Plea for Using Dialectical Phenomenological Psychopathology as an Approach for Substance-Use Disorders.

Substance use is one of the major issues of current public health, as being responsible for a significant share of the global burden of disease (GBD, 2016). As such, it seems reasonable that understanding the characteristics of substance use disorders (SUD) is of utmost importance for public health worldwide. However, defining the features of these disorders has proved to represent a difficult challenge.

Although the array of SUD has long been part of official classification systems (such as International Classification of Diseases – ICD, or Diagnostic and Statistical Manual of Mental Disorders – DSM), there is no consensus regarding some of their crucial aspects, as their nature or major causes. These controversies may determine pragmatic consequences for mental health (Hall et al., 2015): for example, if addiction is understood as a brain disease, society tends to be more tolerant of addicted persons than if it is understood as the result of a fully voluntary behaviour.

My opinion is that the time is ripe for new contributions to the debate around SUD, especially if they may enrich the discussion and help to avoid the danger of falling into the same conceptual stalemates. In this editorial, I would like to argue that the dialectical approach of phenomenological psychopathology (DPP) would add to this debate as it has been advocate to contribute in other fields of mental health (Dörr-Zegers, 1990). To do so, I would like first to present the relations between phenomenological psychopathology and dialectics, and then to put forward some reasons why and how this approach might contribute positively to the contemporary debate on SUD.

Dialectics and phenomenological psychopathology: a framework for SUD

Phenomenological psychopathology, although a classical discipline, has recently garnered unprecedented interest as a way of addressing many deadlocks in psychiatry (The Lancet Psychiatry, 2021). Its main contribution is the in-depth analysis it offers of the core objective of psychiatry: the altered experiences of suffering persons. This is not to say that the biological, psychological or social pathways leading to mental disorders are not to be considered or are of secondary importance, but just that before one seeks the reasons why something happens, it is important to gain awareness of the “whatness” of this something (Fernandez & Koster, 2019).

Phenomenological psychopathology adds to this investigation by examining the conditions of possibility of subjective experiences; i.e. the pre-reflective “lenses” through which any experience comes to consciousness (Fuchs et al., 2019). As such, it goes beyond the mere description of subjective psychological states to identify the pre-reflective structure which enables them. The modifications of these pre-reflective conditions of possibility are the core essence of mental disorders. Disturbed subjective experiences and objective behaviours are, as it were, epiphenomena of these latter modifications. This means that every subjective state can be understood as being framed by an implicit presence of otherness, a balance between present, past and future, a pre-reflective relationship between distance and proximity with the world, and the implicit presence of a self and its identities, to name a few of these pre-reflective lenses.

As a consequence, we could say that the ultimate object of phenomenological psychopathology is the whole of human experience. The full understanding of any particular subjective aspect or behaviour must build on its relationship to and meaning for the structured whole of existence. The recent endeavour to propose phenomenological psychopathology as a leading epistemological framework for mental health has called for it to take on a new form stressing this aspect of the relationships of partial experiences to structured subjectivity. This approach is also compatible with the contemporary need for science-based and person-centred clinical care. The main feature of this new perspective is the introduction of dialectical principles to phenomenological psychopathology, constituting a dialectical phenomenological psychopathology (DPP).

One core notion of DPP is anthropological proportion (Blankenburg, 1982; Messas et al., 2018). This focuses on the balance between the conditions of possibility of experience, both between them and in relation to the whole person. For instance, the focus of DPP may be, as I will mention below, the internal relationships between the dimensions of past, future and present or, simultaneously, between time and intersubjectivity. Psychopathological phenomena arise when there is a failure of the dynamic process of balances and imbalances of these dialectic-related conditions of possibility, resulting in the over-domination of one dimension, known as anthropological disproportion. From this perspective, psychopathological experiences cannot be satisfactorily assessed by a list of distinct criteria lacking any internal cohesion. Rather, they must be addressed by taking the overall personal structure of the experience into account. This does not mean that DPP disregards clinical findings originating both from the empirical sciences and interpretive methods; its purpose is to coordinate them in a meaningful form.

I argue that a DPP approach can enrich the contemporary debate by offering:

1. An unspecific account of the psychopathology of SUD

As a general phenomenon of life, substance use is initially situated in the dialectic between freedom and determination. Changing consciousness is, prima facie, a possibility available to humans to modify themselves in their individual anthropological proportions. DPP helps to shed light on the preferred existential sense associated with particular substance use and thus how this sense articulates with psychopathological situations. There are two possible senses: synergy and antagonism. In synergy, substance use serves to amplify the individual’s main anthropological disproportions. Examples of this are cocaine use by people who are already extremely agitated or extroverted, or marijuana use by people with withdrawn personalities and tending towards isolation. On the other hand, in antagonism, the person seeks to reduce some uncomfortable anthropological disproportion, so that the use acts as a kind of self-medication.

This general understanding enriches the understanding of two perspectives relevant to the debate: vulnerability to drug abuse and comorbidities. Regarding the former, it allows us to understand, for example, why certain stages of life (e.g. early adulthood) and certain temperamental styles are vulnerable to substance use becoming problematic. With regard to comorbidities, it allows many of them to be understood as implicated in the overuse of synergistic or antagonizing self-regulatory mechanisms. Vulnerabilities and comorbidities can thus be viewed from a dialectic between a person’s subjective structure and his or her hedonistic preferences or self-regulatory needs. It is this dialectic that influences or chooses the meanings of altered consciousness on experience. This perspective goes beyond a rigid understanding of comorbidity as the simultaneous presence of two independent overlapping morbidities. Without failing to consider the co-occurrence of altered subjective experiences and substance misuse, the dialectical perspective allows us to observe the dynamics by which they interact (Moskalewicz, 2016).

2. A dive into the debate on the specific psychopathological experiences related to substance use

Usually, the major disease-like category of SUD is addiction. Although it is reliable and easily communicated, it is based on the assumption that a psychopathological diagnosis can be based simply on separate epistemological dimensions: subjective experiences (compulsive yearning and craving for the substance, drug tolerance), observed altered behaviours (repeated use even with harmful results), and somatic alterations (such as withdrawal syndrome). Although I have no intention of exhausting the perspectives by which the topic can be addressed, I would like to put forward a DPP definition of addiction. I suggest that addiction is a specific form of structural modification in which dialectical complexity is abolished from the conscious grasp of reality (Messas, 2021).

I will exemplify with the dimension of pre-reflective time (Kemp, 2018). In this altered state, the relationship between past, present and future is distorted, determining a pathological domination of the present over past and future. The outcome of this pre-reflective structural modification is a proneness to experience the same subjective state, constituting a pathological present continuous that disregards both the constituted roles of personal history and the future consequences of the intoxicated behaviour. The use of the substance is both involved in causing this alteration and required to sustain it.

This structural understanding also gives coherence to the aspects of addiction. Disordered affect, craving or compulsion gain meaning as part of a wholeness, characterized by this restriction of dimensions of time to the present, lending all experiences a sense of intensity and urgency. It also gives coherence to the cognitive alterations often reported in addiction. Loss of memory and executive functions are seen as a subjective consequence of an existence totally devoted to the present, closed to the mechanisms attaching past experiences to current ones (memory) and future ones (executive functions). By the same token, it enables functional psychoses – i.e. schizophrenic or affective psychosis – to be distinguished from substance-induced psychotic disorders (Di Petta, 2014).

In particular, the notion of anthropological proportion helps us to dialectically integrate the idionomic (personal) with the nomothetic (general) conception of addiction. As has been defended recently, while a general diagnosis is necessary, it is not sufficient for clinical purposes (Maj et al., 2021). For the contemporary needs of person-centred care, it is crucial to know how a generally-defined disorder manifests in the specific features of a person. To build on the aforementioned example, instead of a clear-cut diagnosis of addiction, the dynamic nature of anthropological proportions allows us to observe the singular mode by which the past and future are subsumed to the present and how they can change throughout biographical development.

In addition, shifting the diagnostic focus to a specific structural anthropological disproportion rather than to a specific set of conditions helps to overcome some flaws in the diagnosis of SUD, such as the existence of more than 2000 ways to diagnose a DSM-5 SUD, as well as the fact that two patients can be diagnosed as having an addiction without sharing a single core feature of the usual criteria of addiction! (Saunders, 2017). Since the same anthropological disproportion can be expressed by distinct subjective states and observed behaviours, such multiple variations can be seen as epiphenomenal manifestations of the same core ontological phenomenon.

3. A new outlook for clinical care

Based on what I mentioned above, it follows that when coping with SUD, clinical care cannot be understood as something static, divided up into clear-cut categories of success or failure of care. Rather, it points to a dialectical conception in which care is tantamount to enabling a patient to resume the possibilities of personal development (Fulford & Stanghellini, 2019). This perspective is benefitted by the dialectical notion of anthropological proportions, since it allows the observer to frame the scientific object, human existence, with a focus on the movement of the pre-reflective structure of experience. The main result of this shift of focus in clinical care would be an emphasis on the notion of recovery. Although the classical idea of cure should be maintained, especially for the initial stages of severe addictions, in broad terms we can say that DPP invites science to abandon the use of old-fashioned clearcut categories as criteria for building strategies and evaluating treatments. Essentially, what a dialectical approach promises is a restoration of a healthy dynamic between the balanced and unbalanced dimensions of personal experiences, guided by a decision-making process shared between patient, their relevant persons and clinician.

Conclusions

Dialectical phenomenological psychopathology seems to offers an approach to SUD that seems to be very much tuned with the mental health agenda of the twenty-first century. After decades of epistemological and ontological simplification of the science of psychopathology in order to gain a more easy-to-implement conception of mental health, it is welcome to address complex topics by complex methods, categories and aims. After all, if any scientific endeavour has inevitable social consequences, be they intended or not, we should rather bet on one that might offer more consistent and sustainable solutions for mental health problems in our contemporary societies.