Whilst I was studying, this essay was by far my favorite to write, naturally; I felt like I was writing about myself and it was rather therapeutic. While researching for it, I made discoveries about the nature and treatment of mental illness which I never expected to come across. The results I found educated me about how much certain branches of philosophy can influence the field of mental illness. The content makes for an interesting read for both sufferers and those curious about the subject, and also for those whom are interested in the subject of philosophy as a whole.
‘What role should phenomenology play in our conceptualisation of mental health?’
My focal point in this essay is to bring to the attention of the reader the significance of phenomenology in the field of mental health; both in the diagnosis and treatment of mental illness. I have researched and sourced three papers. Firstly I have given an analysis of Ghaemi, whose sole argument regards the significance of phenomenology, mainly in drawing a distinction between differing episodes in bipolar affective disorder. He stresses the point that there needs to be more recognition around ‘mixed episodes’, and that they are, despite common belief, more prevalent than either of the two extremes of mania and depression. Following this, I studied the work of Johnson. This paper was based on a study conducted in a mental institution, encompassing the experiences of the inpatients and psychiatric nurses. What has been brought to light by this paper is that more emphasis ought to be placed on gaining an insight into the world of the patient, as opposed to commonplace techniques merely involving textbook type theories. Lastly I reviewed Morris’s article in which he claims that philosophers (writing on mental illness and health) themselves have an impact on psychiatry and the lives of the mentally ill. In this sense phenomenology has certainly had an influence on psychiatric medicine.
Ground breaking phenomenological based research has shown, as Ghaemi states in his paper, that- as opposed to previous research claiming that in bipolar affective disorder there are two opposite poles of mood (known as ‘mania’ and ‘depression’) and the affected patient experiences one of two of them during varied phases- these states do exist, and can be experienced individually, but they can also occur together; as one. In psychiatric terms such states are defined as ‘mixed episodes’.
Ghaemi is of the strong opinion that phenomenology must play a large role in today’s psychiatric methodology in order for it to move forward; so much so that he believes the implementation of phenomenology must be put in place before the patient is diagnosed. He holds the view that, when dealing with disorders such as bipolar, the answers we strive for in our research ought to include the question of ‘…how manic and depressive syndromes differ phenomenologically’. (p.123)
In light of this, the aim of Ghaemi’s paper is to survey and critique what is the modern consensus regarding the state of the ‘…phenomenology of mood states and the clinical implications of that knowledge’. (ibid)
In reaction to some psychiatrists and other philosophers who still hold the view that bipolar disorder is a mental condition, consisting only of opposite poles of mood occurring separately, Ghaemi is an advocate of the theory which argues something different: that, in actual fact, mixed states not only exist but they are more common than poles of mood that occur alone. According to Ghaemi, the two poles of mania and depression are nothing more than the two most extreme forms of mood- they do not stand alone and there are various states which exist in between.
Phenomenological research has also shown that, during either depressive or manic episodes (in patients diagnosed with bipolar), the patient’s concept of time differs from the norm. In mania this manifests itself by causing the patient to experience life- quite literally- in the here and now. The sufferer only cares for the present moment and does not worry about or fear the future (nor do they look forward to it) as other ‘normal’ people naturally do. In this sense the manic patient enjoys every aspect of life, as if everything and everyone were entertaining. The manic patient becomes somewhat boisterous. Moreover, during a depressive episode, there is no present nor future, only past. Those of us who are unaffected by mental illness are able to look on the past with fondness and enjoy reminiscing on joyous memories. Sadly, for patients suffering from the depressive side of bipolar it is a completely different story. The past for them is tragic, dark, unrelenting and destructive, a place of punishment and regret.
Extensive research has been carried out which suggests that- in patients with bipolar disorder- one’s perception of time becomes warped throughout phases of depression and mania. The results lead to the conclusion that ‘…the subjective experience of time was slowed in the depressed [and] sped up in the manic’. (p.124)
Further, it has been proposed that the sufferer’s circadian rhythms are altered and become irregular throughout periods of interrupted sleep. Empirical research (in phenomenology) has shown that this kind of sleep disturbance contributes to the symptoms of mania. As for depression, it seems that, due to restlessness of sleep, a characteristic associated with bipolar depression, the usual REM cycle is either disrupted or ‘…more time [is] spent in REM’. (p.125) Therefore, one of the most important strategies in the treatment of bipolar- within both manic and depressive phases- is to control and regulate sleeping patterns. Clinical evidence also highlights that ‘…insomnia is an early prodromal sign of a new manic episode and that sleep regulation is an important feature to maintaining stability’. (ibid)
In light of this evidence, it is vital for psychotherapists and the like to place emphasis on the patient’s perception of time; of their memories from the past, the way they are feeling in the present and their hopes for the future. In depressives, the central aim is to draw the individual away from the past (and especially away from bad memories and what they conceive to be ‘mistakes’). Living in the past and believing one’s past mistakes to be of high relevance in the present- often as a way of punishing one’s self- is certainly a significant contributor to the sense of misery and sorrow so often inherent in depressive patients. Moreover, those displaying symptoms of mania merit a different sort of treatment. In such cases, what is important for the therapist is to create grounding in the past, for example to enable the patient to recall previous episodes which have led them into danger. Reminiscing on these experiences of the past may help one not to repeat certain behaviours again.
An additional feature offered by Ghaemi is the need for some sort of self-awareness of one’s illness. In some ways this is a fundamental aspect in order for the sufferer to enter into remission. In his paper, Ghaemi refers to such self-awareness as ‘insight,’ and this ‘…insight represents perhaps a prototypic experience that requires phenomenological research. It is a subjective experience, yet one that can be objectively assessed’. (ibid)
Statistics demonstrate that manic patients display a reduction in self-awareness (insight). However, this inadequacy appears to be distinct to mania and thus does not, on the whole, affect the individual afflicted by depression. This aspect within mania appears to be a common reason why so few sufferers seek help, because they lack insight and are essentially unaware of their ill state, and also of course because most people going through a manic phase report it as being ‘fun’. On the other hand, it is far easier for medical professionals to diagnose depression or a depressive episode; on the grounds that ‘patients experience depression with insight; thus they seek help for it’. (ibid)
In addition, patients with bipolar may have no knowledge of their past manic episodes and only seek help when they are depressed, giving the impression they are suffering with something like clinical depression, as opposed to bipolar. In such cases, one may easily be misdiagnosed and prescribed the incorrect medication, generally causing the patient to deteriorate.
The central aims in Ghaemi’s paper which have been discussed above, and as referred to in his conclusive paragraph, are creating a recognition of ‘…mixed mood states’ but also that, although these mixed states appear to be ‘…more common than pure manic and depressive states’, it is still important to observe that ‘…there are important features that differ between mania and depression’. (p.125)
Additionally, it is imperative to consider the role of the differing perceptions of time between mania and depression, and in turn to recall the self-awareness factor which is compulsory throughout diagnostics and in aiding the patient on their road to recovery.
Moving on to Johnson’s commentary, the ambition of her study was to gain some insight into the minds and the struggle experienced by mentally ill patients. She describes her study as involving 10 mentally ill patients who were asked questions about their feelings surrounding their illness. A significant feature in the structure of the survey was the use of Heideggerian based phenomenology. The ‘two major themes [were]–struggling and “why me?”’. (p.195)
The latter, she holds, ‘…could be interpreted existentially’. (ibid)
Conclusively, another aim of the inquiry was to educate doctors and carers who play a role in the patients’ lives, and also, of course, to develop an empathy with the patients themselves.
One sole aspect of gaining an understanding and developing empathy with those who suffer from mental illness is the exercise of interpretive phenomenology, according to Johnson. She advocates that we ought to be asking questions about meaning; but not simply ‘…a question about what happened’, (p.196) but more about gaining an insight into the mind of a mentally ill individual and their struggle; it is in respect of developing compassion. All this considered, we must strive to understand and ‘…interpret an experience within the context of their world’. (ibid)
An important phenomenological fact which one must consider whilst reading this transcription, is that, as well as the rest of the world, the patients which participated were all affected by their background and the world around them; shaping ‘…who, what, and how they are’. (p.197) Keeping this in mind, we gain further empathy and compassion with the mentally ill, realising that they are still human beings, just like the rest of us whom are unaffected.
Johnson’s paper covers the topic of ‘struggle’. She explains how the physical struggle that patients (in an institution) experience serves as a sort of metaphor for what really goes on in the mind of someone who is mentally ill. Being literally bound by restraints and trying to struggle free cannot be dissimilar to the way in which mental illness limits one from leading the sort of life which is considered to be ‘normal’ by most people. Further, ‘…the symptoms of mental illness restrict one’s possibilities and thus, one’s freedom’. (ibid)
Another form of struggling which is mentioned is the battle patients fight in order to make some sense of the way they are feeling and their thoughts. Mental illness can be incredibly overwhelming and often involves hearing one or multiple voices, whether it feels like they are inside or outside of one’s head. Those suffering from various forms of mental illness will describe these voices as being bullies or even violent, or that the voices argue amongst themselves. This is incredibly confusing, especially as one feels they are forced to decide which voice to pay attention to, or follow the orders of.
In addition to the types of struggle the patients in the study described, it was also mentioned that it is not uncommon for sufferers to fight the will to commit suicide, and, further, to gain acceptance around failing at taking their own lives. This is possibly the biggest and most significant battle of all.
Returning to what was touched on earlier; Johnson draws attention to Heidegger’s philosophy regarding the struggles we face as human beings and as individuals. His focal point is that every one of us is born into a situation which is- at least in some way- different from any other person. We are then bound, for the rest of our lives, by these circumstances, and therefore also limited by them. Though we may believe that ‘…we have complete control over whom and what we are; there are limitations to what we may become’. (p.199)
More importantly, we are mortal and will all, sooner or later, meet the same ends. In the same way, sufferers must come to accept- according to Johnson- that the lives they lead are finite, and the sad fact is that there are limitations on what they can do due to the nature of their particular illnesses. The patients who participated in the study were told that there were limits to what they could do with their lives- their ambitions, for example- and it became apparent that they struggled greatly to accept these limits.
In addition to the struggle the patients described, the question of ‘why me?’ was also significant. In one sense, Johnson describes this question as literal- as a patient asking why they have been locked up and torn away from their normal lives, for example. In another sense ‘…it was an existential question: Why am I the way I am? Why am I mentally ill?’ (ibid)
For the individual affected by mental illness, it may seem unfair that they, personally, have to suffer. It seems natural to ask ‘why?’ Some may even feel that it is a kind of punishment; that they are perhaps bad people. As I mentioned earlier, acceptance appears to be a key factor in aiding patients with the recovery process. It is key in accepting when one is unwell and acting out of character (such as during a manic episode), and it is key in the sense that it is difficult to come to terms with the fact that, generally, having a mental illness means that it will stay with you for the rest of your life, and you may have to take medication until the day you die. This is a hard fact to accept, and this is why it is important that the right balance between therapy and medication is achieved.
Johnson mentions that one aspect of non-acceptance is patients displaying anger, both at themselves and towards the staff on psychiatric wards or in hospitals. The manifestation of anger is not unusual in the presence of mental illness. It can be a sign of a variety of things. It can be symptomatic of depression in that one may feel fearful or over emotional, even due to lack of sleep or too much sleep. It can also be associated with mania, since manic episodes often involve irritability and arrogance.
At this point, Johnson draws some conclusions. What has come to light as a result of the study is that it is not ‘theories’ which provide medical professionals with real insight into the world of the mentally ill, but empathy, care and attention (to name a few). Whilst the best course of action may often appear to be going ‘by the book’, the nurses who took part in the study held that they were not ‘…concerned merely with a disease. We are concerned with people’s lives and the impact of illness on their lives’. (p.200)
I have discussed more than once in this essay that the lives, backgrounds and the environment in which we are all raised are all of high importance in the way that we develop mentally. Of course, people don’t simply become mentally ill due to the way they were brought up, and having or not having had a ‘difficult’ upbringing does not seal one’s fate as to whether or not they will suffer later in life. But we all handle life and the challenges it throws in our paths differently, and it is crucial to address this in the process of recovery. Moreover, it must be added that mental illness is not simply a result of environmental factors; it is, in most cases, also down to chemical imbalances in the brain.
On a final note, Johnson stresses that family- and their relationships with the patients- plays a principal role in both acceptance and recovery: Accepting the past for what it is and events that had an impact on their present circumstances, and moving towards a strong recovery by rebuilding or strengthening relationships with family, especially for creating a safety net for when the patient is released from hospital.
Advancing to the next paper, Morris announces that the aim of his article is to discover- from a philosophical viewpoint- ‘…the factors that contribute to the causes of mental illness and mental health’. (p.47)
His ambition was to show in which ways philosophy, today, has an impact on and is significant to modern psychiatry.
One of the sole contributing questions in his enquiry was in which ways philosophy has sponsored a ‘…theory of the causes of mental health or illness?’ (p.48)
Morris claims that it is not the direct responsibility of philosophy (and well known philosophers) that there are still immense issues surrounding the subject of mental health and illness. Part of the reason for this, he suggests, is that the majority of, in his own words- ‘disturbed individuals’- have not read any major philosophical works relating to mental illness. Morris holds that the only possible way that said individuals will have read philosophical literature is ‘…in the most casual way’ (ibid), and they certainly would not recall the major names or traditions. However, he wonders, if a certain amount of mentally ill individuals had read some of the major philosophical works relating to mental illness, perhaps we, as philosophers, ought to look into whether the authors had any kind of an impact on the outlook of the reader. On the other hand, embarking on such an inquiry would mean deciphering if the person’s reaction to the philosophy ‘…was the cause and not the effect of the state of the persons…’ (ibid)
Besides this, if we take into consideration that, in general, philosophy is not well read amongst society as a whole (only really by those writing, studying or teaching the subject), our inquiry would yield few enlightening results.
On the other hand, Morris suggests, it may be possible that some philosophers have had and will have an indirect influence on ‘…human thought and culture’. (ibid) This can then be extended to the field of mental health, perhaps. Morris believes that embarking on an inquiry to discover the effects philosophy has had on theories surrounding mental health and illness is worthwhile. The most productive way, he says, is not to view philosophy in the studious, academic sense which it is mostly considered as, but instead to see it as ‘…philosophies of life’. (ibid) On this interpretation we are able to view philosophy as something which has an impact on a person’s livelihood and on life itself. On this account the impact of philosophy is not necessarily down to the philosopher in question alone; moreover it is related to one’s personal opinions and commitments. To look at philosophy in this light is to hold the belief that it ‘…reflects the whole of man’s intellectual, moral, esthetic and religious life’. (p.49)
This type of philosophy is most pertinent in the area of mental health and Illness.
As highlighted by Morris, by far the most popular and relevant philosophy which has had an impact on the theories and treatments of mental health and illness, in European countries, is phenomenology. What is central to phenomenology itself (with regards to psychiatry) is both ‘…signs…and values’. (p.52) Psychiatrics taking a phenomenological approach have created a method which stresses ‘…that the sick person must be seen in terms of how he views and values the world and himself’. (ibid)
In today’s Western society the phenomenological approach to both psychiatry and psychology has become favourable over other techniques. As a result of this reform there is now far more concentration on ‘…sign processes and human values’, (ibid) than there ever was. This, in a way, is a psychiatric revolution.
Finally, to conclude, the phenomenological theory that- as part of a patient’s treatment- therapists and doctors should place strong emphasis on human values and the way in which they view the world (both inside and outside of their minds), is certainly a significant discovery I have made in researching this essay. Supplementary to this, it is also the role of the psychiatric professional to gain an understanding of the patient’s viewpoint. As stated in Johnson’s paper, successful treatment should not merely involve theories and ‘going by the book’, it should also be about gaining an empathy with the patients and acquiring access to their inner, mental, world.
Whilst exploring this topic, I have also come to the understanding that insight, that is, of the patient, is an important faculty in the treatment and characterisation of mental illness. Ghaemi discusses this matter extensively. His paper entertains the theory that insight is central in both the treatment and diagnosis of bipolar, for in mania, for example, patients lack insight and therefore feel no need to see a medical professional. In my understanding, insight is crucial in that it allows the patient to recognise which areas of their life are severely affected by their illness. In some cases, without insight it would be impossible to diagnose certain mental illnesses. Gaining insight of one’s own condition provides a starting point for psychiatrists to offer help.
According to Heideggerian philosophy, all of us are bound by the particular environment we were born into. In the same way, mentally ill persons are bound by the limits set by their illness. This may seem like rather an extreme viewpoint, but what we can take from this, at least, is that- in using a phenomenological approach to treatment- it is important to pay at least some attention to the patient’s upbringing and background.
Lastly, another discovery which displays significance is that phenomenology is now considered to be the leading form of treatment in Europe. More specifically, this type of medicinal practice places focus on the patient’s values and what phenomenologists call ‘signs’. Clearly, phenomenology has taught us a great deal about medicine as a whole and is responsible for a rise in more successful and reputable treatments for mental illnesses. It has shown that we need not rely entirely on medication as phenomenological based therapy focussed on insight and values has shown itself to be prosperous in more ways than one.
- Ghaemi, S. (2007). Feeling and time: the phenomenology of mood disorders, depressive realism, and existential psychotherapy. Schizophrenia bulletin, 33(1), pp.122–130.
- Johnson, M. (1998). Being mentally III: A phenomenological inquiry. Archives of psychiatric nursing, 12(4), pp.195–201.
- Morris, C. (1959). Philosophy, psychiatry, mental illness and health. Philosophy and Phenomenological Research, 20(1), pp.47-55.