The Crisis of Present-Day Psychiatry: Regaining the Personal
The Crisis of Present-Day Psychiatry: Regaining the Personal
(The following is the second of two articles adapted by the authors from lectures given at the University of Zurich upon their receiving the 1998 Dr. Magrit Egnr-Stiftung prize-Ed.)
Present-day psychiatry has fallen into crisis because of the severe limitations of its conception of the person and, as a result, its conception of the patient. It objectifies the patient in a number of ways: 1) It lacks a conception of normality and consequently perceives most aspects of the patient's life in pathological terms; 2) It reduces the patient's problems to a list of pathological symptoms; 3) It tends to conceive of these symptoms as having primarily biological causes; and 4) Its methods of treatment are pharmacological and behavioral. Because of this reductionism, psychiatry fails to distinguish between healthy and pathological features of human life. It fails to view the pathological aspects of patients' lives within the larger context of their personalities and sociocultural milieus. It fails to consider adequately the psychological and social factors that cause and maintain each patient's problems. Finally, it fails to employ treatments that address whole people living daily in their sociocultural worlds.
Yet this reductionism does alert us to important components of human life. To express our point as generally as possible: it alerts us to the anthropological fact that human beings are, in many respects, objects. Although the reductionist conception of the patient does, because of its limitations, signal the loss of the personal, our attempt to regain the personal must incorporate the object-like components of human existence that reductionism pinpoints. Because human beings are, in certain respects, objects, a full conception of people must not disregard this object-like-ness but must rather situate it within the broader philosophical context in which it rightfully belongs.
Regaining the personal will require developing an adequate "philosophical anthropology." This must be a theory of human personal life sufficiently encompassing to include all aspects of human existence that we know to be essential. Previous philosophical accounts of human life have failed to be sufficiently encompassing for two basic reasons.
First, they have ignored some dimensions of human existence. Many of them focus, for example, on the mind and ignore the body. Or, if they do include a discussion of the human body, it often will be the body conceived exclusively as a biological organism, i.e., the body as the science of biology conceives it. Such a conception omits the lived body-the body as we are aware of it in our prescientific experience. Some theories of human existence focus on the sensing and reasoning individual and fail to describe emotions or social relationships. The philosophical anthropology we envision would contain a general depiction of all aspects or dimensions of human reality: psychological, sociocultural, aesthetic, political, religious, biological and neurophysiological, among others.
Second, philosophical theories of human existence have heretofore focused on what is normal in human life and thereby ignored what falls outside the normal, i.e., the abnormal, subnormal or extranormal. For instance, Maurice Merleau-Ponty, whose Phenomenology of Perception we otherwise find extremely valuable, uses Kurt Goldstein's accounts of his brain-injured patients only to further clarify the normal experience of the lived body. There are fragments of a phenomenology of the pathological experiences of these patients, but this experience is never studied for its own sake. Similarly, investigations of the mind in American and British analytic philosophy might consider a few abnormal conditions-the split brain, for example-but such considerations usually serve only to illuminate normal experiences of personal identity or of objects in the world.
Hence the sort of philosophical anthropology that can aid us in regaining the personal is one that encompasses all aspects of personal existence, including psychological, social and religious, as well as all people (normal and abnormal). We would now like to delineate the framework of such a philosophical anthropology. Our anthropology draws on a number of authors in the tradition of phenomenological and existential philosophy and anthropological medicine.
We shall begin with a philosophical sketch of the phenomenon of life itself. This sketch will allow us to highlight certain features of living beings, both human and nonhuman, that we shall call biodynamic vectors. By then contrasting nonhuman with human animals, we shall outline the roles biology, culture and freedom play in shaping human existence. We shall then consider four mental disorders: manic-depressive illness, schizophrenia, sociopathy/histrionic personality disorder and obsessive-compulsive disorder. We shall not view these ways of being human as mental disorders, however, but rather as existential types defined by hypernomia, agonomia, hyponomia and idionomia. We shall conclude by arguing for the crucial historical roles played by people who embody these types.
The Phenomenon of Life
Let us begin at the organic level and note some basic constituents of all living beings. The fundamental task of every living organism is securing its own continued being-threatened as it always is by the possibility of nonbeing-death. This possibility will become its actuality if the organism does not constantly elude this possibility by doing something. Because the being of the organism is never assured, that being must be achieved and repeatedly re-achieved through the organism's own activity.
Nonbeing threatens the living being because the organism is a creature of need: the organism always remains non-self sufficient. The living being cannot perpetuate its own continued being within itself: in order to continue to exist, it must relate itself to the other, the world. The organism depends on the world for the resources that will satisfy its needs. The activity of the organism, then, consists of interaction with the environment. If this interaction stops, the organism dies. Lacking the self-sufficiency that would allow it to continue to exist complete within itself, the organism is a world-dependent being (Jonas, 1966).
And yet the organism must also remain independent from its environment. If the boundaries that separate the life of the organism from the world should vanish, the organism would die. The living being must then maintain its own distinct identity apart from the environment. In order to preserve its own individuality separate from the world, the organism must interact with the world. The self-world relationship is therefore complex: the continued existence of self depends on its relationship to the world, and the continued existence of self depends on its separateness from the world (Jonas, 1966).
These features of living beings are present even at the level of metabolism. The metabolic processes within the organism that maintain its life depend on nutrients continually acquired from the external world. In these ongoing exchanges with the world, however, the metabolic processes within the organism must maintain their own self-enclosing boundaries. If the boundaries between self and world become too porous, the metabolic processes are interrupted in the form that we call death. The organism's metabolism thus exhibits both world-relatedness and self-enclosure: both must be maintained simultaneously for the processes to continue (Jonas, 1966).
Thus, we can note two correlated features of living beings. If one of these features should attain dominance, the other would be threatened: The two features exist in a certain tension with one another. Each requires the other if the life of the individual is to continue, but the increase of one would menace the functioning of the other. Consequently, continued life demands that a balance be struck between them: They must exist in an equilibrium in which neither overwhelms the other. The two features can be characterized in two different ways, showing them in slightly different lights: world-relatedness and self-enclosure, or world-dependence and world-independence.
We would like to call these features vectors of life. Each represents a need of the living being in the sense that they are necessary requirements for living. As needs of life, they draw or pull the living being toward them. In order to capture this sense of a movement or tendency toward them, we call these features biodynamic vectors. The notion of vector expresses direction of movement.
Biology, Culture and Freedom
Now we may pose the questions: What governs this movement or tendency? How is this movement or tendency determined?
In nonhuman animals, these directions of movement are governed primarily by the animal's biology, which shapes and drives its forms of world-relatedness. In lower animals these forms of world-relatedness can be conceived as largely mechanistic. Thanks, for instance, to a mechanistic reflex, a tick in a tree drops on the human being walking below precisely when the air temperature and the concentration of butyric acid in the person's evaporating perspiration surpass a threshold level. In more complex animals, the forms of world-relationship are primarily instinctual, and it is the creature's biology that determines these instinctual forms. Once the instincts emerge, they are relatively fixed and definite. Consequently each species of animal has its own "species-specific environment": an environment related to that particular species and its set of mechanisms and instincts. Different species of animals do not share environments; each has its own. The animal's world-relationship, then, is in reality a species-specific environment-relationship. In addition, the animal's biology determines its forms of self-enclosure (Portmann 1990a, 1990b, 1973, 1956).
In the human animal, however, biology does not achieve this much. Human biology does not fully delineate our forms of world-relatedness. Our biology, in fact, leaves our forms of world-relationship relatively open and underdetermined. The indeterminacy of our biological conditioning renders us instinct-poor. Therefore, the instincts that narrowly define the environment-relationships of nonhuman animals play a much smaller role in human experience and action. As a result, the human being has no species-specific environment. Insofar as humans are determined by their biological makeup, the human individual is capable of living in a very wide variety of environments. This is what is meant by Max Scheler's phrase world-openness. While the nonhuman animal is limited to a relatively narrow environment, the human animal is open to a far broader range of multifarious realities. Through its biology, therefore, the human being remains unfixed, indeterminate, plastic and malleable (Portmann 1990a, 1990b, 1973, 1956; Gehlen, 1988).
The same applies to human forms of self-enclosure or self-relatedness. Our biology only partially determines the forms of our relationships to our own bodies, for example. Human beings are capable of adopting a great variety of attitudes toward and conceptions of their bodies. Our biology thus leaves our forms of self-relatedness unfixed, plastic and ill-defined (Portmann, 1990a, 1990b, 1973, 1956; Gehlen, 1988).
For this reason, human culture must come to supplement human biology because our biology leaves our modes of being too indeterminate and ill-defined. Culture can supplement biology because our biology leaves us plastic and malleable enough to be molded into a variety of ways of being human. Culture imposes its man-made forms on human existence and in this way helps to close the world-openness left by our biology alone. By internalizing social values and by playing social roles, our experience is molded into more or less definite patterns. Culture determines what biology left indeterminate. Socialization into a particular society defines for us the acceptable forms of world- and self-relationship (Portmann, 1990a, 1990b, 1973, 1956; Gehlen, 1988).
And yet culture also leaves us partially open, underdetermined, malleable and unfixed. Even after culture and biology have jointly shaped our mode of being-in-the-world, indeterminacy remains. In this gap of indeterminacy lives individual freedom of choice. After culture and biology have done their work, the indefiniteness of our forms of world- and self-relationship must be rendered definite by voluntary decisions. In human life, therefore, three forces shape world-relatedness and self-enclosure, and world-dependency and world-independency: biology, culture and individual freedom.