order to feel positive about themselves. A common strategy is that of victimisation: by seeing yourself as biochemically sick, you become absolved from the responsibility for your own actions. Yet, this strategy proves far from ideal: by considering yourself as a victim of a disease, you remove your own sense of agency. Other people instead preferred to positively identify themselves with their illnesses,
23
See: Talia Weiner, “The (Un)Managed Self: Paradoxical Forms of Agency in Self-Management of Bipolar Disorder,”
Culture, Medicine, and Psychiatry 35, no. 4. (2011): 448-483.
24 Emily Martin, Bipolar Expeditions: Mania and Depression in American Culture (Princeton: Princeton University Press,
2009), 6.
25 Weiner, “The (Un)Managed Self,” 453. 26
highlighting that for them, their depression was also responsible for the positive sides of their character, such as being a sensitive or creative person. 27
Moreover, the self-illness relation is continuously altered as a person navigates in different normative contexts. Different situations appeal to different virtues a person wishes to see reflected in her personal identity: sometimes the feeling of wanting to be a healthy human being incites a person to identify with her condition and see it as a positive disposition rather than an illness, while at other times a person might refuse the responsibility for the failure of an important life project by attributing this failure to their illness. To be a person (from the latin persona which means ‘mask’) and to have various roles in life, of being a mother, a friend or a student, means for every human being, to have to deal with a range of different expectations which cannot all be met. It is within these normative contexts that every person must navigate one’s sense of identity. This task, that is challenging to everyone, becomes even more strenuous under the condition of mental illness.
1.2 The Frailties of Medical Discourse in Psychiatry
In the previous section, I have given a general outline of the experience of self-illness ambiguity based on several personal accounts. In this section, I will consider the different ways in which self-illness ambiguity is shaped by the predominant medical discourse in psychiatry. Firstly, I will explain through the work of Antoine Mooij how this discourse constitutes a very particular, productive outlook: medical science does not merely describe, but also produces a certain reality. Secondly, I will discuss the implications of this discourse for the problem of self-illness ambiguity.
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Psychiatry as a Medical Science
Throughout history, psychiatry has been influenced by both the natural sciences and the humanities. However, nowadays psychiatry has seemed to neglect its background in the humanities, in favour of a strong orientation towards the natural sciences. Although the 28 predominance of ‘medical psychiatry’ is common knowledge, it is less clear what we actually
mean by it. What do we refer to when we speak of ‘medical psychiatry’? Is this phrase even supported by a coherent conception or vision? In Psychiatry as a Human Science (2012) philosopher Antoine Mooij interrogates the unity of medical science as a whole: as we find a “multitude of themes” in medical science, the unity of medicine as a discipline is not self-evident. Mooij, in the end, locates the unity of the medical discipline, not in the29 subjects of medicine, but rather in one unifying principle: the concept of disease. The concept of disease, Mooij concludes, referring to “an underlying, essentially somatic event exposed by the symptom”, is what brings medical science into being. 30
Underlying Mooij’s inquiry into the nature of medical science are insights from the Neo-Kantian philosopher Ernst Cassirer on the very idea of science. Cassirer famously stresses that there is no immediate way we can know reality: the only access to reality is through the symbolic. Along these lines, Cassirer felt that science in its modern form does not offer a mirror of nature. On the contrary, it generates a “theory-dependent scientific 31 world view, disregarding aspects of the real which cannot be integrated in its conceptual scheme”. Science, argues Mooij, is a form of symbolisation, which just as any form of32 symbolisation, is always one-sided and leaves a residue, to be symbolised by other types of discourse. However, this residue is arguably more pervasive in science, than for example in33
28 Antoine Mooij, Psychiatry as a Human Science: Phenomenological, Hermeneutical and Lacanian Perspectives
(Amsterdam: Editions Rodopi, 2012), 13.
29
Mooij, Psychiatry as a Human Science, 3.
30 Mooij, 5. 31 Mooij, 8. 32 Mooij, 8. 33
natural language. While language offers a symbolisation through a content-wise conceptualisation of everyday reality, science presents a process of formalisation. In 34 science, phenomena are analysed in formal elements, that are either present or absent. This formalisation is no longer related to the fullness of everyday lived experience, but is strictly aimed at functionalisation. Thus, as science offers a form of symbolisation based on a formal abstraction of everyday reality, it necessarily neglects the richness of everyday experience.
Medical science as a form of symbolisation starts when a complaint is transformed into a symptom. Mooij states: “This transformation exercises an effect that is both positive and negative: the complaint ceases to be regarded as a subjective condition (the negative effect), instead becoming an objectifiable symptom of a yet hidden status (the positive effect).” This 35 very first step is what makes medicine as a science possible. As soon as we speak of objectifiable symptoms, we can use concepts and classifications to conceive general understandings. Yet, Mooij also emphasises the negative effect of this discourse: when a complaint is transformed into a symptom, the door closes to different kinds of perceptions and understandings. This is harmful, as a complaint usually has meaning to a person: a meaning that is disposed of, when it is turned into an objectifiable symptom. Furthermore, Mooij stresses how this medical form of symbolisation has become so ubiquitous, that it obstructs the formulation of alternative understandings. He notes that medical science is more than just a mere model or a form of representation: it is a discourse reflecting a development in Western thought. 36
Subsequently, Mooij traces how the concept of disease, and with that, the distinguished medical form of symbolisation, has become manifest in the field of psychiatry. Psychiatrist Emil Kraepelin (1856-1926) had a pivotal role in this development: he came up with important
34 Mooij, Psychiatry as a Human Science, 76. 35 Mooij, 14.
36 Mooij, 14. The specific, medical outlook, Mooij argues, is the product of all kinds of fundamental positions: it would
classifications under the basic assumption that psychiatry, like somatic medicine, would include a range of autonomous diseases rather than different, non-classified “modes of reaction”. It was Kraepelin who turned psychiatry into a nosological (disease-based)37 discipline. With the introduction of the concept of disease, psychiatry became a normative and productive science. Phenomena of lived experience are transformed into formal symptoms, combined into disease profiles and then subordinated to a certain standard; to the normative concept of health. Apart from the functional or teleological normativity we find 38 inherent in this procedure through the concept of health, there is another form of normativity at play in this discourse. Medical psychiatry is also marked by a deontological form of normativity: the medical discourse requires everyone to adopt the same set of rules and to speak the same language in order to participate in it. 39
Present-day psychiatry, both through its biological orientation and classifying systems, is carrying on the tradition of the nosological, medical approach. Most importantly, the newly developed classification systems of the DSM-III, DSM-IV en DSM-5 earned psychiatry new respect as a science: these systems are now foundational to every psychiatric research or practice. Moreover, in contemporary psychiatry, mental disorders are often considered a symptom of a brain dysfunction. Psychiatry presents itself more than ever, as a 40 “symptomatology” investigating the correlations between behaviour and brain dysfunctions, adopting a teleological set of standards. As a result, present-day psychiatry presents a 41 highly productive outlook, creating a reality with profound (normative) consequences.
37
Mooij, Psychiatry as a Human Science, 21.
38 Mooij, 10. 39 Mooij, 10. 40 Mooij, 43. 41
The Reification of Illness
Having established why and how medical discourse presents a unified outlook, responsible for creating a certain reality with profound implications through the work of Antoine Mooij, I now turn to the ramifications of this discourse for the experience of self-illness ambiguity. One of the main problems in dealing with self-illness ambiguity, is that the medical discourse in psychiatry leads to a tendency of reification: a tendency discussed widely by different authors in the field of psychiatry. Reification, or what is also called “the fallacy of 42 misplaced concreteness”, denotes the process “in which people might come to think of mental disorders as ‘entities’ or ‘things’ that cause their symptoms (as opposed to the mental disorder referring to the collection of symptoms itself)”. In this process, classifications of 43 mental disorders which were designed as purely heuristic tools, are made into natural entities. Moreover, as the mental disorder in these types of understandings is perceived as an illness that invades and distorts the person’s authentic self, there is a strong tendency to reify the ‘self’ as well.
Reification or Verdinglichung is widely considered a natural human tendency and an inescapable side effect of our use of language. John Stuart Mill stated for example: “The tendency has always been strong to believe that whatever received a name must be an entity or being, having an independent existence of its own.” However, it is in psychiatry that the 44 reification of diagnoses has taken intractable forms. Early onwards, psychiatrists have warned for the problem of reification, especially since the disease categories in psychiatry elicit understandings of them as natural entities. There are two developments that made the 45 problem of reification in present-day psychiatry more persistent than ever. First of all, the success of the classifying systems of the DSM contributes to this tendency of reification.
42
Dings, “Not being oneself,” 156.
43
Dings, 156.
44 John Stuart Mill in a note written in a book by James Mill: James Mill, Analysis of the Phenomena of the Human Mind,
Volume 2, trans. J. Hoenig (London: Longmans, Green, Reader, and Dyer, 1869), 5.
45 Karl Jaspers was one of the first psychiatrists to warn of this tendency. See: Karl Jaspers, General Psychopathology
Even the writers of the Guidebook to the DSM-4 acknowledge that the tendency of reification is the biggest risk of any syndromal. They explain that, as this approach centers 46 on classifications based on symptoms, we tend to assume an underlying entity uniting all these different symptoms. Secondly, recent developments in neuroscience lead to naturalistic reification: empirical models of anomalies in the brain contribute to the view that mental illness is “an empirically detectable neurobiological dysfunction”. This ‘empirical proof’ 47 further solidifies the status of these disease categories as natural entities.
How does this tendency of reification in psychiatry affect the problem of self-illness ambiguity? In the previous, I have shown by using Mooij’s analysis, how medical psychiatry has a profound productive and normative dimension: it radically shapes our reality. Although the problem of reification is not addressed explicitly by Mooij, his characterization of medical psychiatry as a productive science helps us in understanding that reification in psychiatry leads to the creation of a new reality. When people with mental disorders conceive of their disorders as natural entities, there is an unnecessary level of complexity added to their problematic: their experience and their dispositions are suddenly structured as part of one single entity, their disease. Accordingly, the already difficult problem of self-illness ambiguity, is further complicated: as one sees both the ‘illness’ and the ‘self’ as separate things, one ends up with various conceptual questions of how these two ‘things’ relate. For example, a diagnosed person might wonder to what extent their ‘self’ and their ‘disorder’ overlap or are distinct. Or a person might wonder whether their ‘self’ is the cause of her 48 depression, or whether it is rather an effect of her illness. 49
46 Edo H. Nieweg, “Wat we van Jip en Janneke kunnen leren: Over reïficatie (verdinglijking) in de psychiatrie,”
Tijdschrift voor psychiatrie 47, no. 10, (2005): 687.
47
Paul Hoff, “On Reification of Mental Illness: Historical and Conceptual Issues from Emil Kraepelin and Eugen Bleuler to DSM-5,” in Philosophical Issues in Psychiatry IV: Classification of Psychiatric Illness, ed. Kenneth S. Kendler and Josef Parnas (Oxford: Oxford University Press, 2017): 107.
48 See: Sadler, “The Psychiatric Significance of the Personal Self”, 115.
49 Jette Westerbeek and Karen Mutsaers, “Depression Narratives: How the Self Became a Problem,” Literature and
Furthermore, a particularly arduous consequence of reification is that we tend to conceive the relation between a person and her illness as dichotomous. This is illustrated in the practice of self-management: self-management is a popular new approach to treatment in which patients are seen as ‘expert-clients’, and are actively involved in the management of their own care. In an article on self-management by people with bipolar disorder, Talia 50 Weiner shows how the idea of ‘managing-oneself’, presupposes an understanding of two reified ‘things’, one managing (the self) and the other managed (the illness). Weiner demonstrates how this has led to a harmful dichotomy, in which a detached and rational manager (‘the self’) must be able to manage an isolated mental disorder. She stresses that this model is utterly harmful, as it pushes someone into the role of a detached manager while in fact this person must deal with all kinds of ambiguities that obscure the supposed distinction between the disease and who she is.
The Elimination of Subjective Experience
Having shown how the issue of reification adds another layer of complexity to the already arduous predicament of self-illness ambiguity, I will demonstrate how the involvement of the medical discourse in this problem of self-illness ambiguity goes even further. I have mentioned that the tendency of reification leads to a harmful dichotomy between the illness and the person. This dichotomy, I argue, forms an inescapable result of a fundamental tension which marks modern psychiatry as a whole.
Previously, we have seen in Mooij’s analysis that modern psychiatry is built precisely on the elimination of subjectivity. Yet, this elimination of subjectivity creates a problem for the 51 actual psychiatric practice: in the doctor-patient relation the importance of the subjective experience of the patient is irrefutable. The medical practitioner has always been aware of the subjective dimension of a complaint, the historicity of someone’s existence and of the
50 Dings, “Not Being Oneself,” 15. 51
meaning that should be attributed to disrupted relationships. The practitioner therefore, 52 will undoubtedly make efforts to take these factors into account. However, this practitioner is unable to include this subjective dimension into the discourse that he is given. This profound problem, that the preeminent medical discourse in modern psychiatry lacks the capacity to fathom the subjective experience of the patient, has been addressed as well by psychiatrist Thomas Fuchs. Summarising his criticism on this tendency in present-day psychiatry, he states: “Consciousness and subjectivity are virtually excluded on the theoretical level and undervalued on the pragmatic level, with serious consequences for the validity of psychiatric diagnosis, for empirical research and, above all, for therapeutic purposes.” 53
In conclusion, present-day psychiatry is characterised by a fundamental disunion or tension. On the one hand, its discourse is built on eliminating the subjectivity of the patient, on the other hand, the subjectivity of the patient is crucial to psychiatry, especially in the therapeutic context. Mooij notes that medical psychiatry is built on a “dual foundation”: on the one hand, it is rooted in science, which is built on the exclusion of subjectivity, and on the other hand, it is rooted in practice, where it tries to integrate subjectivity without being able to offer an adequate theory. This fundamental division affects the most intimate 54 questions asked in the predicament of self-illness ambiguity. People with self-illness ambiguity are given a language, a type of discourse that is incapable to help in their self-understanding. This incapacity is not accidental, but is in fact, an essential aspect of55 their language. As their mental disorder is spoken of mainly in terms of general, objectifiable symptoms, their disorder appears to them more and more as a separate and alien entity. Hence, the medical discourse is not only incapable of addressing or helping the predicament
52
Mooij, Psychiatry as a Human Science, 15.
53
Thomas Fuchs, “Subjectivity and Intersubjectivity in Psychiatric Diagnosis,” Psychopathology 43, no. 4 (2010): 268.
54 Mooij, Psychiatry as a Human Science, 16.
55 This issue is dealt with extensively in the work of Serife Tekin. See: Serife Terkin, “Self-insight in the Time of Mood
Disorders: After Diagnosis, Beyond the Treatment,” Philosophy, Psychiatry and Psychology 21, no. 2. (2005): 139.
of self-illness ambiguity due to its exclusion of subjectivity, it deeply and profoundly aggravates its problems.
1.3. Phenomenology: A Promising Alternative
In this section, I will consider an alternative approach to the preeminent medical model in psychiatry offered by phenomenology. Firstly, I will indicate that phenomenological approaches converge in their fundamental contestation of the elimination of subjective experience from psychiatry. Subsequently, I will show how phenomenology through its insistence on the importance of subjective experience appears as a favourable approach, especially in comparison to the medical discourse, to understand the problem of self-illness ambiguity. Yet, I will also raise my concerns with the phenomenological approach.
‘The’ Phenomenological Approach to Psychiatry
What does ‘the’ phenomenological approach to psychiatry consist in? A question this bold, can only be responded to by an extremely cautious and carefully demarcated answer. The phenomenological approaches to psychiatry are manifold, and differ strongly in their considerations of their methodology, their subject and their relation to the empirical sciences. An illustration of this, we find in a discussion between several key figures in phenomenological psychopathology. In several publications, Louis Sass, Josef Parnas, and Dan Zahavi debate with among others Matthew Ratcliffe, on the exact methodology and purpose of the contribution of phenomenology to psychiatry. Moreover, even the history of 56 phenomenological psychopathology is widely contested. While some authors consider Karl Jaspers, whose primary work Allgemeine Psychopathologie is deeply inspired by Husserl, the
56 See: Matthew Ratcliffe, “Phenomenology Is Not a Servant of Science,” Philosophy, Psychiatry, & Psychology 18, no. 1.
(2011): 33-36; or Josef Parnas, Louis Sass and Dan Zahavi, “Phenomenology and Psychopathology,” Philosophy,
founding figure, others prefer Ludwig Binswangers Heideggerian “Daseinsanalyse” as the jumping-off place of phenomenological methods in psychiatry. 57
These controversies withstanding, there is still good reason to speak of a quintessential phenomenological approach to psychiatry: different approaches find its unity in a common agenda. In a paper, Camille Abettan argues that phenomenological approaches to psychiatry converge in their will to contest what Husserl called ‘psychologism’. ‘Psychologism’ is the 58 doctrine that considers the fundamental problem of psychology a causal one. This doctrine is deeply informed by the natural and medical sciences: it holds a mechanical conception of mental life in which mental realities are to be explained by a “sensation-bound naturalism”. 59 Phenomenological contributions to psychiatry criticise this doctrine as it reduces the subject to a mere ‘object’ of analysis. They contend that we cannot understand our inner lives as a “causal chain implicating empirical realities”; thoughts, moods and motivations are more than their physical conditioning. These objections to this naturalistic, scientific approach 60 to psychiatry were first uttered by Husserl. Nowadays, the phenomenological critique of psychiatry is aimed at the ‘medical discourse’, ‘medical psychiatry’ or ‘neuroreductionism’. Still, phenomenological approaches to psychiatry can be defined by its opposition to the same fundamental tendency: to the very elimination of subjective experience from psychiatry.
Thomas Fuchs has provided a substantial exegesis of the position of phenomenology in relation to this naturalistic and scientific doctrine, a doctrine which finds its culmination in neuropsychiatry. In this exegesis, Fuchs argues that this neuroscientific doctrine results in the elimination of subjectivity, which is especially problematic as it always “returns by the
57 Fredrik Svenaeus, “Phenomenology and Psychiatry: A Contemporary Diagnosis Introducing the Work of Thomas
Fuchs,” SATS 6, no. 2 (2010): 202.
58
Husserl contested this causal and objectifying approach to mental life in Edmund Husserl, Logical Investigations. Vol.
1, trans J. N. Findlay (London: Routledge, [1900], 2001). See also: Camille Abettan, “The Current Dialogue Between
Phenomenology and Psychiatry: a Problematic Misunderstanding,” Medicine, Health Care and Philosophy 18 (2015): 534.
59 Abettan, “The Current Dialogue Between Phenomenology and Psychiatry,” 534. 60
back door”. Furthermore, Fuchs contests what he calls the “mirror concept of consciousness”: this view holds that there is an objective world ‘out there’, and that this objective world is represented by images produced inside the brain that become conscious to us. Phenomenology, on the contrary, conceives of consciousness as something inseparably62 linked to that what goes on beyond itself. Consciousness is defined by Fuchs as “an active, 63 self-organising process of relating and directing itself to the world”. Consciousness does not 64 offer an image of the world out there, but is rather what makes our relation to the world possible: it is only by conscious experience that “we are able to enter into a relationship with the world on the higher level of meaning”. 65
Above all, Fuchs’ exegesis indicates the primary site of contestation of phenomenology in relation to the doctrine of ‘psychologism’: the issue of subjectivity. The definition of consciousness Fuchs offers, shows that what is at stake in phenomenological psychopathology, is the meaningful relation of a person with the world. The notion of subjectivity is key in this relation: conscious experiences are characterised by having “a subjective ‘feel’ to them, a quality of ‘what it is like’ to have them.” Fuchs argues that 66 without a phenomenology of subjectivity, psychiatry will be blind to its proper subject: it would operate without “an appropriate methodological description of what it attempts to explain.” Subjective experience, according to Fuchs, is not just an epiphenomenon of67 underlying ‘real’ causal processes: it is itself “an essential part of the systemic interaction of organism and environment.” 68
61
Thomas Fuchs, “The Challenge of Neuroscience: Psychiatry and Phenomenology Today,” Psychopathology 35, no. 6 (2002): 320.
62 Fuchs, “The Challenge of Neuroscience,” 320. 63 Fuchs, 320. 64 Fuchs, 320. 65 Fuchs, 321. 66 Fuchs, 322. 67 Fuchs, 321. 68 Fuchs, 321.
Accordingly, phenomenological approaches to psychiatry hold a radically different view of mental disorders. We have seen in section 1.2. how medical psychiatry conceives of a mental disorder as the underlying cause of a specific cluster of symptoms. Moreover, the disorder is viewed as a deviation of a certain normative standard: that of health. Phenomenology, on the contrary, holds that as we cannot conceive of consciousness separately, mental illness cannot be understood in terms of single, circumscribed dysfunction. Instead, phenomenological psychopathology considers a mental disorder as a structural disturbance of the patient’s relation to the world and to others.” Rather than seeing a mental disorder as a specified 69 deviation of a norm, phenomenological psychopathology views mental illness as an own form of existence: it presents an unparalleled way in which a person relates to the world. 70
Similarly, phenomenological psychopathology adopts a rather different approach to mental disorders: while medical psychiatry offers a symptomatology, phenomenology tries to account for mental disorders by studying the relationship between a subject and the world, and particularly the basic structures that shape this relationship. Phenomenological psychopathology attempts to disclose the original underpinnings of our experience: it tries to bring to light the key determinants, which allow something like a world to emerge. It follows, in the words of Fuchs, “the constitution of self and reality down to the basic structures of corporality, spatiality, temporality, and intersubjectivity.” In adopting this approach, 71 phenomenology tries to do justice to the holistic dimension of experience out of which the crises and disorders of the self arise. A dimension phenomenologists deem lost in medical psychiatry.
The insistence of phenomenology on the subjective experience of patients has been of great significance to psychiatry. It has been of particular importance to psychopathology: as a
69
Fuchs, “The Challenge of Neuroscience,” 320.
70 See: Maurice Merleau-Ponty, Phenomenology of Perception (New York: Routledge University Press, [1945], 2012),
110. Rather than conceiving of the pathological as the absence of the normal, Merleau-Ponty considers the pathological a complete form of existence.
71
symptom-based approach offered by the medical discourse was inadequate in defining mental disorders in a satisfactory way, phenomenology offered an alternative method allowing a reliable description of subjective experience to complement these symptom-based accounts. By integrating subjective experiences into the descriptions of mental disorders,72 patients have increasingly more access to a language more fitted to their self-understanding. Fuchs even argued that, while a medical or neuro-reductionist approach tends to undermine the freedom of will, and self-determination due to its physicalist approach, phenomenology might help in maintaining a patient's sense of autonomy. In relation to the problem of 73 self-illness ambiguity, we can therefore say that phenomenology generally has a positive influence on contemporary psychiatry which is predominantly medical: phenomenology is capable of alleviating a part of the hardship of patients by providing an account of their illness better aligned with the patient’s experience.
The Pitfalls of Husserlian Idealism
Thus far, we have seen how the contribution of phenomenology to psychiatry can alleviate part of the problematics of self-illness ambiguity by offering a methodologically developed theory of subjectivity. However, I still wonder whether contemporary phenomenological psychopathology can really conceive of all the different elements subsumed in the predicament of self-illness ambiguity. Particularly, my concern with the ability to fathom the complex predicament of people with mental illness lies with a specific tendency in the contemporary debate. A tendency that can best be described by looking at Ricoeur’s critique of what he called ‘Husserlian idealism’. 74
In the paper “Phenomenology and Hermeneutics” published in 1975, Ricoeur expresses his concern about the destiny of contemporary phenomenology as he witnesses the
72 Abettan, “The Current Dialogue between Phenomenology and Psychiatry,” 538.
73 See: Thomas Fuchs, “Overcoming Dualism,” Philosophy, Psychiatry & Psychology 12, no. 2 (2005): 115. 74
predominance of what he calls ‘Husserlian idealist’ interpretations of phenomenology. 75 Ricoeur phrases his criticism of these interpretations in a thorough discussion of multiple central beliefs of Husserlian idealism. His general point of criticism is summarised in the following remark: “[P]henomenology, which was born with the discovery of the universal character of intentionality, has not remained faithful to its own discovery, namely that consciousness has its meaning beyond itself.” With this dense phrase, Ricoeur denotes that 76 as there is a tendency in phenomenology to explain everything on the level of conscious experience, phenomenology is at risk to be reduced to a form of transcendental subjectivism, in which phenomenology and psychology are essentially equated. 77 Ricoeur is concerned that the phenomenological method is no longer involved with interpreting the meaning of the world, but rather that phenomenology remains stuck on the level of interrogating subjectivity itself. The main problem for Ricoeur with these contemporary interpretations concerns the issue of self-knowledge. In these Husserlian idealist interpretations, phenomenology is suspicious of anything beyond the immanence of subjective experience and is therefore unable to question the immediate form of self-knowledge that arises from our conscious experience. In other words, Ricoeur contests the image that the only access to ourselves is through the givenness of our experience. For Ricoeur, this offers a too limited perspective; it excludes the possibility of a more explicit self-relation or self-interpretation and as such, it cannot adhere to certain crucial aspects of our personal identity.
Ricoeur remains deliberately vague about the extent to which phenomenology, and particularly the work of Husserl himself, Merleau-Ponty and Heidegger, are prone to the pitfalls of these Husserlian idealist interpretations. However, the shift in his thinking from phenomenology and hermeneutics implies that his discontent with this tendency in
75 Ricoeur, “Phenomenology and Hermeneutics,” 85. 76 Ricoeur, 94.
77 Ricoeur, 87. That is to say, that they only differ in approach. Ricoeur speaks of a parallelism between
phenomenological thought is to be taken rather seriously. Without being able to go into detail, I believe that some of the issues Ricoeur has with Husserlian idealism are manifest in the work of Heidegger and Merleau-Ponty as well. Yet, for now I will focus on the contemporary discussion in phenomenological psychopathology in which this tendency described years earlier by Ricoeur, is even more distinctly manifest. To see how this tendency is reflected in the contemporary debate, we do not need to trace the Husserlian idealist legacy in the theories of different contemporary researchers. Rather, this tendency is revealed in the wide shared belief that the main contribution of phenomenology to psychiatry lies in a descriptive clarification of subjectivity, experience, and selfhood in the context of different psychiatric disorders. This central belief is conveyed, for example, in the introduction of the
Oxford Handbook of Phenomenological Psychopathology published in 2019. In the abstract of the introductory chapter, it states the following:
[This introductory chapter] argues that psychiatry is not only a biological discipline. It must maintain an intense concern with the quality of patients’ experiences by focusing on the “psyche” and not just the brain, which is of interest to psychiatry only insofar as it helps one better understand the relevant psychic phenomena. Thus, one must investigate the relationship between these subjective experiences, the brain, and the way we classify psychiatric disorders. 78
A large part of the phenomenological contributions to psychopathology consists in these descriptive efforts to interpret the alterations of subjective experience of patients according to the type of disorder. By studying certain aspects of our subjective experience, such as 79 embodiment, spatiality or temporality, phenomenology contemplates the variation and alteration in the structure of subjective experience. Generally, the value of phenomenology to psychiatry is thought to consist exactly in this ability to account for the first-person perspective. In doing so, phenomenology furnishes psychiatry with a deeper understanding80
78
Stanghellini et al., “Introduction," In The Oxford Handbook of Phenomenological Psychopathology, ed. Giovanni Stanghellini et al. (Oxford: Oxford University Press, 2019), 1.
79 Rene Rosfort, “Personhood,” in The Oxford Handbook of Phenomenological Psychopathology, ed. Giovanni
Stanghellini et al. (Oxford: Oxford University Press, 2019), 336.
80
