Plea for more Philosophy in Mental Health Care

By Marit Pepplinkhuizen

Opinion/Politics Section Editor

Philosophy and medicine are two of the oldest subjects in academia. The entanglement of philosophy and medicine is reflected in the oath of Hippocrates and in the ancient philosophical discussions on mind and body. In the 17th century, the mind-body problem was a central issue for philosophy, with philosophers such as Descartes and Spinoza discussing the issue at length. However, nowadays it seems that philosophy and medicine have come apart more than ever.

Much to my surprise, when researching my possibilities to get to work with my philosophy degree in a relevant field such as the health care sector, I had to conclude that philosophy is only deemed relevant for health care from the framework of ethics. In academia, however, neurophilosophy and philosophy of robotics are huge upcoming fields, with many psychiatrists and AI professors stating we cannot do without philosophy for questions on, for example, free will and subjectivity. Still, there is no such thing as a philosopher doing philosophy in the health care sector. Hence, it would seem as if philosophers have no business there. The only reason I can come up with for this is that it would not seem profitable to employ philosophers, or, in other words, our capitalist system does not conceive of thinking for the sake of thinking as very useful. It is disastrous, I argue, for the health care sector to leave philosophy to operate in the margins. After all, in health care, it is all about the human being. If we do not reflect on how we actually view man, how, for example, mind and body interact, then how can we account for all the further theorizing on health and illness? In such precarious issues such as issues on life and death, does it not seem evident that we need to tread carefully?

Friedrich Nietzsche was one of those philosophers who reflected on every topic he could reflect on, including health and illness. Being very sickly himself his whole life, this is perhaps not surprising. What, however, motivated him most of all to engage with the discussions on mind and body, was that he completely disagreed with the dualism of Plato and René Descartes. For Descartes, the ‘I think’ is the foundation beyond doubt for knowledge, and also a mover or motor through which thinking is executed. The ‘I’ can be envisioned to be a small man sitting behind a curtain, who is pulling the strings for the events happening on the stage where our thinking takes place. Immanuel Kant was the first to critique this theory, by saying that we can know nothing about the existence of such a small man ‘behind the curtain’. However, we are allowed, as far as Kant is concerned, to imagine the ideal and formal existence of such an ‘I’- a formal existence whose nature we cannot know, because it is itself the ultimate ground for knowledge. Nietzsche radicalizes Kant’s objection: there is no small man, no small puppet-master controlling the mind- or if there ‘is’, it is no more than a fictional construction. For Nietzsche, to think does not mean “to have thoughts”, it would be more appropriate to say that these thoughts have us. There is no ‘I’ that accompanies my concepts; I am these concepts myself. “Thought is, therefore there must be a thinker”; that is what the argumentation of Descartes comes down to, Nietzsche maintains. But, that if there is thought, there must be something, “which thinks”, is, according to Nietzsche, simply a formulation of our grammatical habit which posits a doer for each deed. Nietzsche introduces the term ‘subject-multiplicity’, which means that a human being consists of multiple drives. The drives are struggling against one another for dominance. Thus, there is no ultimate substratum, no ‘I’ sitting somewhere pulling the strings, but an endless and violent variety of drives competing with each other to be the regent.

Nietzsche’s ideas about subjectivity are, thus, a concrete example of how differing views on subjectivity have consequences for how we treat patients. After all, a doctor who assumes a patient is a rational being and has an ‘I’ as a substance of their being, compared to a doctor who assumes a patient has multiple drives and that man is an instinctual being, will inevitably have a very different approach to treatment. I am not arguing for either one here, the point is that each health care institution can have very differing views on human nature and on life and death. This is, of course, also evident from the very differing viewpoints of health care institutions with differing denominations. We are aware that a Christian health care institutions will not treat patients similarly to non-Christian ones, yet, we seem to assume that this is the only aspect on human nature and life and death they can differ on.

The variations in viewpoints on subjectivity are not the only concrete example of the role philosophy can and, in my opinion, should play in health care. There is an approach to mental health care that is especially viable, namely phenomenological psychopathology. Phenomenological psychopathology is the theoretical study of abnormal psychological phenomena, by way of showing the essential structures of the worlds of the mentally ill. It is not only the subjective experience in itself that is central to the phenomenological approach, but it is an understanding of the total way in which human beings exist.

A concrete example of the relevance of phenomenological psychopathology for mental health care is the comparison of the treatment of obsessive compulsive disorder (OCD) in our current health care system with the treatment of OCD in the framework of phenomenological psychopathology. At this moment, patients with OCD are treated with cognitive behavioural therapy (CBT) and with exposure therapy. CBT starts from the view of humans as rational beings that can tweak their beliefs. Exposure therapy entails exposing the patient to that what they are debilitatingly scared of, whether that is spiders, germs or diseases. This goes as far as having to touch toilets with bare hands, having to be in the same room as a giant spider, and/or having to think about a disease the whole day long without doing any activity that would normally relieve the patient of these thoughts. The results of these treatments are fairly good, but there is a lot of relapse and it is certainly not an overall success for every patient.

In phenomenological psychopathology, OCD is being considered rather differently and therefore the treatment differs largely as well. The German philosopher-psychiatrist Viktor Emil von Gebsattel, instead of only treating the symptoms of OCD, analyzed that one of his OCD patients was suffering from the pangs of conscience reproaching him for not doing anything well enough. As is common in OCD patients, it took this patient hours to accomplish ordinary activities. The patient feared odors that were spread all around him causing pain, shame, and disgust. The underlying threat, von Gebsattel surmised, was coming from a fear of death, and the patient’s behavior was a defense mechanism against decay. But his actual disturbance, von Gebsattel maintains, was the impossibility of overcoming nihilism that was blocking his transcendence of himself. His struggle with different forms of decay was, thus, really a struggle with his own death, with his nihilistic tendencies. In other words, the patient could not cope with nothingness. By making a controllable environment, von Gebsattel explains, the OCD patient covers the nothingness and substitutes an open, undetermined future with a predictable pattern. Since it is impossible to overcome nihilism without realizing it first, acknowledging nothingness – nothingness that is at the core of human vulnerability – would be the first step to achieve mental health, according to von Gebsattel. If we take von Gebsattel’s analysis to be plausible, then we have to conclude that today no such therapy exists, and, thus, we have to conclude that there is at the moment no adequate therapy offered for OCD patients. The aforementioned exposure therapy and CBT are in no way related to the kind of therapy phenomenological psychopathologists propose.

It is a shame that almost no mental health care professional works in this vein, which is apparent from the fact that there is exactly one clinic specialized in phenomenological psychopathology in the entire world: The University of Heidelberg. When we know that there are so many abuses in mental health care, like a report that just has been released by the Belgian newspaper De Morgen shows, then why are we not getting upset about it and demand better? Especially when we know that the reason for the underperformance in mental health care is money. The Belgian minister of health care, Maggie de Block, claimed as a response to the report of De Morgen that it is not really possible to measure the effects of mental health care in comparison to health care in general, stating that “every sector wants more money”. Thus, lets not pump too much money into mental health care, since everything is all about measurements, right? Yet, it is also about life and death, just as in health care in general, and I find it appalling to see that being dismissed for reasons of measurement and money. We know that many more people than usual have experienced mental health problems during the COVID-19 crisis, which may have given them some perspective on what it is like to live with mental health problems in daily life. Can we then not, as a society, resist the tendencies to measurability and profitability, and protest the fact that our mental health care is being reduced to the margins?