Abstract
The long-standing tradition of phenomenological psychopathology has been historically concerned with the nature of mental disorders, with a special focus on their basic experiential core. In the same way, much of the recent phenomenologically-inspired work in psychopathology consists in providing precise and refined tools for diagnosis, classification, and nosology of mental disorders. What is striking, however, is the lack of therapeutic proposals in this tradition. Although a number of phenomenological approaches refer positively to psychotherapeutic practices, psychopharmacological intervention has been mostly neglected as a relevant field of attention. This work aims to fill this gap. We maintain that the convergence of phenomenological psychopathology and psychopharmacology exhibit a rich potential for mutual enlightenment, which unfolds into a more adequate psychopharmacological practice. Initially, after discussing Joanna Moncrieff’s drug-centered model of drug action we review some of the major findings in phenomenological literature regarding psychopharmacological treatment. Next, we suggest that Moncrieff’s drug-centered model can be seen as an important tool for improving clinical decision-making, by elucidating its inherent epistemic advantage when compared to mainstream models of drug action. As a result, the drug-centered model proves to be also patient-centered, by focusing on experiential alterations and helping to improve treatment outcomes.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Notes
Stein (2008, p. 47) almost touches this point by suggesting the need for a mutual integration between “mechanism” and “experience”. He stresses that a “detailed knowledge of the psychobiology of psychotropics may allow an integrated approach to conceptualizing their more objective or physical aspects (e.g. their mechanism of action) as well as their more subjective or socially constructed aspects (e.g. our experience of their actions)”. Despite some dispersed mentions of phenomenologists such as Heidegger and Merleau-Ponty, there is no reference to the importance of a more rigorous phenomenological treatment of the philosophical problems raised by modern psychopharmacology.
In general lines, the issue of naturalizing phenomenology corresponds to the interaction of phenomenological first-person descriptions with those third-person descriptions of natural sciences (Gallagher & Zahavi, ). Naturalizing phenomenology thus involves asking whether the phenomenological tradition and its markedly anti-naturalistic tendency can establish a fruitful dialogue with the natural sciences, without implying reductionism. It also implies that the phenomenological task should not be exhausted in a transcendental philosophical clarification, as it should also be open to the investigation of concrete phenomena informed by our best available scientific knowledge, with a view to a more complete approach to experience. In Gallagher’s (1997, 2019) terms, among other things, phenomenology could inform the interpretation of experimental data, or play a further confirmatory role with respect to these same data. Phenomenological reports, on the other hand, can motivate empirical experiments on subpersonal processes behind disordered experiences, in the case of psychopathology and illness in general.
de Haan’s (2021) enactive approach, for instance, understands psychiatric disorders as involving a disturbance in the “complex system of a person-in-her-world”, which comprises a holistic unity of body, mind, and world. This view suggests a paradigm change regarding therapeutic interventions, since the brain does not provide the only locus for searching the underlying causes of psychiatric disorders anymore, as in traditional psychiatry. The same goes for the recent enactive approach to placebo effects and its radically relational and active perspective, which understands pharmacological intervention as interacting with embodied agents in complex social environments (Arandia & Di Paolo, 2021).
Which, not surprisingly gets reflected in the general names attributed to these major drugs classes. Thus, “antidepressants’’, “antipsychotics’’, and “mood stabilizers’’ are given these names because they are thought to act on the very mechanisms that produce these respective symptoms (Moncrieff, 2008; Moncrieff & Cohen, 2006, 2009).
According to Moncrieff and colleagues, there is a turning point in psychopharmacological research from drug- to disease-centered models of drug action around the 1950 and 1960s, which determines its subsequent methodological orientation. Moncrieff (2008) further elaborates on the reasons for such a paradigm change in psychopharmacological research. As expected, they do not revolve around methodological and scientific disputes, only. The reasons are much more external to theoretical grounds and involve different levels of analysis, such as historical, commercial, and ideological perspectives.
Most of the “psychoactive” drug effects can be best described in global rather than dualistic terms. Sedation and activation effects, for example, are simultaneously mental and physical experiences. Other effects also blurry this distinction, such as neuroleptic-induced effects like the akathisia or the “deactivation syndrome” (Breggin, 1993), mostly characterized by “disinterest, indifference, diminished concern, blunting, lack of spontaneity, reduced emotional activity, reduced motivation or will, apathy and in the extreme, a rousable stupor” (Moncrieff, 2008, p. 100). Other global experiential changes can be conveyed in terms of what Ratcliffe (2008, 2015) calls existential feelings, such as the feeling of being ‘a zombie’; feelings of ‘uninvolvement’, feeling ‘drugged’, ‘foggy, ‘empty’, ‘emptied out, devoid of ideas’, feelings ‘of being separated from the outside world by a glass screen’ (Moncrieff, 2008), or the feeling of ‘losing one’s soul’ (Wescott, 1979).
The ontology of psychotropics does not exhibit very clear boundaries. The problem of how they can be correctly conceptualized is still an open question. Stein (2008), for example, highlights some important points: should we distinguish between therapeutic versus enhancement medications? And what about drug abuse? What distinguishes psychiatric medication, legal and illicit substances? Can nutrients (nutraceuticals) be understood as pharmaceuticals? See also Pace-Schott and Hobson (2007) for a general distinction between anesthetics, psychoactive prescription drugs, and recreational drugs.
For more details about these categories, see Messas and Fulford (2021). Tamelini and Messas (2019) and Messas and Tamelini (2021) suggest that one of the focuses for the treatment of schizophrenia consists in the stabilization of the experiential field through antipsychotic intervention, which occurs mainly by producing an increase in corporeality, among other things, bringing back some kind of stability to existence.
Synergy and antagonism are the two ways of self-managing anthropological disproportions, be it to maintain or accentuate, or to reduce or even modify the characteristics of disproportion (Messas, 2021, p. 69). See also Pace-Schott and Hobson (2007, p. 141) for a third-person account of these phenomena: “psychoactive drugs exert their effects by mimicking (agonism) or blocking (antagonism) endogenous substances with which groups of neurons normally communicate with one another.”
The extent of the instantaneity of each consciousness modification is an empirical question, however. Different exogenous substances can act by altering consciousness at different time scales. One essential aspect of any act of consciousness modification is “a dialectic between a typical, relatively stable existential structure and an experience that modifies the previous proportions” (Messas, Ibid.) See also Teal (2009) for the sense of disruption promoted by the use of SSRIs.
A case in point is the emotional indifference induced by neuroleptics to mitigate the effects of psychotic symptoms (Moncrieff, 2008), albeit at the expense of impairing normal cognitive function. In this regard, the accounts of drug-induced experiential changes from the early period of psychopharmacology could offer more insightful examples (See Moncrieff, 2008; Breggin, 1993; Whitaker, 2002). Unfortunately, focusing on this would exceed the limits of this work. Thanks to an anonymous reviewer for drawing our attention to this point.
The interaction between phenomenology and the drug-centered model also seems to be a useful paradigm to assess and discuss the recent rebirth of psychedelic psychiatry (Carhart-Harris & Goodwin, 2017; Nutt, 2019; Rucker et al., 2018). The research based on the drug-centered model would also benefit from considering the recent philosophical work on psychedelics — especially in the context of psychedelic-assisted psychotherapy. See, for instance Letheby (2021) and Johnson and Letheby (forthcoming).
From an enactive perspective, Maiese (2020, pp. 535-6) suggests that psychiatric disorders such as depression should be approached in a pluralistic way, taking advantage of several ways to promote healing. In addition to psychopharmacology and cognitive behavioral therapy, alternative interventions such as dance-movement therapy and music therapy can target sense-making distortions through a more specific focus on affective framings, embodied know-how, and online intelligence helping to reestablish people with depression.
In a similar vein, de Haan (2020, p.32) suggests that the one-sided appeal to a brain-centered view of psychiatric disorders can also affect patients’ experience of agency and self-understanding. If, on the one hand, this approach was once depicted as promoting destigmatization (psychiatric disorders are outside the patient’s control; it is just genetic “bad luck”), on the other hand, accepting this perspective also comes at the cost of diminishing patients’ agency over treatment decisions. In de Haan’s terms, “less responsible also means less able”.
References
Aftab, A., & Stein, D. J. (2022). Psychopharmacology and explanatory pluralism. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2022.0470
Aho, K., & Guignon, C. (2011). Medicalized Psychiatry and the talking cure: A hermeneutic intervention. Human Studies, 34, 293–308. https://doi.org/10.1007/s10746-011-9192-y
Arandia, I. R., & Di Paolo, E. A. (2021). Placebo from an enactive perspective. Frontiers in Psychology, 12, 660118. https://doi.org/10.3389/fpsyg.2021.660118
Binswanger, L. (1964). On the manic mode of being-in-the-world. In E. Straus (Ed.), Phenomenology, pure and Applied (pp. 131–132). Duquesne University Press.
Blankenburg, W. (2001). First steps toward a psychopathology of “common sense. Philosophy Psychiatry and Psychology, 8(4), 303–315. https://doi.org/10.1353/ppp.2002.0014
Breggin, P. (1993). Toxic Psychiatry: Why Therapy, Empathy and Love Must Replace the Drugs, Electroshock, and Biochemical Theories of the "New Psychiatry" Fontana, London
Brown, W. A., & Rosdolsky, M. (2015). The clinical discovery of imipramine. American Journal of Psychiatry, 172(5), 426–429. https://doi.org/10.1176/appi.ajp.2015.14101336
Carhart-Harris, R. L., & Goodwin, G. M. (2017). The therapeutic potential of psychedelic drugs: Past, present, and future. Neuropsychopharmacology: Official Publication of the American College of Neuropsychopharmacology, 42(11), 2105–2113. https://doi.org/10.1038/npp.2017.84
Cowen, P. J. (2011). Has psychopharmacology got a future? British Journal of Psychiatry, 198(5), 333–335. https://doi.org/10.1192/bjp.bp.110.086207
Crichton, P., Carel, H., & Kidd, I. J. (2017). Epistemic injustice in psychiatry. Bjpsych Bulletin, 41(2), 65–70. https://doi.org/10.1192/pb.bp.115.050682
Davies, W. (2016). Externalist Psychiatry. Analysis, 76, 290–296. https://doi.org/10.1093/analys/anw038
de Haan, S. (2020). Enactive Psychiatry. Cambridge University Press.
de Haan, S. (2021). Bio-psycho-social interaction: An enactive perspective. International Review of Psychiatry, 33(2), 471–477. https://doi.org/10.1080/09540261.2020.1830753
Fernandez, A. V. (2014). Reconsidering the affective dimension of depression and mania: Towards a phenomenological dissolution of the paradox of mixed states. Journal of Psychopathology, 20(4), 414–422.
Fernandez, A. V., & Køster, A. (2019). On the subject matter of phenomenological psychopathology. In G. Stanghellini, M. Broome, A. Raballo, A. V. Fernandez, P. Fusar-Poli, & R. Rosfort (Eds.), The Oxford Handbook of Phenomenological Psychopathology. Oxford University Press.
Fricker, M. (2007). Epistemic injustice: Power and the Ethics of Knowing. Oxford University Press.
Fuchs, T. (2011). The brain–a mediating organ. Journal of Consciousness Studies, 18(7–8), 196–221.
Fuchs, T. (2014). Psychopathology of depression and mania: Symptoms, phenomena and syndromes. Journal of Psychopathology, 20, 404–413.
Gallagher, S. (1997). Mutual enlightenment: Recent phenomenology in cognitive science. Journal of Consciousness Studies, 4(3), 195–214.
Gallagher, S. (2019). Phenomenology and the cognitive sciences. In G. Stanghellini, M. Broome, A. Raballo, A. V. Fernandez, P. Fusar-Poli, & R. Rosfort (Eds.), The Oxford Handbook of Phenomenological Psychopathology. Oxford University Press. https://doi.org/10.1093/oxfordhb/9780198803157.013.24
Gallagher, S., & Zahavi, D. (2012). The phenomenological mind. Routledge.
Goldsmith, L. P., & Moncrieff, J. (2011). The psychoactive effects of antidepressants and their association with suicidality. Current drug safety, 6(2), 115–121.
Harrington, A. (2018). Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness. W. W. Norton & Company
Harrison, P. J., Baldwin, D. S., Barnes, T. R. E., Burns, T., Ebmeier, K. P., Ferrieer, I. N., & Nutt, D. J. (2011). No psychiatry without psychopharmacology. British Journal of Psychiatry, 199(4), 263–265. https://doi.org/10.1192/bjp.bp.111.094334
Healy, D. (2002). The creation of psychopharmacology. Harvard University Press.
Horwitz, A. V., & Wakefield, J. C. (2007). The loss of sadness: How psychiatry transformed normal sorrow into depressive disorder. Oxford University Press.
Huxley, A. (1954). The Doors of Perception. Harper & Brothers
Jaspers, K. (1968). The phenomenological approach in psychopathology. British Journal of Psychiatry, 114(516), 1313–1323. https://doi.org/10.1192/bjp.114.516.1313
Jessell, L., & Stanhope, V. (2021). How do you try to have anyone comply or at least be pliable with you if that person’s not even medicated?”: Perspectives on the use of psychiatric medication within recovery-oriented practice. Psychiatric Rehabilitation Journal. https://doi.org/10.1037/prj0000493
Johnson, S., & Letheby, C. (2022). Psychedelic therapy for body dysmorphic disorder.Journal of Psychedelic Studies, 6(1), 23-30. https://doi.org/10.1556/2054.2022.00200
Kramer, P. (1994). Listening to Prozac: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self. London: Fourth Estate
Kuhn, R. (2005). Psicofarmacologia e análise existencial. Revista Latinoamericana de Psicopatologia Fundamental, 8(2), 221–243. https://doi.org/10.1590/1415-47142005002003
Leder, D. (2016). The distressed body. Rethinking illness, imprisonment, and healing. The University of Chicago Press.
Letheby, C. (2021). Philosophy of Psychedelics. Oxford University Press.
Maiese, M. (2020). An enactivist approach to treating depression: Cultivating online intelligence through dance and music. Phenomenology and the Cognitive Sciences, 19(3), 523–547. https://doi.org/10.1007/s11097-018-9594-7
Messas, G. (2010). A phenomenological contribution to the Approach of Biological Psychiatry. Journal of Phenomenological Psychology, 41, 180–200.
Messas, G. (2021). The existential structure of substance misuse: A psychopathological study. Springer.
Messas, G., & Fulford, K. W. M. (2021). Three dialectics of disorder: Refocusing phenomenology for 21st-century psychiatry. The Lancet Psychiatry, 8(10), P855-857. https://doi.org/10.1016/S2215-0366(21)00357-6
Messas, G., & Tamelini, M. (2021). From phenomenological psychopathology to phenomenological psychiatry: The cases of schizophrenia and substance misuse. In P. Gargiulo, & H. L. M. Arroyo (Eds.), Psychiatry and neuroscience update. Springer. https://doi.org/10.1007/978-3-030-61721-9_10
Minkowski, E. (1970). Lived time: Phenomenological and psychopathological studies. Northwestern University Press.
Moncrieff, J. (2008). The myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment. Palgrave MacMillan
Moncrieff, J. (2018). Research on a ‘drug-centred’ approach to psychiatric drug treatment: Assessing the impact of mental and behavioural alterations produced by psychiatric drugs. Epidemiology and Psychiatric Sciences, 27(2), 133–140. https://doi.org/10.1017/S2045796017000555
Moncrieff, J. (2020). It was the brain tumor that done it!“: Szasz and Wittgenstein on the importance of distinguishing Disease from Behavior and Implications for the Nature of Mental Disorder. Philosophy Psychiatry and Psychology, 27(2), 169–181.
Moncrieff, J., & Cohen, D. (2006). Do antidepressants cure or create abnormal brain states? PLoS Medicine, 3(7), 0961–0965. https://doi.org/10.1371/journal.pmed.0030240
Moncrieff, J., & Cohen, D. (2009). How do psychiatric drugs work? BMJ, 338(7710), 1535–1537. https://doi.org/10.1136/bmj.b1963
Moncrieff, J., Cohen, D., & Porter, S. (2013). The psychoactive effects of psychiatric medication: The elephant in the room. Journal of Psychoactive Drugs, 45(5), 409–415. https://doi.org/10.1080/02791072.2013.845328
Nutt, D. (2019). Psychedelic drugs - a new era in psychiatry? Dialogues in Clinical Neuroscience, 21(2), 139–147. https://doi.org/10.31887/DCNS.2019.21.2/dnutt
Pace-Schott, E. F., & Hobson, J. A. (2007). Altered states of consciousness: Drug-induced states. In M. Velmans, & S. Schneider (Eds.), The blackwell companion to consciousness. Blackwell.
Parnas, J. (2011). A disappearing heritage: The clinical core of schizophrenia. Schizophrenia Bulletin, 37(6), 1121–1130. https://doi.org/10.1093/schbul/sbr081
Parnas, J., & Zahavi, D. (2000). The link: philosophy-psychopathology-phenomenology. In D. Zahavi (Ed). Exploring the self philosophical and psychopathological perspectives on self-experience. John Benjamins Publishing Company.
Presti, D. E. (2017). Altered states of consciousness: Drug-induced states. In M. Velmans & S. Schneider (Eds.), The blackwell companion to consciousness (2nd ed.). Blackwell: Wiley.
Ratcliffe, M. (2008). Feelings of being. Oxford University Press.
Ratcliffe, M. (2009). Understanding existential changes in psychiatric illness: The indispensability of phenomenology. In M. Broome, & L. Bortolotti (Eds.), Psychiatry as cognitive neuroscience: Philosophical perspectives (pp. 223–244). Oxford University Press.
Ratcliffe, M. (2015). Experiences of depression. Oxford University Press.
Rucker, J. J. H., Iliff, J., & Nutt, D. J. (2018). Psychiatry & the psychedelic drugs. Past, present & future. Neuropharmacology, 142, 200–218.
Sass, L., & Parnas, J. (2003). Schizophrenia, consciousness, and the self. Schizophrenia Bulletin, 29(3), 427–444. https://doi.org/10.1093/oxfordjournals.schbul.a007017
Scrutton, A. P. (2017). Epistemic injustice and mental illness. In I. J. Kidd, J. Medina, & G. Pohlhaus Jr. (Eds.), The Routledge Handbook of epistemic injustice. Routledge.
Shorter, E. (2009). Before Prozac. The Troubled History of Mood Disorders in Psychiatry. Oxford University Press
Spiegelberg, H. (1972). Phenomenology in psychology and psychiatry: A historical introduction. Northwestern University Press.
Stanghellini, G., Trisolini, F., Castellini, G., Ambrosini, A., Faravelli, C., & Ricca, V. (2015). Is feeling extraneous from one’s own body a core vulnerability feature in eating disorders? Psychopathology, 48(1), 18–24. https://doi.org/10.1159/000364882
Stein, D. J. (2008). Philosophy of psychopharmacology: Smart pills, happy pills, and pep pills. Cambridge University Press.
Svenaeus, F. (2006). Phenomenology listens to Prozac: Analyzing the SSRI revolution. In F. Svenaeus (Ed.), Medical technologies and the life world: The social construction of normality (1st ed., pp. 164–183). Routledge.
Svenaeus, F. (2007). Psychopharmacology and the self. In K. W. M. Fulford, & J. Z. Sadler (Eds.), Oxford handbook of philosophy and psychiatry (pp. 1171–1184). Oxford University Press.
Svenaeus, F. (2018). Phenomenological bioethics: Medical technologies, human suffering, and the meaning of being alive. Routledge.
Tamelini, M., & Messas, G. (2019). Pharmacological treatment of schizophrenia in light of phenomenology. Philosophy Psychiatry & Psychology, 26(2), 133–142.
Teal, J. (2009). Nothing personal: An empirical phenomenological study of the experience of “being-on-an-SSRI. Journal of Phenomenological Psychology, 40(1), 19–50. https://doi.org/10.1163/156916209X427972
Tellenbach, H. (1980). Melancholy. Duquesne University Press.
Thompson, J., Stansfeld, J. L., Cooper, R. E., Morant, N., Crellin, N. E., & Moncrieff, J. (2020). Experiences of taking neuroleptic medication and impacts on symptoms, sense of self and agency: A systematic review and thematic synthesis of qualitative data. Social Psychiatry and Psychiatric Epidemiology, 55(2), 151–164. https://doi.org/10.1007/s00127-019-01819-2
Thornton, T. (2007). Essential philosophy of psychiatry. Oxford University Press.
Varela, F. J. (1996). Neurophenomenology: A methodological remedy to the hard problem. Journal of Consciousness Studies, 3(4), 330–350.
Wescott, P. (1979). One man’s schizophrenic illness. British Medical Journal, 1(6169), 989–990. https://doi.org/10.1136/bmj.1.6169.989
Whitaker, R. (2002). Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the mentally ill. Perseus Publishing.
Zahavi, D. (2018). Phenomenology. The basics (1st ed.). Routledge.
Acknowledgements
We would like to thank two anonymous reviewers for their very helpful comments that significantly improved an earlier version of this paper.
Author information
Authors and Affiliations
Contributions
Both authors contributed equally to the writing of the article.
Corresponding author
Ethics declarations
Ethics approval
Not applicable.
Competing interests
The authors have no competing interests to disclose.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Lopes, M.V., Messas, G. Towards a phenomenological approach to psychopharmacology: drug-centered model and epistemic empowerment. Phenom Cogn Sci (2023). https://doi.org/10.1007/s11097-023-09921-2
Accepted:
Published:
DOI: https://doi.org/10.1007/s11097-023-09921-2