Osborne P. Wiggins, PhD

(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.

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 

. The notion of vector expresses direction of movement.

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.

In order to explain further how our beings are determined by our world-relatedness and our self-enclosure, we must introduce another cardinal component of human existence: the component that Helmut Plessner has called eccentric positionality (Plessner 1982, 1981, 1970).

The eccentric positionality of human beings means that the person both coincides with his own being and fails to coincide with his own being. The human being is both centered in its being and not centered in its being: I am both identical with myself and different from my self. 

Take my relationship to my own body, for example. To a certain extent, I am my body; I coincide with my body; mybody and I are one. But in other ways my body is something different from me: it is an object or thing which I use. 

For example, I use my hands to type on my computer. When I type, I am unaware of my hands. In this case I am my hands; I do not distinguish between my consciousness, which thinks the thoughts, and the hands, which type these thoughts. My consciousness and hands are one reality; they perform together as an indivisible unit. But my hands could not always type on a computer. Years ago I had to teach myself, i.e., my hands, how to type. My hands were then objects about which I had to think, and I had to consciously guide them in each movement. Now that my hands have learned how to type, I do not think about them and I do not consciously direct them. They have become so thoroughly unified with my thinking that my thoughts immediately appear as words on the computer screen. But, of course, this immediate appearance of the words my mind thinks is mediated: it is mediated by my typing hands. Hence Plessner speaks of my relationship to my own body as one of "mediated immediacy."

Or take the emotions I feel as another example. When I am feeling certain strong emotions, I simply am those emotions; my being is enveloped in those emotions. But I can also decide to "get a hold" on my emotions and change them. I may tell myself to calm down or to not get so excited. Of course, I may not succeed entirely when I try to control my emotions. But this partial success perfectly demonstrates the eccentric positionality of human beings. My emotions are not identical with me because I can control them, but they are to a certain extent identical with me because I cannot completely control them; I am compelled to simply be them.

The biodynamic vectors are enclosed within the human being's eccentric positionality. To a certain extent, I simply am my own form of world-dependency: my relationship to the world is to some degree given and unalterable; it is who I am; it is my very mode of personal existence. But to a certain extent, I can control and change my world-dependency. It is not entirely given once and for all because I can modify it. My dependency on the world is something toward which I can take a stand. And I can take a stand toward it because I am not identical with it. 

The biodynamic vectors, then, are part of the eccentric positionality of human life: our lives coincide with our own personal forms of world-relationship and self-enclosure. Yet we can also take a stand toward these and change them. We can thus speak of the "bounded freedom" of human beings. Our biodynamic vectors have been shaped by biology and culture. From the point of view of the individual, these vectors are given: they define and determine who that individual is. They are given to the individual, forged by biology and culture. But, nevertheless, the individual can take a stand toward them, attempt to control and modify them. Because these vectors are determined by biology and culture, the choices are bounded. But because the individual can-to some extent-control and change those choices, the individual to some degree remains free. Each individual's relationship to their own biodynamic vectors is a relationship of bounded freedom (Plessner 1982, 1981, 1970).

Biology, culture and freedom shape people differently. For example, some people enjoy playing social roles, and they are able to conform their behavior to the requirements of these roles easily and comfortably. Such people are able to identify themselves with their roles, at least during the times they are playing them. Other people, however, feel uneasy and awkward while enacting social roles. These people experience considerable "role-distance," even when they force themselves to play the role. These alternatives, role-identification and role-distance, are the result of biological, cultural and personal determinants. These determinants shape us differently, so we each have different attitudes toward our social roles.

Notice, however, that we humans, unlike nonhuman animals, can play social roles, and we can play them because of our eccentric positionality. When I am playing a social role, the role is both something I am and something I am not. When I am teaching, I am a teacher. And yet I am also manipulating my role. I adjust it and modify it; I shape it and mold it. I have control over how I play the role, but I do not have complete control because the role is also something I am. 

We suggest that role-identification and role-distance manifest possible directions in the biodynamic vectors we mentioned earlier, namely, world-dependence and world-independence. Role-identification manifests the individual's world-dependence. Role-distance evinces the person's world-independence. Many people, in their daily role-performances, are able to balance role-identification with role-distance. They play the roles naturally enough but they do not entirely identify their personal being with the roles. Such an equilibrium in each individual's relationship to their social roles manifests an equilibrium in their world-dependence and world-independence. Of course, such an equilibrium is rarely constant in human life. Vacillating, the individual is able to identify with those roles sometimes but feels deeply alienated from them at other moments. The vectors, as tendencies in human life, change: they move the person in different directions at different times. But precisely in this change and vacillation is disclosed the unfixed and plastic character of human existence. Indeed it is in the change and vacillation that we must come to terms with ourselves and make a decision that selects one alternative from the open range of possibilities confronting us.

Personal life thus emerges as a broad spectrum of possible ways of being human. This spectrum is broad because our biology leaves us world-open, and our culture, supplementing biology, shapes us in a vast variety of ways. And even after biology and culture have placed each of us in different regions along this wide spectrum of humanity, the indeterminacy that remains must rely on individual free will to decide finally how each of us shall live.

This broad spectrum of humanity includes those we are accustomed to referring to as mentally ill. We would first like to note that it is the world-openness of human beings that makes it possible for those who behave in ways we call mentally ill to survive. Human life can assume many different individual forms and continue to exist in the world because each form inherently retains the indefiniteness and lack of fixity that allow it to adapt to its surroundings. If a "deviant" form of nonhuman animal appeared in the world, it could probably not survive. Its "deviant instincts" would lead it to behave in ways that, because of their fixed structure, remained too maladaptive. Deviant forms of human behavior, however, remain sufficiently open to adjust to a variety of situations. 

We shall now draw upon the anthropology we have sketched to indicate some central components of four different mental disorders. We shall contrast these components in people suffering from manic-depressive illness, schizophrenia, sociopathy/histrionic personality disorder and obsessive-compulsive disorder. We wish to set aside any pathological conception of these types of human being, however. While they clearly have biological, genetic, social and psychological determinants, we shall not address these at this time. We shall characterize these human types as particular kinds of being-in-the-world, referring to them as 

The individual who is prone to manic-depressive illness often identifies powerfully with established social roles and values. In the depressive subtype-even when depression is absent-this determined striving will always succeed. In fact, such an individual will overidentify with society's norms. Following Tellenbach and Alfred Kraus, we shall call this overidentification with established social values 

. Hypernomia manifests an excessive dependency on the established social world as well as too little independence from this world. In manic phases, such individuals often rebel against established roles and values. But the very vehemence and determination of their rebellion demonstrates how dependent they remain on the values against which they rebel (Tellenbach, 1961; Kraus, 1977).

Unlike the person with manic-depressive illness, the person with schizophrenia is characteristically unable to identify with society's established values and roles. Such people end by negating or perhaps transcending society's norms. These individuals may even open up a new world. We shall call this inability to conform 

. Agonomia evinces an inability to connect to the established social world (Kraus, 1977; Drr, 1992). 

Those prone to sociopathy or histrionic personality disorder are less concerned about identifying with society's values than with manipulating these values in the service of their own self-interest. This underidentification with social norms we label 

 Hyponomia manifests too weak a connection with the shared social world (Drr, 1992). 

Individuals suffering from obsessive-compulsive disorder have no choice but to adhere strictly to their own idiosyncratic values. Because these personal values contradict established social norms, they may feel ashamed of their enslavement to those values and try desperately to conceal this enslavement from others. We call this over-identification with one's own idiosyncratic values and rules idionomia. Idionomia exhibits an extreme form of self-enclosure (Drr, 1992). 

We therefore recognize at least four possible ways to relate oneself to the social world: hypernomia, agonomia, hyponomia and idionomia. In the existential types sketched above, these modes of world-relatedness are fixed and unchanging. Those with manic-depression are unable to act otherwise than to strive determinedly to identify with established social norms. Individuals with schizophrenia are also unfree: they cannot identify with society's values and roles. Quite independently of any choice on their part, human beings with sociopathy or histrionic personality disorder remain under-identified with social values. People with obsessive-compulsive illness cannot choose to stop adhering absolutely to their own idiosyncratic rules. In short, people who have manic-depressive disorder must be hypernomic; those with schizophrenia must be agonomic; individuals with sociopathy or histrionic personality disorder must be hyponomic; and people with obsessive-compulsive illness must be idionomic.

This necessity to maintain these forms of world-relatedness arises from both biological and social causes. Scientific research in neuroscience and cognitive neuroscience has begun to explicate crucial biological determinants in individuals who instantiate these types (Spitzer, 1999). Such determinants have left these people less world-open than others who experience more flexibility and malleability in their forms of value-relatedness. Most people can identify with their culture's values to a significant degree while at other times feeling alienated from the accepted societal norms. Individuals who exemplify the mentally disordered types, however, have biological structures that render one form of value-connectedness dominant and pervasive. Other kinds of value-relatedness are relatively unavailable to these individuals. With regard to their forms of value-relationship, they are inflexible and unchangeable.

Of course, what we have just said must be qualified to some extent. People of these existential types do feel drawn to some degree in contrary directions. For example, those prone to manic-depression, dominated as they are by their hypernomia, still experience some inclination to negate established values. In other words, they may, to a degree, gravitate toward agonomia. And they may also experience an impulse toward idionomia. But it is hypernomia that ultimately controls the active self: the pull of hypernomia remains too strong to be resisted. Other forms of value-relatedness may exert some pull on all such people. We may, therefore, see transitional types such as the individual with schizoaffective illness.

A second qualification that must be emphasized is human freedom, however deficient it may appear in these existential types. Even people who grapple with this kind of personal fixity remain capable of acting and reacting in unpredictable ways.

These four existential types should be viewed, therefore, as simply four different ways of being human. Depending on how they are shaped by biological, cultural and personal factors, many people may approximate these types to some degree. However, the types described lie at the extremes of the broad spectrum of humanity mentioned previously. Therefore, their voices-together with the voices of those of us whose vectors bring us closer to the human center-should be heard. All of us together constitute a plurality of forms of world-relatedness, enabling humans to inhabit this world as well as countless and unfathomable past and present worlds.

Indeed these existential types may and do have crucial and even essential roles to play in human history. The hypernomic type performs an invaluable conservative function in maintaining social standards and in disapproving of deviations from those standards. Deviations from the culture's values are seen by the hypernomic individual as shortcomings and therefore, requiring redress. Hypernomic individuals provide strong and selfless support for social norms and institutions. Without them, the inherent flimsiness of cultural standards could easily lead to social breakdown. 

In times of social breakdown, however, the agonomic type can play a crucial, even a revolutionary, historical role. Agonomic human beings envision innovative value systems. In their alienation from accepted norms, their intense authenticity, their capacity to perceive details that others miss and their metaphysical preoccupations, they may expound other and newer values. They may see themselves as having the "saving knowledge" that can deliver humankind from its deepening crisis. More than once in human history the agonomic's vision of a "new heaven and earth" has rescued communities from the deadends into which their traditional values have led them.

Hyponomic individuals, on the other hand, are supremely adaptable to the rapid shifts in values and mores that characterize times of change and crisis. Outstanding performers, they may pick up the values of the moment and express them passionately and perfectly. And with equal gusto, they undermine the old as they embrace the new. 

Finally, idionomic people may retain for all of us what appears to be no longer of value in the present but which may regain value in the future. With seriousness of purpose, devotion to their tasks, a strong capacity for work and scrupulous attention to detail, they preserve that which is of value and would otherwise be obliterated.

We certainly recognize that extraordinary suffering is often associated with these types. Nonetheless, if we are right about the important historical functions performed by the individuals who embody them, it would be a grave mistake to seek elimination from the human gene pool of the genes that produce such people. Indeed, if we are right, these genes need to remain in order to continue to give rise to people of these types. The search for these genes and genetic mechanisms constitutes a central project of present-day psychiatric research. We caution that the eradication of such genes, if they exist, would be a grave mistake. Humanity needs hypernomic individuals to strive forcefully to maintain its existing standards. It also needs agonomic people who envision radically new ways of life as well as hyponomic individuals who undermine the old and make way for the new and embrace it. In the meantime, idionomic people preserve that which is of old but unnoticed value: tomorrow such value may once again become essential to us. Without hypernomic people, our traditional social structures will lack their main human support and will be threatened with collapse and, without agonomic individuals, we will lack the new vistas needed when our traditional institutions do inevitably collapse. Hyponomic people can facilitate this collapse while idionomic individuals hold back the tide and preserve that which may prove useful again in the future. The human race needs such extreme qualities-our continued existence may even depend on them.

Present-day psychiatry lacks an adequate conception of the person because it possesses only disconnected elements and fragments of such a conception. In order to regain the personal we need a comprehensive notion of human life that incorporates and integrates biological, social, psychological and other perspectives. We do not deny that fruitful work has been done in mainstream psychiatry in recent decades. But this work, in order to focus on its chosen domain, inherently abstracts from other features of the patient. Hence it is not surprising that these investigations produce only parts of a whole. And misconceptions arise when the parts are not recognized for what they are: separate parts. When one perspective on the person is taken in isolation and treated as if it were somehow the main or the central aspect of personhood or mental illness, error follows. The numerous perspectives on human existence need to be comprehended from within a larger philosophical anthropology that includes them all. We have sought to sketch such an anthropology.

But more is needed. The values that undergird psychiatry need to be explicated and grounded so that the field can protect itself from misuse by large economic, political and social forces. Such an ethic would require that patients be treated in ways that address their full and equal humanity as they deal with the illnesses that can cause so much suffering.

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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. Because of this reductionism, psychiatry fails to distinguish between healthy and pathological features of human life. It fails to consider adequately the psychological and social factors that cause and maintain each patient's problems.

The Crisis of Present-Day Psychiatry: Regaining the Personal

(The following is the first of two articles adapted by the authors from lectures given at the University of Zurich upon receiving the 1998 Dr. Margrit Egnr-Stiftung prize-Ed.)

Let us begin with an example. Suppose I am traveling from the United States to Switzerland, anticipating skiing with my son in the Alps. My anticipation becomes vivid and lively. I recall excitement mixed with joy at rapidly soaring down the mountainside, and I am now quite anxious to re-experience this thrilling adventure with my son-eager to be heading down the mountain with him. Later, as we stand on the crest of a deep and winding slope, the speed, thrill and admixture of danger and adventure will infuse my being. 

If, in this condition of excitement and joy, my body were connected to a monitor and tested, it would register certain physiological patterns that might be identical to those of an anxiety attack. So, from one point of view, my anticipation of a thrilling ski adventure could be mistaken for an anxiety attack. This point of view would, of course, have to disregard my subjective experiences, which are those of a person filled with joyful excitement. 

Granted, in colloquial English we say, "I am anxious," but in this case it is meant in the sense of "I am anxious to meet my son." This anxiety is of joyful expectation, just the opposite of morbid anxiety. Indeed, if the only categories at one's disposal were pathological categories, my organic condition would have to be classified as an anxiety attack. 

Therefore, in order to misinterpret my condition as an anxiety attack: 1) my condition must be decontextualized, i.e., my personal situation-that of a man traveling to go skiing with his son-would have to be disregarded and my organic condition alone considered; and 2) the decontextualized organic condition must be viewed as falling under some pathological classification system. If taken, these two steps would categorize my state as an 

 In the modern climate of thought, the first step-ignoring the person's subjective experiences-is easy enough to take. Indeed, this would be viewed as required for a strictly scientific test. Science itself demands that subjective experience be disregarded and organic reality alone examined. Only in this way, the modern mind assumes, is a truly objective result reached. 

The second step does not appear to follow as easily from the proclivities of the modern mind, however. But it does easily follow the modern specialization of the sciences. As they more precisely isolate specific provinces of reality, some sciences have focused on pathological conditions, leaving the study of healthy states to other disciplines. For example, American psychiatry has become determined to define mental disorders as thoroughly as possible, and it has indeed made some progress in this regard. But American psychiatrists rarely study mentally healthy people.

Psychiatry and the Specialization of the Sciences

This concern with the pathological and neglect of the healthy is part of the specialization and resulting fragmentation of the sciences in Westernized countries. The increasing precision with which scientists study those aspects of the world in which they are interested focuses on ever more restricted dimensions of reality. One result is that the various sciences, now so many and so specialized, have little contact with one another. This is certainly true of the disciplines that study human life-too many and too vast to be comprehended by a single mind. For example, psychiatrists, in order to treat mental disorders, must study psychopathology, neurophysiology, psychopharmacology, behavioral therapy and psychotherapy, as well as a variety of medical disciplines. Hence, while psychiatrists know the special sciences peculiar to their field, they are disinclined to study philosophy, humanities and social sciences. 

The other force that leads psychiatrists to ignore philosophy, humanities and social sciences is the remedicalization of psychiatry. Today, most American psychiatrists emphasize the fact that they are physicians, i.e., practitioners of a medical specialty. As they see it, psychiatry is simply one specialty within medicine, on a par with cardiology, orthopedics and gynecology. In order to validate this claim, psychiatrists increasingly strive to practice psychiatry the way other doctors practice their specialties. Hence it is thought to be desirable if the diagnostic manuals, treatment procedures and outcomes testing in psychiatry resemble as closely as possible those of the other medical specialties. In order to see how we have arrived at this predicament in psychiatry, let us take a few historical steps back, returning to the birth of psychiatry during the Enlightenment.

The Enlightenment and the Origins of Modern Psychiatry

Psychiatry was born in the 18th century as part of the Enlightenment, a period when people, inspired by the new scientific spirit, were able to view mental disturbances as illnesses rather than as the result of sin or witchcraft. Mental problems were thus conceived in causal terms rather than moral or religious ones. Although the mechanisms within the individual producing these disturbances were unknown, the mere conception of these disturbances as due to causal mechanisms revolutionized our understanding of them. But this mechanistic conception of mental problems did not exist, as it does today, in theoretical isolation. Like all science at that time, this view formed merely one subsidiary branch of an all-encompassing metaphysical view that included social, political, religious and moral conceptions. To see this clearly, one must grasp the overall character of the Enlightenment. 

The Enlightenment perpetuated and reinvigorated the Renaissance ambition of a universal philosophy of reason in whose light human beings could shape themselves and their entire social world. This universal discipline bore the name 

. However, the sciences at this time were part of philosophy-the two had not yet been distinguished. Ren Descartes reformulated the age-old belief that all the sciences were but branches of the tree of philosophy. Therefore, this universal philosophy included physics and mathematics as well as the sciences of the human mind, society and politics (Husserl, 1970). 

Moreover, in its all-embracing unity, this universal philosophy included political and moral values. Its ultimate ideal was to be life-guiding and action-directing, with no distinction between daily life and philosophical reason. Life-including the collective, social life-should be shaped by philosophical reason. Nothing less than the reformation of the entire society under the guidance of a normative rationality was the aim of these thinkers. Hence the value-ideals of the French and American Revolutions-liberty, equality and universal  human rights-were designed to guide this political and social reformation. The idea of value-free scientific knowledge still lay a century in the future. 

When Enlightenment thinkers, like Dr. Benjamin Rush in America, took psychiatry (yet to be named) as their subject matter, they applied to a delimited group of phenomena a universally broad philosophical system that encompassed every kind of reality. While the illness was perceived from a mechanistic point of view, the patient was still seen as a human being with human rights deserving of inclusion in the full privileges of universal humanity. Hence physicians were able to regard mental disturbances as illnesses like other natural diseases; yet they still were able to see patients as potentially capable of living in a moral community. This vision at least provided the ideal for their treatment, which physicians called 

. In moral treatment, mental patients were unchained; with the goal of integrating patients into daily life, psychiatrists dressed them in proper clothing, took meals with them, engaged in ordinary social interactions with them and sometimes even married them (Bockoven, 1972; Zilboorg, 1941).

Even during the Enlightenment, however, forces were at work that would eventually undermine this grand conception of a universal philosophy. The Enlightenment ideal declined partially because of the advances in knowledge steadily accruing in physics, anatomy and other natural sciences, which were bought at the price of specialization. As researchers began to specialize in separate fields, and as knowledge grew, specialists in one field became unable to keep abreast of advances made in other fields, bringing an end to universal understanding. 

Philosophy continued to exist, of course, but in philosophy it was difficult to show the progressive advancement of knowledge so obvious in the natural sciences.  Philosophers such as Georg W.F. Hegel still sought to integrate human knowledge and values into one single system of thought, but these all-encompassing systems were espoused by only a few. As a result, philosophy, now conceived as distinct from science, became intellectually discredited. And so it stands today-except that the separate sciences receive even more respect, and philosophy receives even less.

Before looking more closely at the state of psychiatry today, let us lay bare some of the factors that made this increasing scientific specialization and diversification possible. In order for scientists to carve out a distinct domain of reality for scientific investigation, they must perform certain acts of abstraction. Scientists must consider the properties of one domain of reality alone and disregard other realities, sometimes even other properties of the same reality. For a physicist to study, for example, the electrical currents moving through a microphone, the fact that the microphone is a cultural tool with a particular social function and value must be disregarded. Of course, the function it performs for speakers and audiences may remain somewhere in the back of the physicist's mind. But this background awareness does not constitute any part of the scientific understanding of electricity. The science of electricity has abstracted from the social functions of the objects through which the electricity moves. To abstract from certain aspects of reality, then, is to systematically disregard those aspects of reality. 

The field investigated by a particular science can be defined and understood only by abstracting from and disregarding those aspects of reality studied by other sciences. It is this systematic disregarding that separates the fields of science from one another. Of course, connections are sometimes made between fields. But this only produces other specialized scientific fields like psycholinguistics or sociolinguistics. The history of science in the modern period has been the history of the division of reality into disparate regions by the growing specialization and separation of the sciences (Husserl, 1970). 

In numerous ways philosophy has served as the handmaiden to this increasing specialization and separation. One of the ways it has done so is by finding metaphysical justifications for the abstractions that the sciences have made. For example, since the natural sciences systematically abstract from the values things have, they are said to be 

. Although this abstraction was probably originally motivated by the need to liberate science from religious and political control, it purified nature for characterization in mathematical terms. 

Philosophy aided this abstraction by constructing a metaphysical dualism that strictly separated mind (where values were relocated) from body, thereby excluding values from the external world, confining them within the inner domain of consciousness. This mind/body dualism, in fact, served extremely well as a device for ridding nature of whatever properties the various sciences sought to disregard: It was always possible to resituate those properties within the inwardness of the mind, thereby denying their presence in the outer world. It was accordingly easy for modern philosophy to help the emerging science of biology, for it allowed this science to abstract from the teleology of organic beings by restricting all teleology to consciousness alone. In this way, living beings could be conceived as determined solely by the same kind of efficient causality that governed the rest of nature (Jonas, 1966).

The Equivocal Face of Present-Day Psychiatry

Now we return to the present in which psychiatry, we contend, has entered a crisis. This present-day crisis of psychiatry, we admit, is peculiar because, while numerous psychiatrists recognize psychiatry's critical condition, many others believe the field has never been in finer shape. Those who contend that psychiatry is doing quite well will point pridefully to refined diagnostic instruments like the 

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

, and its many specialized handbooks, algorithms and tests. More proudly still, they will list the vast array of fourth-generation drugs that so effectively relieve many symptoms that previously defied therapy. And the practical efficacy of these drugs, they will say, can now be explained through our rapidly mounting knowledge of the biologic and genetic mechanisms involved in the pathogenesis of mental disorders. 

For the first time ever, they will boast, psychiatry now equals the other specialties of medicine in the scientific rigor of its research and knowledge, the reliability of its diagnoses, and the safety and efficacy of its treatments. Thus, through these rapid advances, psychiatry has attained the scientific status that makes it as respectable as any other branch of medicine. 

Since many psychiatrists herald this newly acquired elevated rank among the sciences, how can we claim that psychiatry has entered a period of crisis? We claim this because we think psychiatry has managed to acquire this appearance of a respectable science only by dangerously fragmenting its conception of the patient. 

The following represents the crisis of present-day psychiatry:

Psychiatry lacks a conception of healthy mental life; i.e., it lacks an understanding of psychological normalcy. As a result, most aspects of patients' lives are perceived in pathological terms. Indeed, the very term 

Psychiatry lacks adequate conceptions of the many disorders of which it speaks. It has forsaken all serious attempts to understand the patient's experiences, deeming any such attempt unscientific. As a result, it has reduced mental disorders to a list of observable symptoms. 

Psychiatry lacks therapies appropriate for mental disorders due to this lack of conceptions. Thus, treatment procedures have become simplistic and reductionistic; therapies are now primarily pharmacological and behavioristic.  

In the briefest terms, psychiatry, a firstborn child of the Enlightenment, is in crisis today because its conceptions of mental illness and patients are too restricted and abstract. Present-day psychiatry lacks an adequate understanding of its patients and of itself as a healing discipline. It is necessary to at least return to the aspiration of the Enlightenment image of psychiatry as part of a comprehensive theory of human life, nature and society. In other words, psychiatry needs again to find its place within a universal philosophy of humanity that forms the basis for both the sciences and ethics.

It was not that long ago that we witnessed the frightening misuses to which psychiatry can be put when it lacks an understanding of itself and its patients. In both Nazi Germany and the Soviet Union, psychiatry was used as an instrument of the greatest collective crimes against humanity the world has known. It should be emphasized that in these totalitarian regimes, psychiatry was not simply one of the instruments for state crimes, it was a very important instrument. 

Psychiatry could serve such demonic political purposes because its understanding of patients was insufficient to distinguish between mental illness and mental health. Consequently, perfectly normal people could be classified and treated as mentally ill. Mental illness meant 

 to social or political categories, while mental health meant 

 to those categories (Beer, 1997; Lifton, 1980; Gluzman, 1989; Savenko and Vinogradova, 1996).

Currently, in the United States, there is no adequate conception of mental health. By default, then, mental health comes to mean 

. For children this means conformity to the expectations of parents, teachers, school counselors and other adult authority figures. Mental health in adults means conformity to society's expectations. 

There exist large numbers of mental health experts or professionals-social workers, clinical psychologists, psychiatrists and so on-who are prepared to misdiagnose nonconformity as a mental disorder. Such misdiagnoses occur readily when the only categories that mental health professionals possess are categories of pathology, and when the criteria for mental pathology are as simplistic and reductionistic as they are today. 

The social and political forces at work in America today remain, of course, very far from those in Hitler's Germany or Brezhnev's Soviet Union. But from our vantage point, the condition of psychiatry in the United States today is not that far from what it was in those countries. The crisis we have described entails psychiatry's lack of any firm grounding in a humanitarian and ethical understanding of the people it treats. Without this understanding, psychiatry could easily become the pawn of a variety of external forces. 

Indeed, it is already becoming the pawn of these external forces: In 1998, managed care companies and health maintenance organizations began transforming psychiatry to serve their economic aims. Under this transformation, American psychiatry has fallen into a further reductionism: Economic constraints now lead clinicians and researchers to regard patients from very limited perspectives. 

The fact that managed care organizations have significantly reduced the amount of time psychiatrists may spend with their patients is an indication of how this happens. For example, a psychiatrist's first contact with a patient is often restricted to thirty minutes; follow-up sessions are even more restricted. These severe restrictions threaten even the possibility of nonmedication-centered approaches, simply because they may be more time-consuming. Moreover, few funding organizations have an interest in proving their effectiveness. 

On the other hand, pharmaceutical companies are eager to pay for research showing the effectiveness of their medications. As a result, there are far more investigations of pharmacotherapy than of other approaches. Moreover, medications are quick and easy for the clinician to prescribe, easy for the patient to take and usually successful in reducing the patient's symptoms. In this way, biological psychiatry has justified the limitations on time and money imposed by managed care corporations. These corporations, conversely, by referring to the published research, deny payment for nonmedication-centeredapproaches. 

The result is that patients' problems are treated as primarily chemical imbalances in the brain. In this way, managed care businesses lead psychiatrists to practice medicine as if biological psychiatry sufficiently explained mental disorders. Biological psychiatry thus assumes a prominent role in present-day psychiatry, not because its hypotheses have been scientifically proven, but because clinicians must think in its terms in order to practice within the limits imposed by managed care companies. Consequently, psychiatric treatment and research move more and more toward a reductionistic conception of the patient.

This relationship between managed care companies and biopsychiatry arises from an elective affinity between the two. The sociologist Max Weber borrowed Johann Wolfgang von Goethe's phrase 

 to signify a noncausal process in which two sets of interests seek one another out and reinforce one another (Weber, 1958). In this example, managed care corporations do not actually dictate psychiatric approaches. Psychiatrists still are free to choose their individual treatment plans and research projects. But these choices must be made within the restrictions on time and payment imposed by managed care companies. As a result, psychiatrists increasingly perceive an affinity between the needs of their patients and the provisions of biopsychiatry. Thus, managed care companies have created working conditions for physicians in which the only reasonable thing for psychiatrists to do is conform to the treatment and research programs of biological psychiatry.

The impact of managed care on the basic direction of psychiatric practice and research illustrates the alarming malleability of psychiatry today. Psychiatry is in crisis because it has lost its moorings to an ethically grounded vision of the patient that is sufficiently holistic to appreciate human personhood in its full breadth.

Beer MD (1997), History of the psychiatric profession and its institutions. Current Opinion in Psychiatry 10:412-418.
 

Bockoven JS (1972), Moral Treatment in Community Mental Health. New York: Springer Publishing Co.
 

Gluzman S (1989), On Soviet Totalitarian Psychiatry. Amsterdam: International Association on the Political Use of Psychiatry.
 

Husserl E (1970), The Crisis of European Sciences and Transcendental Phenomenology; An Introduction to Phenomenological Philosophy. Evanston, Ill.: Northwestern University Press.
 

Jonas H (1966), The Phenomenon of Life: Toward a Philosophical Biology. Westport Conn.: Greenwood Press.

Lifton RJ (1986), The Nazi Doctors: Medical Killing and the Psychology of Genocide. New York: Basic Books.
 

Savenko YS, Vinogradova LN (1996), Russian psychiatry: tendencies of development. Independent Psychiatric Journal  2:50-52 (English translation 83-85).
 

Weber M (1958), The Protestant Ethic and the Spirit of Capitalism. New York: Charles Scribner's Sons.
 

Zilboorg G (1941), A History of Medical Psychology (in collaboration with George W. Henry, M.D.). New York: W.W. Norton.

Let us begin with an example. Suppose I am traveling from the United States to Switzerland, anticipating skiing with my son in the Alps. My anticipation becomes vivid and lively. I recall excitement mixed with joy at rapidly soaring down the mountainside, and I am now quite anxious to re-experience this thrilling adventure with my son-eager to be heading down the mountain with him. Later, as we stand on the crest of a deep and winding slope, the speed, thrill and admixture of danger and adventure will infuse my being.

Author | Osborne P. Wiggins, PhD

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The Crisis of Present-Day Psychiatry: Regaining the Personal

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