The Crisis of Present-Day Psychiatry: Regaining the Personal

September 1, 1999

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 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.)

Psychiatry's Limitations

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.

Eccentric Positionality

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.

Philosophical Anthropology

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 existential types (Kraus, 1977).

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. 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. 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. 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.

Toward Regaining the Personal

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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