Phenomenology in Medicine

The phenomenology of Heidegger, Merleau-Ponty and Sartre, and its implication of an embodied conception of mind, poses a significant challenge to the dualistic assumptions that have shaped medicine since the seventeenth century. What does it mean to say that mind is embodied, and how might the shift from a dualistic to an embodied conception of the mind alter certain aspects of contemporary medical practice?

Phenomenology describes the perception of consciousness and structures from a first-person experience (Woodruff Smith, 2013). It has a strong basis in what can be experienced through sensory qualities (e.g. seeing, feeling), but also has broader applications, including the perception of the meaning of objects or situations to an individual. The works of Heidegger, Merleau-Ponty and Sartre challenge the previous dualistic perception of mind and body described by Descartes in the 17th century. Cartesian or substance dualism describes the idea that there are only two forms of substance in the universe: the physical and the mental (Thibaut, 2018). Subsequently, the mind and body are considered to be separate philosophical entities. Dualism perpetuated medicine for centuries after Descartes’ death with a number of implications for how patients’ conditions were viewed and treated. In this essay, aspects of phenomenology will be explored in the context of modern psychiatry to emphasise the importance of how different perceptions of the relationship between mind and body can affect patients’ and doctors’ beliefs about mental illness and how these can contribute to developing treatment and care.

Dualistic ontology was pervasive in psychiatry until the turn of the millennium (Fuchs, 2009). It has been linked with reduced understanding of the connection between mind and brain and with stigmatisation of the mentally ill (Raese, 2014). Dualistic framing of mental illness even contributed to a split of psychiatry from other medical specialties such as neurology which, by exploring the neurological basis of disorders, was considered to be more objective and specific (Thibaut, 2018). In terms of psychiatric treatment, an assumed separation of brain and mind led to incomplete or atomistic understandings of patients and the treatments they required leading to unsatisfactory treatment outcomes (Raese, 2014). In the past, patients’ illnesses were categorised into either the physical or the mental as a binary. Contemporary medicine is becoming more comfortable with acknowledging that mental illness might exist somewhere between the two, leading to greater emphasis on combining specialties, as in neuropsychiatry (Fuchs, 2009).

In a paradigm shift away from dualism, neuroscientists and psychiatrists now emphasise the close link between physical brain structures and aspects of the mind like consciousness and emotions (Fuchs, 2009). Embodied cognition, in simple terms, refers to the idea that aspects of the body, beyond the brain, have a strong influence on the mind (Wilson, 2017). The concept of embodiment has been used increasingly over recent years to inform descriptions of common psychiatric conditions (Fuchs, 2009). Embodied concepts of mental illness are useful to psychiatrists as they give equal importance to quantifiable neurobiological dysfunction and the subjective views of the patient. Interpretations of phenomenology, while not without their own problems, can be used to explore what it means to inhabit an experiencing body and what happens when a functioning mind is disrupted.

In phenomenology, the body can be experienced as both subject and object (Fuchs, 2009). Perceptions of the body as subject are internalised and personal and can be explained through Heideggerian ontology. In Being and Time (1962, f.p. 1927), Heidegger developed the concept of “equipmentality” as a way of describing the physical qualities of objects, such as tools. Tools are related to, not through detached study, but physical use – they have “readiness-to-hand” (Heidegger, 1962). If used without issue, equipment effectively becomes part of us – it is “phenomenologically transparent” (Wheeler, 2011). A subject body works in the same way, operating in actions without requiring specific attention (Fuchs, 2019). Dasein, another Heideggerian concept, is also important in the description of the subject-body. It describes the experience of “being there” as an entity observing and engaging with the world’s objects and experiences (Horrigan-Kelly, 2016), applying to both bodily sensation and “existential” feelings such as “feeling at home”.

Perception of the body as an object body arises when the phenomenological idea of “readiness-to-hand” is turned back on itself as a method of observing one’s own body. A functioning ready-to-hand body has little need to consider itself as an object, but when a body or mind lose its function through inadequacy or illness, equipmentality is lost. The body becomes explicit and its physicality is exposed. In this sense, it becomes “present-at-hand”, a term Heidegger used to describe objects when not in their usage states (Wheeler, 2011). The present-at-hand body is also the body that is perceived by others, including doctors, as our internalised consciousness limits intersubjectivity to the point where we cannot perceive another’s Dasein experience.

A phenomenological understanding of psychopathology may be based on disturbances of these aspects of embodiment, creating distinctions which can be used to loosely categorise mental illness (Fuchs, 2019). Disturbances of the subject-body may disrupt an individual’s embodied sense of self, presenting as schizophrenia for example, whereas disturbances of the object-body may present themselves as problems with body image, for example in anorexia nervosa (Fuchs, 2019). Phenomenological insights into psychopathology provide new ways of interpreting psychiatric disorders through novel models which balance changes to sense of embodiment with neurophysiological dysfunction, linking mind and body on a continuum, overcoming previous dualistic conceptions. The work of philosophers such as Varela and neuroscientists such as Damasio have developed theories of embodied mind and emphasised the connection of brain structures and cognitive processes such as consciousness and emotion (Fuchs, 2009). These conceptions of mind connect specialties that have been divided based on dualistic assumptions. Neuroscientific and psychiatric concepts such as neurobiological dysfunction and disturbed social interaction, respectively, become joined in a circular interaction. In this view, disruption to any point in this constant feedback-feedforward pattern of mind and body can contribute to mental illness. An embodied view supports the idea that neurophysiology and phenomenological inner-world are not only connected, but enmeshed (Fuchs, 2009). It has been argued that the brain is a relational organ, forming neuronal circuitry and excitation patterns in response to the experiences of the living body leading to formation of behavioural patterns and habits (Fuchs, 2009).

Heidegger considered the concept of embodiment to be “problematic” (Heidegger, 1962), but the idea was picked up by Merleau-Ponty in Phenomenology of Perception (Merleau-Ponty, 2013 f.p. 1945) where he argued that people are unified wholes, not dualistic entities. Regarding embodiment, Merleau-Ponty emphasised the Husserlian concept of “intentionality” which describes the idea that human actions, including thoughts and emotions, have directedness and are related to objects (Matthews, 2004). In this way, perception and experience are not passive, but come from active involvement as embodied entities in the world. As humans, we experience other people as the unified wholes of body and mind, observable through their behaviours which express intentions (Moya, 2014). The concept of intentionality can be harnessed in both psychiatric diagnosis and treatment. In consultation, behaviours and habits can be explored in the context of intentionality, an appreciation of which may give a psychiatrist a greater insight into a patient’s psychopathology. For example, depression, often categorised by loss of directedness of goals for action, can be defined as dysfunction of intentionality (Fuchs, 2009). In terms of treatment, appreciation that the psychiatric patient’s intentional perspectives of the world may have been warped can help support therapies like Cognitive Behavioural Therapy which, through developing adaptive behavioural strategies and habits can improve mental health (NHS, 2019).

A contemporary of Merleau-Ponty, Sartre also developed ideas of embodiment, intentionality and reflection. In Being and Nothingness (Sartre, 2003, f.p.1943), he argued that consciousness is intentional (Rowlands, 2013) and transcendent, or has “no content”. This becomes problematic – it generates a paradox of self-consciousness, solved by the idea of “pre-reflection” (Rowlands, 2013). “Pre-reflective” self-consciousness, based on ipseity or basic self-awareness, “is the only mode of existence which is possible for a consciousness of something” (Sartre, 2003). It mediates our perception, describing the awareness we have of things before reflecting on our experience (Hirjak, 2013). Pre-reflective awareness and individual’s sense of self are established and developed through social interaction (Heinz, 2012). Psychiatry is increasingly understanding that this development has a cultural basis, leading to an appreciation that cultural variations and social context shape an individual’s embodied experience (Kirmayer, 2017). Literature on ethnographic research, combined with intercultural clinical work, supports the idea of “pathoplasticity” – variations in symptoms, articulation and behavioural expression of mental illness based on cultural input (Kirmayer, 2017). For example, commonalities regarding the content of delusions in schizophrenia can be linked to one’s cultural background (Kirmayer, 2017). Studies also show that metaphoric framings for illness result in adaptation of one’s sense of pre-reflection by promoting predispositions to perceive the world in certain ways (Gibbs, 2006). Culture forms on multiple scales, from nations to families. With this evidence in mind, sensitivity to a patient’s culture may reveal rich information which psychiatrists can use to guide their patients in forming new and adaptive thought and behaviour patterns in psychotherapy.

Critics of phenomenology and embodiment argue that there are risks inherent to distinguishing mental illness in this way. It could be argued that embodiment arguments oversimplify psychopathology or brings it into a realm of conjecture too abstract to be of any clinical use (Rajos-Goristiza, 2013). Defining schizophrenia, depression and other mental illnesses on the basis of disturbed embodiment may be flawed as it relies on subjective interpretations of the patient’s expression of their illness perspective. It is impossible to understand the mind of another in its entirety – one can never gain access to another’s consciousness (Hafner, 2015). There is concern that an embodiment approach could conflate stereotypes of mental illness with an understanding of their pathology, undermining empirical and objective methods supplied by modern neurology such as imaging. This could lead to issues of misinterpretation of the patient experience to form inadequate or inappropriate diagnoses, pathologizing of normal behaviours (Pickersgill, 2013) and unhelpful treatments, deepening mistrust of an already controversial specialty (Self, 2013).

In conclusion, the concepts of embodiment and phenomenology have had multiple effects on modern practices in psychiatry. Perceptions of psychopathology are changing to accept that mental illness may not be rooted solely in either mind or body, but somewhere between the two. Analysis of the self-conscious and how culture and social background affect patients’ perspectives of their own condition is also significant. There are critics of a drive towards an embodiment approach, who argue that it represents an abstraction from the more objective methods promoted by other specialties. However, it can also be argued that increasing understanding of embodiment and phenomenology demonstrate a sea-change in psychiatry for the better. As embodiment assumes no dualistic separation of mind and body, understanding psychopathology in this way could be a more balanced and enlightening approach, emphasising the need to incorporate medical and emotional support, treating mind and body in an integrated way. It also encourages psychiatrists to consider the patient’s perspective of their illness experience in relation to their symptoms and take account of cultural influence on their condition. It can be argued it provides a foundation for a more hopeful perspective on mental health, less about classifications and separations and more about appreciation of how the infinite meanings of a patient’s life, body and mind can affect them simultaneously.

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