Beyond the Mental–Somatic Divide
On the limits of medical explanation and the entanglement of life, body, and society
In the existing scholarship, most critical inquiries into disease are focused on psychiatry, as if the domain of somatic medicine were philosophically and politically unproblematic. On the one hand, this is very understandable, for mental diseases often occupy the foreground in normative disputes and socio-political struggles connected to medicine. Even a brief look at the history of medicine shows that some of the most controversial disease categories, entangled with social oppression, political repression, or, more recently, the commodification of medical care, emerge from the field of mental health.
Consider diagnoses such as Drapetomania, a condition causing enslaved people to flee captivity, and Disaesthesia Aethiopica, a condition that rendered slaves ‘lazy’, in the pre-abolition United States. From a radically different socio-political context, we can point to the Soviet diagnosis of sluggish schizophrenia, a slowly progressing and virtually undetectable form of disease that was regularly used for detaining and subjugating political dissidents.
From our contemporary era, we can mention the rise of psychopharmacology and the ever-increasing use of psychoactive medication in affluent societies, which goes hand in hand with the commodification of medical care and the expansion of medical jurisdiction. With this movement, an increasing number of conditions that were considered to be indicative of political, socio-economic, or existential problems are becoming medicalized. What was once an expression of existential unease can now be routinely captured by medical diagnosis and subjected to therapeutic intervention.
This double movement towards commodification and depoliticization is brilliantly articulated in the following passage from Capitalist Realism:
“The current ruling ontology denies any possibility of a social causation of mental illness. The chemico-biologization of mental illness is of course strictly commensurate with its de-politicization. Considering mental illness an individual chemico-biological problem has enormous benefits for capitalism. First, it reinforces Capital’s drive towards atomistic individualization (you are sick because of your brain chemistry). Second, it provides an enormously lucrative market in which multinational pharmaceutical companies can peddle their pharmaceuticals (we can cure you with our SSRIs). It goes without saying that all mental illnesses are neurologically instantiated, but this says nothing about their causation. If it is true, for instance, that depression is constituted by low serotonin levels, what still needs to be explained is why particular individuals have low levels of serotonin. This requires a social and political explanation; and the task of repoliticizing mental illness is an urgent one if the left wants to challenge capitalist realism.” (Fisher, 2009, p. 37)
This is an excellent passage that not only explains that psychiatric categories are not neutral or merely descriptive but also that they are deeply entangled with broader structures of power, economy, and social organization. However, this critical scrutiny, largely focused on mental health, has had an unintended effect on somatic medicine. It allowed the latter to remain in a relatively unexamined position, as though it did not have similar normative biases or exposure and entanglements with politics, economics, and social organization.
Undoubtedly, the domain of mental health has attracted a greater share of critical scrutiny in comparison to somatic medicine. The majority of critical inquiries concerning somatic medicine focus on its outer layers, such as the accessibility of health, rather than delving deeper into the ontology of disease categories and their entanglement with socio-economic and cultural forces. In critical scholarship on mental disorders, Thomas Szasz probably remains one of the central figures. In his book The Myth of Mental Illness, he famously argued that psychiatric conditions are not biological abnormalities but rather metaphors for problems in living (1961).
From Mental Illness to Disease as Such
The problem with the Szaszian approach does not stem from the defence of mental disorders as natural kinds. On the contrary, the problem with this critique lies in the fact that it does not go far enough. It isolates psychiatry or a domain of mental disorders as an exclusive sphere where this critique applies. Unless we presuppose some form of natural teleology, all medical diseases, whether mental or somatic, can be understood as just such ‘metaphors’ for problems in living. No diseases need to be seen as natural kinds. This does not mean that they lack a biological substrate, or that nothing detrimental is occurring in the organism’s physiology.
The cognitive, experiential, and corporeal processes described in pathology are entirely real. However, the framework that interprets these processes as transgressions of a biological norm or as ontological errors is too philosophically naive. The view that a disease is an instance of something having gone wrong in the living fabric of the world either presupposes a form of natural teleology or implicit normativity in the order of nature. These are loaded presuppositions, and the burden of proof rests on those frameworks that implicitly or explicitly uphold them.
Fisher’s reasoning, according to which biological descriptions of disorders focused on individual organisms and their subsystems do not exhaust their causal explanation, can be expanded beyond the domain of psychiatry to encompass all of medicine. It is unlikely that more than a small number of medical disorders can be explained exclusively in terms of processes internal to the individual organism.
Living bodies are not isolated entities. They are embedded within multiple overlapping environments that are at once chemical, biological, social, discursive, and experiential, which are themselves continuously shaped by human activity. In these environments, or spheres if you like, individuals do not function as self-contained units but more as nodes within dynamic networks that are continuously modified by inputs and outputs across heterogeneous modalities. Tracing the causal processes implicated in various diseases will almost inevitably lead beyond the abstracted boundaries of the individual body. It will lead to the inseparably intertwined domain of corporeal interactions, experiential configurations, and semiotic formations, where the distinction between internal and external becomes increasingly arbitrary.
Against the Mental–Somatic Distinction
Isolating mental diseases as a privileged field of critical concern that needs to be approached on fundamentally different grounds from so-called ‘physical’ or somatic conditions reinforces the mental-physical dichotomy that science and philosophy are trying to overcome.
It seems quite obvious that somatic diseases, insofar as they enter the domain of lived experience and discourse, necessarily involve an irreducibly mental dimension. Pain, fatigue, anxiety, anticipation, and interpretation are not merely secondary effects but integral parts of how disease is lived. Conversely, what we refer to as mental disorders have their corporeal correlates, at neural, endocrine, and cellular levels. Even though this mental-somatic distinction can and does prove to be useful in many contexts of medical care, it cannot be taken to mark a fundamental ontological schism.
This means that the fundamental normative and critical questions that have been developed in relation to mental disorders in many instances can be extended to the entire field of medicine. If we accept that psychiatric conditions are susceptible to historical, political, social, and economic conditioning, there is no reason to assume that the same forces do not also influence somatic disorders. The real difference here lies not in a kind or a category but in a degree and visibility.
This is why it is important to extend critical inquiry into the domain of somatic disease. Not to shift attention away from psychiatry, but rather to show that the conceptual, normative, and political problems often associated with mental disorders are in fact relevant for the entire domain of medical practice. There is a need for an integrated framework in which the critical inquiry into the disease can proceed without reliance on a mental-somatic distinction that may, in fact, obscure more than it clarifies.
Great piece!