Rough sketches: Problems of the Medicalization of Psychology

I started my first job (ever) as a medical scribe last month. Two days ago, I finished training and am awaiting my very own "solo" scribe shift, where I go rounds with a doctor in the ER and write his chart for him. These shifts were 8 hours long from 2 pm- 11 pm, 2-3 times a week. My experience there was very novel and fascinating. This was a world that I had always thought about living in theoretically. It was quite a different experience seeing it with my own eyes. And so the shifts were immersive for me, despite it appearing run of the mill for everyone else. I brought along some baggage with me for my mind during idle times. These were the questions that I've thought about regarding the Philosophy of medicine. I thought that the ER was the event for wrestling with the problems of the philosophy of medicine the most. To see things firsthand in real life gave a unique perspective.

Among the various thoughts that arose in me as I shuffled through from room to room with a clipboard in my hand, the problem I dwelt on the most was my encounter with the psych patients, if we were to give them enough decency to call them that. And it's particularly problematic because it appears that the medical field hasn't gotten over Descartes. I dwelt and I dwelt on this. I thought to myself, maybe I'm not even over Descartes, as I used to be his most ardent supporter in high-school. The past cringy twitter bio "Cogito ergo sum", still paralyzes me when it comes up to this day. I've since become an anti-Cartesian and then realized most of modern philosophy indeed has become so as well. And yet there's this Cartesian foundation inherent in the medical field. The fact that people who come with issues of the brain are divided into Psychiatry and Neurology patients, the classic Cartesian dualism applied in real time.

But enough with this fanaticism with Descartes. The problem of psychiatry, philosophically, isn't just about this apparent parallel. Medical decision making is a unique skill that takes into account ontology, epistemology and ethics all without realizing it. Many say that Medicine is the most "human science" as it deals with humans face to face. However, it's clear that medicine is neither a science nor a humanity. Medicine is a discipline in itself, one that appears practical but really is a lifestyle of investigation into the core of what it means to be a human. Perhaps I can't speak of psychiatry, but the way that the emergency department handles psych patients, in general, is quite problematic. If every staff member in a hospital acts itself out authentically, the most paradoxical contradiction of inauthenticity is in forced restraint of psych patients who are deemed to pose "a danger to themselves or to others". There's something about that that doesn't appear right, and the mood shifts immediately from calm to anxious. Clearly, it isn't an empathy of the rather anxious patients that poisons our mood. Rather it is in the mere act of carrying it out that we feel uneasy, the most unlike ourselves. And that kind of uneasiness forces us to inauthentically follow protocol, to submit to "the one". In feeling that mood in an altercation that occurred in the hospital, I began to ponder what kind of problems arise from them.

The medicalization of psychology has a history of ethics. Those that we have deemed "twisted" and "abnormal" not from physiology, we have cast and labeled psychotic. Governments all over have decided to "treat" these people through medicalization. It has now become quite standard for people to have "psychiatrists" for a multitude of problems. All from depression to schizophrenia. Government mandate leaves the healthcare sector as the executors of its will. This kind of angle is very unique. For the government's decision to medicalize is unlikely to have come from doctors advocating for Freud. Really, the agenda, wherever it came from or wants to go, has dictated the scope of how medicine treats these people.

This can yield to a litany of skepticism for those interested in seriously considering the metaphysics and epistemology of mental disorder from both sides. Questions flung around varying the "how can we know?" dogma will likely confuse the two fields that have received mental disorder as a problem to be treated. Ontologically we may ask, what is mental disorder? Epistemologically we may ask, how can we know if what we're looking at is mental disorder? Trying to answer a question with an epistmeological foundation will likely yield very unfruitful results vice versa.

Considering the question ontologically while trying to fit it in the medical discipline is to try to fuse the horizon of illness with this new notion of mental illness. It has been categorized in a paper that we can see illness as an "unhomelike being-in-the-world" (Svenaeus, 2014), which when considered can be quite revealing. However, trying to fuse that with metnal illness is quite problematic. If we switch over to epistemology, we would come across the problem of other minds and trying to get at the "other's" perspective. How can we know if a person we suspect as having mental illness is feeling an "unhomelike being-in-the-world"? Psychiatrists and psychologists alike can delve into this problem of quantification and diagnosis to try to bring out evidence for such a thing. But can we agree with this sentiment for those patients that aren't aware of their condition?

Things may be clear with cases like depression but fusing illness with other mental illnesses are going to take more legwork. It is the task of the physician to take the patient qua patient, and try to reveal what is wrong with the patient that causes this "unhomelike" feeling. The question of mental disorder as an illness brings back to the fundamental question about what illness is. Are risk factors of breast cancer really worthy of a diagnosis for a patient to be treated? This crosses boundaries as well from metaphysics to epistemology.

Clinical medicine may not think about this at the moment, but all these problems are dealt with when medicine is being practiced. It is the event itself. I find the problem of the medicalization of psychology very revealing to me because it exposes this unexplored horizon of medicine. Many of the problems have not been worked out, and the philosophy of medicine is a relatively young field. Even more so, my aspiration to be a doctor is unlikely to benefit from armchair theorizing about how medicine should be run. But I still think it's what makes the field of medicine so rich and laden with philosophical problems worthy of investigation. Medicine has a history that as a collective reveal not only the result of political compromises or Cartesian commitments. Rather, medicine engages with the questions of philosophy from the angle of a tradition that itself has its own philosophical problems. And this particular truth, this disclosure of being, that's left behind as it's revealed and at the same time perpetuates and adapts is why the task of thinking is itself to reveal being. It's not only philosophy of medicine, but rather a philosophy as a way of life.

Perpetual Draft: Living Dangerously: Existentialism reconsidered

"What if everything in the world were a misunderstanding, what if laughter were really tears?" 

- Søren Kierkegaard 

        Kierkegaard, a theologian and voracious writer in his day, is widely considered by most people to be the "father of existentialism". This quote comes from his Magnum Opus "Either/Or". Kierkegaard's pseudonymous author (fictitiously named "A") of the first part, the "either", or the "aesthetic", considers the dubious nature of objectivity and indirectly invites the reader to consider the slipperier and much more unpaved path of subjectivity. This foundational turn in thinking away from the then dominant Hegelian "scientific" approach of the time and towards the priority on the individual's own subjective notions and personal experience is what many consider the "ground" of existentialism. Kierkegaard's later pseudonymous author Johannes Climacus would say "Subjectivity is truth".

        From this viewpoint, many newcomers to existentialism– both amateurs and academics alike– may use this lens when examining the history of 20th-century thought associated with Kierkegaard's objections and stance. This would lead many to group together the writings of Sartre, Camus, Heidegger and like-minded thinkers with Kierkegaard against the "scientifically" oriented philosophers of the time (neo-Kantians, Hegelians, Cartesians). However, the identification of this movement is potentially a serious misinterpretation of these writer's ideas grouped into the genre/mood of "existentialism". If one biases himself with this perspective when looking back, he might turn towards calling existentialism simply a glorified "relativism" where everyone's perspectives are simply a manifestation and anchor of the culture of the time. 

       However, there are positives in looking at the structure of thought related to the fundamental ideas Kierkegaard had preached. Except, he didn't really begin this movement of thought. Arguably, almost two centuries prior, the mathematician and theologian Blaise Pascal, a contemporary of René Descartes  (arguably began the whole scientific systematic doubt built into the philosophical attitude of "rationalism"), should be considered the first "philosopher" associated with the ideas of existentialism. 

"Custom is our nature"

        Cries Pascal who also invented the calculator. Opposed to Descartes' quest for a method to certainty about the existence of the outside world (which ultimately led to a proof on the existence of God in the rest of the meditations you probably didn't read), what isn't talked about in seminar is Pascal's analysis of the dangers of systematizing Christianity throughout the world. At this point in the 17th century, the foundations of uprooting the custom of the time through theological beliefs towards a more scientific view begun rolling. And yet, Pascal himself also was a staunch defender and supporter of the newly formed scientific method. This turn towards the reliance on Science for answers to small functional questions and its overeager interpretation towards a "theory of everything", was preached by another thinker ahead of his time: "Friedrich Nietzsche". 

"God is dead. and we have killed him"

        Nietzsche's madman in Zarathustra laments. Nietzsche is also considered to be one of the "existentialists" and arguably came to the same conclusion as Kierkegaard in regards to the "Herd/Crowd" that tempts inauthentic behavior conforming to society. All these parallels despite Kierkegaard being theistic while Nietzsche arguably atheistic in origin. 

        If one has read this far into existentialism, the glaring contradiction in ontological belief should be enough to raise alarm to the chaos of trying to contain these great thinkers into the small close-minded Parisian notion of Existentialism that another philosopher many decades later "Jean-Paul Sartre" had coined in his "Existentialism is a humanism" public address.

"Existence precedes essence"

       Sartre declared as the tag-line for existentialism. It basically asserts the priority of one's own existence and its subjective potential to be anything one wills as the basis for finding "truth" as opposed to "essence" or the objective facts about us. Sartre will go on to assert his famous notion of radical freedom as an extreme culmination of his thesis.

        Sartre's attempts at popularizing existentialism backfired on what his main goal in defining existentialism was. Many thinkers/philosophers at the time rejected the label despite being associated with "existentialist beliefs". Among them, Sartre's friend and contemporary "Albert Camus" of "the Stranger" fame. What Sartre gives us is indeed a very shaky attempt at trying to capture the common qualities of many profound ideas that come to be vaguely associated with the "existentialist movement". In addition, the timing was both a blessing and a curse. With existentialism coming into vogue in the post world war II era, many are biased towards dismissing existentialism simply as a "post-war mood" not to be taken seriously in today's more stable and more technologically advanced society. 

        And all these misunderstandings of existentialism aren't simply unfounded because of a philosopher's nitpicky biases, they're completely understandable considering that the fundamental tenet of existentialism relies on bias itself: "subjectivity". However, existentialism should be reconsidered further in its proper place in the history of thought. What exactly was Sartre responding to, and why was it urgent for him to issue a public address on what Existentialism is then later deny having written it? 

        Underlying all these questions comes one philosopher also inaccurately labeled an existentialist– Martin Heidegger. Heidegger was a philosopher at the time of Sartre. Many of the French existentialists (Sartre, De Beauvoir, Merleau-Ponty) had read excerpts of his work and were deeply influenced by them. Heidegger's importance in understanding existentialism's pivot towards prioritizing the individual originated from a well considered and thought out reaction against– Edmund Husserl. Although still influenced by the "rationalistic" tradition, Heidegger considered Husserl's novel method of Phenomenology revolutionary.

        Husserl, tried to bridge the idealism of the Hegelians and Neo-Kantians at the time with a "scientific" attitude unlike the kind of systematic doubt and rationalization that originated with Cartesian thought. He came up with phenomenology and its slogan to "return to the things themselves". Heidegger thought this approach to philosophy as revolutionary but found it too idealistic and lacking. Heidegger thought that while "returning to the things themselves" is a revolutionary concept, ultimately phenomenology should really be focused on the everydayness of the human being and its relationship with the world (as opposed to the analysis of a mind as disembodied and distinct from the world). 

        While existentialism has a shakiness in its definition, it still remains a useful term to signify embracing the history of thought that pointed towards those doubtful of the foundations of the rationalistic tradition. Seeking answers to what it means to be from many gods, to one God, to modernizing technology and back to many gods. Heidegger thinks that this all is a fundamental misunderstanding of what it means "to be". A society relates to itself and tries to perpetuate this relation from taking a stance on what it means to be. When a human being embodies the dogmas of society, one ultimately takes a stance on what it means to be, all loaded with inherited goals, fears, attitudes, etc. Existentialism, like many movements or schools, reveals and also necessarily conceals.

        Nietzsche famously said to "live dangerously" and I think that should really be the slogan of Existentialism if it were to persist and be true to what unites these thinkers. Existentialism isn't an ethics* nor is it grounded in it (it really isn't a humanism). Rather, it is a way to follow Socrates' advice to "know thyself" and one's condition, the fact that is common to all human beings– our existence. Existentialism first grounds oneself in the everyday– to not cast away emotions, goals, etc. but rather to be aware of them in addition to whatever one decides to pursue in life. From there we take a stance on what it means to be. There are many dangers about this kind of living. For one it is ultimately the human being that must take this stance and must not rely on others, an ideology, etc. So in a sense, anyone who proclaims himself as an existentialist that follows existentialist principles makes him really a pseudo-existentialist (I'm looking at you rick and morty bandwagoners). Another danger is the fear of the potential consequences of thinking existentially. One may come across the anxiety-inducing "existential crisis" or follow the train of thought towards "nihilism". Being afraid to deal with this face to face tempts inauthenticity and conformity on taking a stance one doesn't actually want to take.

And so ideally, you would not commit yourself to existentialism. If we take existentialism as a mood, the existentialist attunes himself to the mood of society, wherever he may be. Really, that's what a philosopher is; what a philosopher should be. There's a lot of heavy baggage with movements like existentialism, rationalism, thomism, etc. Sometimes they're baggage that we can't justify carrying for where we're headed, wherever we go as individual philosophers. But we at least should take the ideas in mind. Movements are so named historically not because we are "done with them" or "solved them", rather they mark an important point in the western canon. A voice that revealed a part of our being that we inherit. And as we march forward in time, we must embrace that history, even if the truest revelation of our being in the present means to stand firm and resist it. "Live dangerously".

* although it can be an application of it– check out Simone De Beauvoir's "Ethics of Ambiguity" for an idea of how an existentialist ethics may look like.

Things cut from the article:

A fundamental attitude that questions the prevailing thought while at the same time, loading the word with the idea of "existence", etymologically originated in the greek word ek-sistence meaning "to stand out". For what it means "to be", what it means to exist, is what defines existentialism and not merely a "post-war mood" where "subjectivity" reigns supreme. Surprisingly, this misunderstanding– the reign of opinion stemming from subjectivity, is the kind of prevailing mood of today with the whole "fake news" ad hominems thrown from both sides. Facts are thrown out as a source of knowledge, and opinions that are perceived as powerful– often the ones loaded with provoking strong feelings– prevail. Labeling existentialism as this kind of thinking does the true meaning behind existentialism injustice.