Psychiatry, Health, and Phenomenology

February 19, 2020

Blog 3: Psychiatry, Health, and Phenomenology

Credit: Chris Gash

These past few weeks, I've been ruminating on ideas brought up in my bioethics class and mind-body physiology class, particularly about psychiatry. My bioethics professor specializes in neuroethics and brought up how neuroscience is progressing more and more towards fully understanding acute pain through brain scans and what not (that is, the mind-body connection in terms of actualizing subjective acute pain and quantifying/qualifying it from the outside via scans). Intrigued, I asked about psychological pain. He winced a bit and commented that I've just opened pandora's box. In brief, he explained that psychiatry doesn't really follow the framework of the traditional framework for medicine in its epistemology, conceptual frameworks and ethics (that is, the connection between what we know from empirical approaches and what we do about them).

My professor said that psychiatry, and to a large extent most complementary and alternative approaches, act on the principle of abductive reasoning (or "ex juvatibus" reasoning). This can be conceptualized best, I think, in a proposition:

Y --> "X" <--> Z

Here we can think of Y as "treatment", X as the hidden mechanism and Z as the desired outcome. Between administering a treatment Y and the outcome Z, psychiatry does not have thoroughly detailed mechanisms to understanding why things work compared to biological diseases. I thought of schizophrenia as a counter-example and my professor rebutted saying that one may think we know so much about schizophrenia through serotonin receptors and what not; but really, we are far from understanding what it is, opting instead to treat people with an x amount of factors (arbitrary) that may bring up schizophrenia without actually knowing why it is that these factors make up schizophrenia. 

The mere order of events of treatment Y to outcome Z (feeling better/less symptoms) is a fallacy (post hoc fallacy) that is mitigated by the scientific method. At its most basic form people are compared with similar symptoms and are given different treatments to examine the outcome of Z or are given no treatment and see if one feels better (Z). As science is more confident of the correlation between Y and Z, one may be prompted to investigate these middle terms (X or perhaps more middle terms, more mechanisms) to fully understand how treatment Y works. Psychiatry is far from this aspect of the process compared to the understanding of pneumonia, for example.

But psychiatry's problems are the tip of the iceberg for medicine in general. Broadly, medicine is moving more towards a more holistic definition of health (biopsychosocial model for example); but only in a perfect world does theory lead directly to praxis in a good way. In reality, the practice of medicine can work, or often rely, on this ex juvantibus reasoning, focusing on the effect of the treatment (because of the effect) that drives the reason for doing it rather than work of existing literature suggesting some kind of effect. 

Without these classes, I would've hit the iceberg and sunk in a quagmire of cognitive dissonance. So far, my mind-body physiology class has brought together my thoughts on this small intersection between the inner life and the biological life. We can see this best through this example of psychiatry, where I think the integrative aspect towards holistic rather than purely reductionistic frameworks shines through best.

Iceberg Metaphor, from Open textbook hong kong

Treating psychiatric disorders involves balancing what can be done physiologically or pharmaceutically with what can be done cognitively or existentially (what my professor calls balancing "equipoise"). While focusing on the effect of a treatment and building one's clinical knowledge on this (casuistry) is one way of healthcare (and has been for many thousand years with Chinese medicine, ayurveda, etc.), modern medicine is more comfortable knowing that what is being done is precise and accurate. Having one effect may be one thing but giving a treatment and having multiple effects would cause a headache. To steer clear of this, the balance of weights (equipoise) here rests on the other side of the coin in the "mind-body" schemata; the mind and its experience of illness. Whereas disease is viewed physiologically, illness is experienced phenomenologically; linked together almost in a Cartesian unity. The mind being seated somewhere, somehow (be it spiritually or from a complex neural network system that regulates itself through supervenience), in the body (or with the body?). However, there are other ways to think about this that doesn't have to fall into a dualistic dogma that is then easily dismissed afterwards. 

I propose that phenomenology is this central alternative framework to balancing this problem of psychiatry's constellation of emotions, behaviors, thought patterns, etc. with the physiologic manifestations. Phenomenology's slogan, according to its "founder" Edmund Husserl, is to return to the things themselves; that is– the phenomena– rooted in the subject's experience and interpretation. There is something irreconcilable about one's experience of his phenomena that cannot be accounted for in his physiology. We can learn a great deal about how this is done through the existential phenomenologists such as Martin Heidegger, Maurice Merleau-Ponty, for the foundational thinkers; and to Medard Boss, Frederik Svenaeus and Richard Zaner for the more medically focused phenomenologists. 

If we take the example of schizophrenia and try to conduct a phenomenology of it as an illness, one must consult the paradigm schizophreniac and engage in a shared investigation into what it means to live with schizophrenia. How phenomenology differs from the usual way that psychiatry investigates this is that phenomenology "brackets" aside any other kind of pre-conceived notions when describing the phenomena. When a schizophreniac talks about hearing "voices" in their head, a phenomenologist would not point at hallucinations related to an upsurge in dopamine in a specific area of the brain, for example. Neither would she try to think about how she hears voices in her head (her internal voice, her imagined voice of her mother speaking or a deeply rooted childhood phobia of horses manifested in a deep male voice, for example). These pre-theoretical assumptions or "biases" affect the understanding the phenomena of schizophrenia, leading astray the phenomena itself.

Questions that can come up when conducting a phenomenology would be, to begin broadly, "how does the world show up for you?", or if not asking it directly, it can be a driving question framing the phenomenological inquiry. The ways in which the patient responds could then drive the meaning-making or interpretation that the investigator is trying to get the patient to disclose. This is where integrative medicine shines through, which defines health largely in the context of the relationship between the practitioner and the patient. From this carefully considered inquiry, I think that treatment outcomes can be improved in this reflective way, especially since the patient is involved in this process of understanding an illness that is solely his. 

While I've above described in broad strokes how a phenomenology of schizophrenia could be conducted (at least in a mediating relationship between a practitioner/investigator and the patient), I don't mean to say that phenomenology should be done alone in the clinic. Rather, I think that this method can be a methodological framework for a more patient-centered approach when considering treatment. Phenomenology can be a useful tool in a practitioner's kit of conceptual tools that they can use to help the patient be restored to health.

Still from Terrence Malick's Tree of Life

Health here, as I re-emphasize, is intrinsically united by its biological, social and psychological parts. And so when a psychiatrist, for example, desires to use pharmaceuticals to address a patient's low levels of serotonin, he is also aware of the socio-cultural and psychological (and might I add, existential) dimensions of the treatment. In integrative medicine, the psychiatrist may add suggestions on changing one's approaches to eating (both biological via nutrition and the social dimension of eating) as well as employ mindfulness based stress reduction techniques or cognitive behavioral therapy designed to address the patient's mental-existential faculties and to be aware of changes that he may not altogether expect. 

Every person, according to Heidegger, has an ontological characteristic of "thrownness", or the sense of being thrown into the world, not deciding before hand to live in this time period or be put in this cultural and socio economic context. Nevertheless, one still feels embodied and immersed in the world. One way in which the patient may interact with the world is through the body (Merleau-Ponty, Zaner)– that physiological make up that affects the way the world shows up for us (either very obviously as in getting a paper cut and experiencing a deep seething pain or more implicitly in a sense of unease at the end of the day that may be attributable to food consumption or serotonin levels). While scientists may observe from the outside changes in serotonin levels or blood clotting factors rising, that is not how the phenomena of an illness is grasped in its entirety. Illness relates heavily with a person's being. As Svenaeus suggests, illness is an unhomelike "being-in-the-world", which refers to a sense of uncaniness when engaging with the world, usually resulting in the rather 'passive' sense of the body coming to the forefront as an active constituent of the world to pay attention to. 

Person falling. Source: google images

On the flip side of the coin, there are certain mechanisms that we do understand that can contribute to systemwide changes in the body from the mind; this is what I'm learning about in my mind-body physiology class and is why I think it is pivotal to the intersection between biomedicine and phenomenology. I've been learning about how cortisol, the main stress hormone, has overarching effects on different systems by interacting with the HPA axis (hypothalamic pituitary adrenal) in the brain. An increased amount of cortisol produces the stress response, and when exposed to chronic stress, lower levels of estrogen and testosterone are affected downstream, leading to infertility or other syndromes; growth hormone is decreased (leading to low protein synthesis, immunity, glucose); thyroid hormone levels are lowered, resulting in lower basal metabolic rate (and hence lower fatigue).

The relationship between the rest of the organs with the HPA axis is rather fascinating and has a strong implication towards the role of the mind in perceiving stress, which can be physical, social, mental, or existential. But as far as we understand them as mere "objects" of scientific inquiry, we must not forget the strength of the phenomenological perspective when exploring illness. These physiological mechanisms work in such a way (a naturalistic way) to present and contribute to the phenomena that the patient experiences (the "life-world", as Husserl put it), which is always already interpreted as the act is happening. The relationship to the phenomena for the patient is thus personal.

The care of the patient means that the patient should be cared for (Peabody, 1927), and if medicine is to progress, it must take care in balancing the multi-dimensional aspect of a human being: their existential, biological, social, psychological layers entwined in an inseparable, indivisible unity. I think it's human nature to be rather curious about oneself; but this can happen only when one is open to be so– that is, when one's body and mind is free to attend to its inherent sense of wonder. But what happens when one is ill and cannot help but attend to their sickness? Is it not similar to when one is too busy to stop and smell the flowers? This is why I don't think that we could be content in our modern secular age with reasoning focused only on the effect, especially in the ethics of healthcare. This consequentialist approach lacks the driving force of the cause, the explanation of the how entangled in the why. So we must investigate beyond merely the ordering of events in ex juvantibus reasoning (X treatment happens then after the Z effect happens) and inquire into the physiological, neurological, existential, social, anthropological, psychological aspects of human being and the ambiguous milieu its being is enmeshed with.