Reprinted with permission from Openmind 100:10-11 (November/December 1999) © 1999 Mind (National Association for Mental Health)

POST-PSYCHIATRY

Pat Bracken and Phil Thomas

As we head into the last months of the nineteen nineties it is worth reflecting on the achievements of the ‘decade of the brain’. Neuroscience promised to reveal the secrets of the nervous system and to render human consciousness and behaviour understandable in terms of a scientific vocabulary. Psychiatric patients have been scanned with all sorts of instruments and their biology intensively scrutinised. The general public, too, have been fed with promises of ‘breakthroughs’ in the media concerning the drug treatment of mental illness. The pharmaceutical industry has presented us with new ‘wonder drugs’ for schizophrenia and depression. These developments have served to underscore the message that madness and distress are essentially biological phenomena which will ultimately be ‘conquered’ by developments in our understanding of the brain and the treatments which will spring from this. Judged in terms of numbers of publications and levels of research funding the decade of the brain has been a great success for the neuroscientists. But what about patients?

This biological trend is part of a wider cultural shift towards understanding ourselves in a technical idiom. All sorts of human difficulties are now regarded as the rightful concern of psychological experts and their knowledge. Scientific psychiatry and psychology tell us that human experience is ‘something’ which can be analysed and explained in much the same way as other ‘things’ in the world. This is the key assumption of all technical and scientific approaches and underscores biological and cognitive developments. One of the great attractions of a technical paradigm is that it reveals a world which is open to prediction and manipulation. However, we should not forget that paradigms can conceal as much as they reveal. In their frantic efforts to convert the human world into something amenable to ever more manipulation and control, psychiatry and psychology obscure the essential mystery that lies at the heart of human experience.

In his work, the German philosopher Martin Heidegger continually sought to bring us back to this mystery. Heidegger’s central concern was the way in which the world shows up as meaningful and coherent for us. He rejected any explanation of this phenomenon in reductive terms, that is, that science and its language could be used to explain the complex depths of our meaningful world, a world which itself created science. His philosophy begins with lived human experience which is always ‘meaning-full’, always orientated and always value-laden. The world that we live in holds together for us because of the way in which things in that world (eg trees, cars, household objects, people etc.) exist in relation to one another, and it is this that gives our world meaning. We therefore experience our world as, first and foremost, a world involving relationships of significance. A scientific explanation of the world, however, misses out these ‘subjective’ relationships altogether and attempts to explain everything in purely ‘objective’, and supposedly ‘value-free’, terms. For instance, a tree is a tree because of it’s specific physical and chemical properties and functions, not because of the way in which it exists for us in relation to the world around it. This approach has had many successes and has allowed us to manipulate our environment in various ways. The achievements of physical medicine, based on biological science, are often the stuff of our daily news.

Traditional approaches in medicine attempt to explain illness by ‘working up’ to ‘subjective’ human reality from the ‘objective’ descriptions of physics, chemistry, biology and (more recently) computer science. The neuroscientific approach to human reality attempts to explain the value-laden world of individual human being using the ‘value-free’ language of science. Along the way it makes the claim that the scientific world-view is an account of the world ‘as it really is’.

Phenomenological accounts of illness, derived from Heidegger and other philosophers, attempt to reverse the direction of understanding, stressing the primacy and irreducibility of human experience, or ‘being-in-the-world’. The psychiatrist Medard Boss, a follower of Heidegger, writing about scientific approaches to the body says:

” The natural scientific research method treats the body as it might treat works of art. Given a collection of Picasso paintings, for instance, this method would see only material objects whose length and breadth could be measured, whose weight could be determined, and whose substance could be analyzed chemically. All the resulting data lumped together would tell us nothing about what makes these paintings what they are; their character as works of art is not even touched by this approach” (Boss, 1979, p. 100).

In other words to understand the importance, or otherwise, of a loss of pigment from a painting by Picasso we would first need to understand what the painting as a whole means. To reach this understanding we would need to reach beyond the canvas itself : to the personal and historical context in which it was painted. Analysing the nature of the pigment or counting the number of times the artist has used a certain colour does not help. Removing the same amount of colour from two different paintings might result in contrasting effects.

Attempts to explain the nature of human experience through the medium of reductive science are similarly misconceived. Many psychologists and psychiatrists appear blind to the absurdity of this quest and continue to maintain that biological and cognitive explanations of anxiety, depression and madness are just around the corner. As a result many patients find that professionals from these disciplines fail to engage with them as full human beings who have lives as well as symptoms.

For Heidegger, human reality is both primary and irreducible. Instead of being ‘something’ in the world and thus open to scientific explanation Heidegger views human experience as the basis upon which the world shows up at all. He talks about human being as a ‘clearing’ in which the world is revealed. As such, it is beyond the easy grasp of human science which is, itself, a product of that clearing. This is not to say that we cannot, should not, seek to illuminate the nature of this clearing. The point is that this illumination can only be at best an interpretation, it is a mistake to present it as a form of scientific explanation. In addition, the fact that this clearing exists at all is a source of wonder for Heidegger. It is, simply, a mystery.

The American psychologist Louis Sass relates these Heideggarian themes to the experience of madness. He points out that many aspects of psychotic experience can be understood as a concern with the fact that human existence is not just ‘something’ in the world but rather provides the framework through which the world can be revealed. In the course of everyday life we are not aware of this framework, not aware that our reality is constructed and shaped in a particular way. Madness involves a confrontation with this framework. This confrontation is experienced by all involved: patients, relatives and professionals. Sass argues against understanding madness as a deficit state and instead suggests that it often involves a hyperalertness and a ‘hyper-realisation’ that the coherence and meaningfullness of reality are dependent on the ‘clearing’ of lived human experience. He suggests that many of the concerns which become apparent in the course of psychosis resonate with the preoccupations of contemporary artists and writers. These concerns often relate to the constructed, and thus contingent, nature of selfhood and reality.

Science, religion and art are different ways of exploring the mystery which lies at the heart of human experience. Our argument is that madness is often (we do not claim always) also the product of this mystery. If this is so, then there are good reasons to be wary of attempts to account for psychosis in a purely scientific or technical idiom. By definition, psychosis involves a person being in a state where ordinary, accepted, reality is put into question. The experience of time, space and the coherence of the world becomes fragile. Our point is that there is a need for professionals to maintain a sense of wonder and at times to help their patients grapple with their preoccupations rather than simply seek to get rid of them. This is in no way to underestimate the pain and terror which are, so often, a part of psychosis. Instead, we are suggesting that professionals can be of most use to psychotic patients when they remain open to this existential aspect.

In the words of Heidegger:

“Celebration … is self-restraint, is attentiveness, is questioning, is meditating, is awaiting, is the step over into the more wakeful glimpse of the wonder – the wonder that a world is worlding around us at all, that there are beings rather than nothing, that things are and we ourselves are in their midst, that we ourselves are and yet barely know who we are, and barely know that we do not know all this.”

(Thanks to our colleague Peter Relton for his comments on a draft of this article).