medicalized psychiatry and the talking cure: a hermeneutic intervention

THEORETICAL / PHILOSOPHICAL PAPER

Medicalized Psychiatry and the Talking Cure:A Hermeneutic Intervention

Kevin Aho • Charles Guignon

Published online: 24 August 2011

� Springer Science+Business Media B.V. 2011

Abstract The dominance of the medical-model in American psychiatry over the

last 30 years has resulted in the subsequent decline of the ‘‘talking cure’’. In this

paper, we identify a number of problems associated with medicalized psychiatry,

focusing primarily on how it conceptualizes the self as a de-contextualized set of

symptoms. Drawing on the tradition of hermeneutic phenomenology, we argue that

medicalized psychiatry invariably overlooks the fact that our identities, and the

meanings and values that matter to us, are created and constituted by our dialogical

relations with others. While acknowledging the importance of medical and phar-

maceutical interventions, we suggest that it is only by means of the dialogical

interplay of the talking cure that the client can both recognize unhealthy and self-

defeating ways of being and be opened up to the possibility of new meanings and

self-interpretations.

Keywords Medicalized psychiatry � Psychotherapy � Hermeneutic

phenomenology � Talking cure � Charles Taylor � Martin Heidegger

Introduction

The practice of psychotherapy is on the decline in American psychiatry today.

A 2005 study showed that just 11% of psychiatrists provide psychotherapy to all

their patients, down from a low of 19% in 1996 (Mojtabai and Olfson 2008; Kaplan

2008; Harris 2011). By ‘‘psychotherapy,’’ we mean any form of treatment of mental

K. Aho (&)

Florida Gulf Coast University, 10501 FGCU Boulevard South, Fort Myers, FL 33966, USA

e-mail: [email protected]

C. Guignon

University of South Florida, 4202 E. Fowler Avenue, Tampa, FL 33620, USA

e-mail: [email protected]

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Hum Stud (2011) 34:293–308

DOI 10.1007/s10746-011-9192-y

and behavioral problems that primarily use some version of what Freud called

‘‘the talking cure’’. In the broad sense of this word, traditional psychoanalysis and

various forms of depth and humanistic psychologies count as psychotherapy, as do

group therapy, role-playing therapies, journaling and other forms of treatment that

emphasize the client’s self-expression as having a curative effect. To say that

psychotherapy is in decline, then, is to say that although a number of studies have

demonstrated that talking to a patient is an effective form of treating mental

problems (e.g., Smith and Glass 1977; Smith et al. 1980; Landman and Dawes 1982;

Mojtabai and Olfson 2008), traditional talking cures no longer are seen as offering

the primary or best path to treating these problems. What takes center-stage today is

a form of treatment, handled primarily by physicians, that uses pharmaceuticals to

affect changes in brain chemistry. This biologically based approach to mental

problems makes up what might be called ‘‘medicalized psychiatry’’.

In this paper, we draw on the tradition of hermeneutic phenomenology to argue

that medicalized psychiatry tends to disregard the fact that our identities are context

dependent. As a result, it overlooks how the meanings, values, and self-

interpretations most important to us are created and constituted not by some fixed

biological or neurochemical attribute but by our ongoing dialogical relations with

others. In making this argument, we recognize the importance of pharmaceutical

interventions when used in conjunction with psychotherapy. That efficacy

notwithstanding, our aim is to make the case that we are first and foremost

embodied and linguistic beings, and that it is only by means of the dialogical

interplay of the talking cure that we can both recognize unhealthy and self-defeating

ways of being and be opened up to the possibility of new meanings and self-

interpretations.

The Limits of Medicalized Psychiatry

The emergence of medicalized psychiatry over the last 30 years can be attributed to

a number of factors. With advances in neuroscience, pharmacology and genetic

research there is an increasing dependence on biological explanations of various

forms of mental distress, which explains them in terms of genetic predispositions,

lesions in the brain, or chemical imbalances of neurotransmitters (such as serotonin,

norepinephrine, and dopamine). In addition, following the Health Management

Organization (HMO) Act of 1973, managed care organizations (MCOs) have

emerged which emphasize the reduction of health care costs and the elimination of

unnecessary, long-term services resulting in the explosive growth of quick-fix forms

of treatment such as medication. And finally, beginning in 1980, dramatic changes

were made to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III),

emphasizing neutral and objective diagnostic criteria, free from the context-bound

and apparently subjective elements of psychiatry’s traditional tool, psychoanalysis

(Kutchins and Kirk 1997; Horwitz 2002; Aho 2008).

The decline of psychotherapy or the ‘‘talking cure,’’ especially psychoanalysis or

depth psychology, and the new dominance of medicalized psychiatry is rather

stunning, considering that back in the 1960s and 1970s the talking cure was all the

294 K. Aho, C. Guignon

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rage. It appears in novels, such as Philip Roth’s Portnoy’s Complaint, in such plays

as Peter Shafer’s Equus, in television programs such as The Bob Newhart Show,

in numerous Woody Allen movies, and in countless cartoons in The New Yorker.

It became a running joke that celebrities and the wealthy had spent fortunes and

years in any number of different kinds of psychotherapy with little effect. Indeed, by

the 1970s there were over 130 different therapies, each with its own metapsychol-

ogy and conceptions of technique (Hale 1995: 335; Shorter 1997: 306). As

psychotherapy turned into a set of disjointed theories and techniques in the 1970s a

number of core diagnostic and methodological problems became clear.

In the first place, outcome studies have shown that no therapeutic approach

appeared to be superior to any other and that the rates of recovery among those

patients treated with psychoanalysis or psychotherapy usually did not exceed the

rate of spontaneous remission of those who were untreated (Horwitz 2002: 196–197;

Eysenck 1952). Furthermore, the talking cure was found to be totally ineffective in

treating serious psychiatric illnesses such as major depression, schizophrenia, and

bipolar disorder. This was made clear in a famous 1980s court case involving Rafael

Osheroff and the Chestnut Lodge hospital in Virginia. Osherhoff, a physician who

was suffering from major depression, sued the Chestnut Lodge for malpractice for

subjecting him to 7 months of intensive, albeit useless, psychoanalysis and denying

him access to medication. He eventually was able to transfer to a different hospital,

was successfully treated with anti-depressants and released shortly thereafter.1

The Osherhoff v. Chestnut Lodge case fortified a growing distrust in the medical

community regarding the efficacy of psychotherapy and created the perception

that treating major psychiatric disorders with psychotherapy alone could constitute

a form of medical malpractice (Shorter 1997: 309–310; Klerman 1990, 1991).

Exacerbating this problem of medical legitimacy from a diagnostic perspective was

the inability of psychiatrists to consistently agree in their diagnoses of patients who

presented the same symptoms. Critics often point to the 1949 study by psychologist

Philip Ash that revealed how three psychiatrists who had examined 52 male patients

in a clinical setting were able to reach the same diagnostic conclusion regarding the

patient’s condition only 20% of the time (Ash 1949; Spiegel 2005).

This lack of diagnostic precision prompted a dramatic shift in attitude regarding

the value and efficacy of psychoanalysis and psychotherapy, culminating in 1980

when the American Psychiatric Association (APA) published the third edition of its

diagnostic manual, the DSM-III. Spearheaded by psychiatrist Robert Spitzer, this

new edition set out to provide strictly scientific techniques for diagnosis according

to methodological criteria that hearken back to Isaac Newton. Whereas psycho-

analysis regarded an individual’s behavior as a sign of inner processes or

unconscious conflicts that need to be explained by psychoanalytic theory, the DSM-

III and its successive editions, rejected all theory and instead focused strictly on

identifying objectively discernible correlations between behavioral phenomena and

diagnoses. As Richard Wyatt (1985), former chief of the Adult Psychiatry Branch at

1 Unfortunately, Osherhoff returned home only to find that his wife had left him, his hospital

accreditation had been rescinded, and his partner had removed him from their joint medical practice

(Shorter 1997: 309).

Medicalized Psychiatry and the Talking Cure 295

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the National Institute of Mental Health (NIMH), put it, ‘‘Good psychiatry requires

careful observations and descriptions, unvarnished by theory’’. DSM-III, then,

unlike earlier versions, ‘‘attempts to describe things as they are,’’ eliminating the

intermingling of interpretation and observation. ‘‘DSM-III adds objectivity,

reliability, and prognostic validity… [by using] the minimal level of inference

necessary to characterize the disorder’’ (Wyatt 1985: 218, cited in Lewis 2006: 5,

emphasis added).2

In other words, the scientific nature of the new DSM resides in the fact that, like

Newton, it makes no hypotheses (non fingo hypothesis) about the underlying causal

processes at the root of the disorder (APA 1994: xxi–xxii).3 On this view, human

beings come to be understood as loci of ‘‘decontextualized clusters of symptoms’’

to be correlated with pre-established diagnostic categories (Sinaikin 2010).

All empirically unsubstantiated talk of Oedipus complexes, projection, repressed

sexuality, sublimation and so forth are rejected. The goal was an objective,

ideologically neutral psychiatry that was uncorrupted by the theoretical principles

that characterized the talking cure. And, although Spitzer and his allies claimed to be

etiologically neutral in terms of the cause of a disorder, their scientific pretensions

made it clear that mental disorders cannot be socially constructed or context

dependent, and this led to an increasingly reductive and biological nosology. The

result is that mental disorders have come to be regarded largely on the medical model

as analogues to physical diseases and, like diabetes or high cholesterol, may require a

lifetime of medication for the maintenance of health and the prevention of relapse.

The criticisms of medicalized psychiatry are well established. The problem that is

most often cited is that there is little to no evidence that mental illnesses are, in fact,

brain diseases. In this regard, psychiatry’s position of scientific validity is highly

dubious. Unlike other branches of medicine, the psychiatrist cannot refer to

anything biological that is causing the abnormal behavior or emotional distress.

The Surgeon General’s most recent report on mental health states:

The precise causes (etiology) of most mental disorders are not known… All

too frequently a biological change in the brain (a lesion) is purported to be the

‘cause’ of a mental disorder, based on finding an association between the

lesion and a mental disorder. The fact is that any simple association—

or correlation—cannot and does not, by itself, mean causation (Surgeon

General 1999, chapter 2, sec. 5, para. 1, 9).

Although this may soon change with advances in neuroimaging technologies and

recent brain anatomy research (e.g., Kramer 2005; Rajkowska et al. 1999; Cotter

et al. 2001), as of now, the lack of clear biological markers makes it impossible for

a psychiatrist to demonstrate the presence of a disease entity. Indeed, studies suggest

2 It appears that the psychiatrists designing DSM-III were ignorant or Hanson (1958) and Popper’s

(1963) arguments that show how all observations are unavoidably theory-laden, and that the worst theory

is a concealed theory.3 Maintaining a position of etiological neutrality, the DSM-IV claims that the causes of mental disorders

are largely unknown and could have a behavioral, psychological, or biological cause. ‘‘Whatever the

original cause, it must be considered a manifestation of a behavioral, psychological, or biological

dysfunction in the individual’’ (APA 1994: xxii).


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that only specific psychotic disorders such as schizophrenia and bipolar disorder

reveal characteristics of a disease not because of chemical or biological evidence

but because symptoms generally resemble each other across different social and

cultural contexts, and patients respond positively only to a specific class of

medication such as clozapine and lithium (Horwitz 2002: 190; Klerman 1989). On

the other hand, the long list of non-psychotic disorders in the DSM vary widely on

the basis of context, and the class of drugs prescribed to treat them—usually anti-

depressants such as Prozac, Zoloft, Celexa, and Paxil—are not disease-specific at

all. They are used with mixed results to treat a wide array of conditions including

panic anxiety, phobias, generalized anxiety disorder, social anxiety disorder,

insomnia, obsessive–compulsive disorder, and depressive disorders (Horwitz 2002:

191; Healy 1997).

A second concern for critics is the way in which medicalized psychiatry maps on

to the expectations of managed care which emphasizes the efficiency, speed, and

cost-effectiveness of pharmaceutical treatments over substantive, long-term talk

therapy. Indeed, with insurance providers imposing strict limits on the number of

psychotherapy sessions allowed for patients because of their expense, pharmaceu-

tical treatments are the norm, with psychiatrists being replaced by primary care

physicians who have little or no formal training in psychotherapy (Conrad 2007: 63;

Cushman and Gilford 2000). And those psychiatrists that are still practicing are

rarely offering the 45-min sessions of talk therapy once or twice a week for each

patient, a practice that used to be standard. In order to survive in the age of managed

care, they are now filling their days with assembly-line treatments, offering

accelerated 12–15 min sessions of up to 40 patients per day, just enough time to ask

about their medications and make prescription adjustments. The deeper questions

regarding the relational crises and the underlying life-story of the patient remain

largely unexplored (Harris 2011).

Finally, critics have pointed to the controversial and well-known relationship

between medicalized psychiatry and the pharmaceutical industry. With the FDA’s

loosened restrictions on direct-to-consumer advertising for psychiatric medication,

it is now much easier to promote both the diagnoses and the medications that treat

them. As medical sociologist Peter Conrad writes, ‘‘the common tagline: ‘Ask your

doctor if [Viagra, Paxil, Zoloft, etc.] is right for you,’ reflects the new relation

among pharmaceutical manufacturers, consumers and physicians’’ (2007: 154). The

result is a drug-related marketing explosion, with many psychiatrists serving as

‘‘key opinion leaders’’ with financial ties to drug companies (Elliott 2010).4 This

creates obvious conflicts of interest by the very people who create and define the

diagnostic criteria for the DSM. In a piece in The Washington Post, Shankar

Vedantum describes the extent of this problem:

Every psychiatric expert involved in writing the standard diagnostic criteria

for disorders [in the DSM] such as depression and schizophrenia has had

financial ties to drug companies that sell medications for those illnesses… Of

the 170 experts in all who contributed to the manual that defines disorders

4 Studies have shown that pharmaceutical companies are spending up to $3 billion a year or $10 million

a day on direct-to-consumer advertising (Lane 2007: 114).


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from personality to drug addiction, more than half had such ties, including 100

percent of the experts who served on work groups on mood disorders and

psychotic disorders (Vedantam 2006; Lane 2007: 114).

With psychiatry’s problematic alliance with Big Pharma, the scant biological

evidence for mental disorders, and the dehumanizing, mechanistic approach of the

medical model, American psychiatrists are becoming increasingly self-critical,

asking whether or not this model strips away the intimacy of the therapeutic

encounter and the possibility for personal growth and insight that only the talking

cure can offer (e.g., Lewis 2006; Bracken and Thomas 2005; Blazer 2005; Sinaikin

2010). In a recent New York Times article documenting the decline of talk therapy,

psychiatrist Donald Levin explains how the turn towards medicalization in the last

three decades has left him feeling unfulfilled and empty. ‘‘I miss the mystery and

intrigue of psychotherapy. Now I feel like a good Volkswagen mechanic’’ (Harris

2011).

Although we do not deny that there are biological or genetic components to

behavioral and emotional problems, and we are in no way against the use of

psychiatric medication, we are nevertheless concerned that medicalized psychiatry

paints an overly mechanistic and de-contextualized picture of the self. At the same

time, however, our reasons for resuscitating the talking cure have little to do with

alleviating dysphoria or increasing the client’s social adjustment. Our concern,

rather, is for the client to come to an understanding that his or her identity and the

meanings and values that matter to him or her are not given and fixed (Schafer

1980). On the contrary, meanings and values are created and constituted through

ongoing dialogical exchanges with others. Drawing on the tradition of hermeneutic

phenomenology, we argue that humans are fundamentally social and linguistic

beings who can make sense of their issues and themselves only through their

relations with others. On this view, the interplay of the talking cure is essential

because it brings these social meanings to light for the client and opens up the

possibility of new identities and new ways of envisioning what is at stake in the

client’s life.

How Does the Talking Cure Work?

For all the doubts that can be raised about medicalized psychiatry, one might claim

that the efficacy of the talking cure is even more dubious. Unlike the scientific gold

standard of double-blind placebo tests that are used to determine the effectiveness of

medication, it is impossible to establish the efficacy of the talking cure with

controlled trials. This is because in psychotherapy, as medical sociologist Allan

Horwitz explains, ‘‘neither patients nor therapists can be blinded to whether or not

they get a certain treatment: their membership in the treatment group is a component

of therapy’’ (Horwitz 2002: 194).

Furthermore, the very idea of trying to help someone who is ill by engaging them

in dialogue seems to be a strange idea from the outset. A person suffering from

malaria, for example, might spend the entire night raving and muttering outlandish


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things. Yet it is clear that sitting by this person’s bed, taking notes and responding to

what he says, will do nothing to cure his fever. When mental problems are thought

of as organic diseases comparable to malaria, then it is natural to assume that what

we are dealing with in a case of mental illness is an organism with some defect in its

electro-chemical system, a defect that should be treated by adjusting the appropriate

chemical balance. The fact that today’s medications are still relatively primitive and

blunt instruments, with unintended side-effects, does not mean that we will never be

able to cure mental illness with chemicals or that chemicals will always have

deleterious effects. In fact, this situation seems to suggest nothing more than that we

ought to increase spending on research into psychopharmaceuticals in order to find

increasingly precise and efficacious treatments.

These criticisms of psychotherapy suggest that medicalized psychiatry starts out

from a fundamental ontological assumption, namely, that humans are at the most

basic level self-contained organisms, sophisticated sorts of physical objects, no

different in type from other living organisms. When asked what justifies this

assumption, the answer will usually be: ‘‘Well, what else could they be?’’ We no

longer believe in demons inhabiting human bodies, and for the same reasons we

have doubts about other sorts of nonphysical entities—whether they be spirits, or

meanings, or underlying purposes in creation—supposedly distinct from but

interacting with organisms. Seen from this standpoint, trying to help people by

talking to them looks as backward as shamans shaking rattles and droning

incantations over the bodies of the sick.

At the same time, however, there is substantial evidence that supports the

efficacy of the talking cure (Smith et al. 1980; Landman and Dawes 1982; Mojtabai

and Olfson 2008). Indeed, despite the decline of the talking cure in psychiatric

practice, many psychiatric offices either have a resident psychotherapist to whom

clients can be referred or have a list of recommended psychotherapists who can back

up the physician’s plan of treatment. In fact, it would be hard to find a competent

psychiatrist who felt that talking to a client can never do any good. So the

question—How does the talking cure work?—becomes all the more pressing. We

will address this question in the spirit of hermeneutic phenomenology, suggesting

that there are at least three things the talking cure can offer clients that medication

alone does not seem to provide. We will proceed from the most obvious to the most

speculative.

Psychotherapy as Modeling a Way of Life

The first contribution of psychotherapeutic dialogue is the most apparent and reveals

the extent to which we are, in Merleau-Ponty’s words, ‘‘intercorporeal’’ beings

(1960/1964). To describe the psychotherapeutic encounter in terms of intercorpo-

reality is to suggest that the therapist is not at all the sort of ‘‘blank screen’’ Freud

imagined he or she must be. On the contrary, the therapist is encountered by the

client as the expressive embodiment of a particular way of living and a way of

being-with-others. From a phenomenological perspective, the client does not

initially experience him or herself as an isolated mind or consciousness that is

separate and distinct from the therapist. Prior to any conscious or theoretical sense


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of separation, the client is already bound up with the therapist’s way of being; they

are both woven together in a single inter-subjective situation. ‘‘The other person,’’

says Merleau-Ponty, appears through an extension of that compresence; he and I are

like organs of one single intercorporeality (1960/1964: 168). Caught up with each

other in this way, the client empathically absorbs, takes in, and mirrors the

expressive meanings projected by the therapist in, for instance, the way he or she is

compassionate, caring, perceptive, at ease with him or herself, steady, and

apparently successful in living. Merleau-Ponty (1988) refers to this pre-reflective

mirroring in terms of a ‘‘transfer of the corporeal schema,’’ a phrase that is meant to

capture the unique way the human lived-body senses and resonates to the feelings

and emotional states of others (1988, cited in Fuchs 2002: 322).

As an embodied model of this sort, the therapist cultivates a particular kind of

situation, giving the client an image of a way of life that presents an alternative to

the chaotic, fearful and demoralized experience that has become the norm for the

client. Presented with the even, assured responses of the therapist, the client is given

access to a life form that is characterized by greater steadiness, coherence, and

balance. It also seems likely, then, that the context of the therapeutic dialogue can

have an impact on a person’s felt and embodied sense of the world and his or her

place in it. The office of a therapist can provide a sort of safe haven from the chaotic

situations in which many individuals find themselves, and it provides an awareness

of the importance of lived-context to one’s sense of wellbeing.

Psychotherapy and the Dialogical Self

Following from this initial point, a second way the talking cure can help a client is

by providing a new frame for organizing and making sense of what life is all about.

To see how this works, we need to formulate an understanding of human existence

that provides an alternative to the objectifying outlook of the medical model.

Hermeneutic phenomenology has suggested we see a human being neither as a

quantifiable object or thing nor even as a living organism with modifiable functional

attributes. Instead, the suggestion is that we think of a human as an embodied, self-

interpreting way of being, that is, a being whose identity is constituted in part by its

self-interpretations and self-descriptions (Taylor 1985a, b).

This hermeneutic understanding of human existence starts out from the

recognition that humans are beings for whom things matter or count in some way

or other. In other words, we are beings who find ourselves located in a world of

meanings, where the meanings things have is a crucial determinant of our agency.

This is especially evident in higher-level types of human agency. Consider, for

instance, a man who has some socially unacceptable characteristic, perhaps an

unsightly facial scar, and who feels a sense of shame in interacting with others in

public space. In one sense, this is similar to the dysphoria an animal might feel in

being an outcast among others of its kind. But unlike the animal’s brute feelings, the

man’s responses are quite different. For one thing, his ways of acting in the public

world express an understanding of what is wrong with him that elicits what we think

of as shame, in contrast to guilt. This experience of shame may remain largely

inarticulate, though it will manifest meaningfully in his actions. He looks downward


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when he is in public, trying to hide his face; he perhaps withdraws into solitude,

keeps the shades in his house pulled down; he avoids the company of all but a few

people whom he trusts. This initial way of acting is a proto-interpretation insofar as

it makes manifest his sense of the meaning of his situation and an understanding of

what his footing is in public space.

What is distinctive about humans, however, is not this initial, first-order

interpretation (for which correlates might be found in other animals), but rather the

ability to formulate a second-order interpretation about his initial proto-interpre-

tation. In his actions, reflections and exchanges with others, he takes a stand on his

situation and endows it with a meaning. He sees, perhaps, that what he feels in being

socially shunned is the kind of shame a misfit or outcast might feel. Moreover, he

can embed his sense of his current condition in a larger-scale narrative about who he

is and what his life is amounting to as a whole. These second-order interpretations,

brought to expression with greater or lesser degrees of clarity depending on the

particular case, are what make him distinctively human.

The important thing to see is that the self-interpretations and self-evaluations

that make up his explicit inner reflections are not simply a sort of inner monologue.

On the contrary, as Bakhtin (1982), Taylor (1991) and others have suggested, self-

reflection typically takes the form of dialogues with real or imagined interlocutors

who play a significant role in this person’s life.5 People who have a spouse or

partner or closest friend will know what it is like to experience events through the

lens of self-talk that is custom-made for telling that significant other what happened

during the day. So, for example, an annoying confrontation with a colleague at work

might be experienced in terms of a verbal formulation for complaining later in the

day to one’s partner: ‘‘I had another run-in with so-and-so this afternoon, and…’’

In this respect, many of our experiences are pre-shaped by an anticipated tellingintended for the ears of one who cares. In Ricoeur’s (1984) vocabulary, the

experience is prefigured with a particular narrative structure that anticipates the type

of configuring it will be given in a later act of telling. The structure of our

experience, on this view, is dialogical. Even the most solitary activities are seldom

merely ‘‘I’’ experiences; instead, they are generally ‘‘we’’ experiences. The same is

often true of self-doubts and self-criticism, as well as feelings of pride and joy.

These reflections and feelings are typically experienced through the medium of a

dialogical exchange with, for instance, a parent who may no longer even be alive.

As Bruner (1968) observed, this dialogical structure of experience begins in early

childhood. A very young child, for instance, may fall down and then look up

at the parent for a moment, as if awaiting a response. If the mother laughs and says,

‘‘That wasn’t so bad,’’ the child will come to have a qualitatively different feeling in

response to future accidents of this sort than if the mother says, ‘‘Oh, you poor thing;

that’s terrible!’’ So from the earliest years, we not only absorb and mirror the

expressive meanings of our significant others, our feelings and sense of reality are

shaped, from the ground up, by these kinds of dialogical interchanges. As Taylor

5 Taylor (1991) correctly notes that Freud recognized this phenomenon to some extent in his account of

the superego as the introjected voice of the parent in The Ego and the Id. See also Richardson et al.

(1998).


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says, ‘‘we are aware of the world through a ‘we’ before we are through an ‘I’’’

(1985b: 40).

Observations of this sort suggest that the human self is from the outset not the

encapsulated center of experience and will imagined by the philosophical tradition,

but is rather an inter-subjective and dialogical self, the crossing point of a number of

ongoing dialogues with actual (or imagined) interlocutors, for example, with role

models, parental figures, bosses, colleagues, and loved ones. The man with the

disfigured face we considered a moment ago provides an example of the dialogical

nature of not just experience, but of identity itself. He feels shunned because of his

appearance, and he articulates his experience through dialogical interchanges with

parents, passers-by, and other internalized interlocutors. As he tries to find his

footing in public space, he does so in terms of a to-and-fro exchange with voices

that confirm or challenge his interpretations. In its most forceful form, this view

holds that the self is nothing other than the sum total of all the dialogues in which it

is engaged. There is no ‘‘real me’’ beneath the dialogues that has an identity

independent of these interchanges. In Taylor’s words, ‘‘the ‘I’ is constituted as an

articulate identity defined by its position in the space of dialogical action’’ (1991:

313). What we call the ‘self,’ then, is primarily and always a space of interchange.

Although our self-interpretations come to expression in all our ways of acting in

the world, language plays a crucial role in the process of dialogical self-constitution.

For language is the medium in which the fields of contrast that make possible our

distinctively human forms of agency are sustained and made explicit. I can know

that what I feel in a particularly embarrassing situation is shame rather than guilt not

because of any qualitatively distinctive feature of the feeling. Instead, I can grasp

my experience as an experience of shame because I grasp how this word and other

related words are used in my cultural context. My experience of shame is related to

my feeling humiliated as a result of having done something socially inappropriate,

regardless of the intentions I might have had at the time, and shame matters to me

because I aspire to dignity and a feeling of worth in the presence of others in my

world. These words in turn gain their meaning from their relations to other words in

the language I have come to master in growing up in this world. It is this linguistic

grasp of things that makes it possible for me to feel emotions of the sort I feel and,

indeed, to be the sort of person I am in the particular contexts in which I find myself.

As Taylor says, ‘‘Our emotional language … is irreducible. It becomes an essential

condition of articulacy; and import and goal, the language of feelings and

consummations desired, form a skein of mutual referrals, from which there is no

escape into objectified nature’’. (1985a: 57) It follows on this view that the

linguistically articulated field of possible feelings, desires and interpretations we

absorb in growing up into a particular lifeworld consists not just of tools one has on

hand for bringing ideas to words. Our language is, instead, the condition for a person

to be human in the specific way he or she is. To say that humans are embodied, self-

constituting beings, then, is to say that they find themselves through dialogical

interchanges within the public field of meanings into which they are, to use

Heidegger’s (1927/1962) word, ‘‘thrown’’.

These observations about identity and language provide us with a way of

understanding how talk can play a crucial role both in constituting a person’s


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identity and transforming that identity through therapeutic dialogue. In discussing

his situation with a thoughtful, caring professional, the man we described earlier can

come to see that his feelings of shame about his appearance are not really the

appropriate response to his situation. Through conversation with a caring ‘‘other,’’

he can see that the fact that he feels he is being shunned does not entail that he has

done anything shameful. As a result, he can be led to see that the negative responses

of others to his presence do not reflect on him, but rather indicate problems they

have in dealing with anything that is unusual or different. As he follows different

strands of the skein of meanings shaping his experience, he may be led to

experience things in a different way, and thereby change his life. In short, the self-

constituting interpretations that have defined his identity are transformed through

the discovery of new articulations and types of description, which in turn create new

possibilities of experience and feeling. Dialogical interchange of a constructive sort

can help to make him into a different sort of person.

Note the difference between this conception of change and the conception that

seems to be presupposed by medicalized psychiatry. Followed to its logical

conclusions, medicalized psychiatry seems to assume that humans are basically

objects in the material world, organisms that are more complex but not essentially

different from other organisms. It would seem to follow from this view that

changing the electro-chemical processes occurring in their neural systems must be

the only way to bring about change. In contrast, hermeneutic phenomenology shows

how humans are distinctive among other organisms in that their linguistic

formulations about themselves and the world they share with others are not merely

special sorts of behavior, but actually play a crucial role in constituting their own

being. It may not be surprising that scientific data have shown that changes in ways

of speaking produced by dialogue actually bring about chemical transformations in

the brains of test subjects (e.g., Begley 2007; DeGrandpre and White 1996).6

Understood this way, therapeutic dialogue is not just a nice add-on to treatment

through drugs. It clearly can be a profoundly important component of any therapy

aimed at producing lasting change.

Psychotherapy as Poetic Language

A final way in which talk therapy plays a role in personal transformation might be

gleaned from Freud’s The Ego and the Id (1923/1989). The context of this particular

6 DeGrandpre and White have shown that the effect of drugs is itself conditioned by the socio-historical

context of meanings in which they are taken. That is why the 50% of American troops who had become

heroin addicts while in Viet Nam had no trouble overcoming their addictions, whereas ordinary street

addicts have a hard time shaking their habits. Most interestingly, the authors show that rats in captivity,

given the options of either stimulating the pleasure center of their brains by electrodes or eating, will

starve to death, whereas rats living in the wild lose interest in stimulating the pleasure centers of their

brains almost immediately. The effect of stimulation of the pleasure center seems to be almost entirely

due to environmental conditions, in this case, captivity. The authors conclude that, although

‘‘psychoactive drugs … are drugs because they alter … users’ psychological experience, differences

among such drugs will not be found in their molecular structures, their cerebral sites of action, or in the

licit/illicit context of their use.’’ Instead, the differences are due to ‘‘the multiplicity for and meanings of

their use’’ (1996: 28).


123

discussion is Freud’s attempt to describe the interactions of personality subsystems

and, in particular, to describe how what is unconscious (especially the repressed)

can come to consciousness. We need not accept all of Freud’s metapsychology in

order to gain insight from his explanation of the talking cure. What is of interest

here is his account of how the unconscious (i.e., what is happening in the id) plays a

role in us under ordinary conditions. Freud sees the unconscious as a seething

cauldron of drives, dark desires and needs. It is achronic, illogical and amoral, and

so lacks any of our familiar ways of organizing and being ordered in mental life.

Because these unconscious thought-processes are constantly condensing, fusing,

and splitting apart, what occurs within the id is inchoate and amorphous, lacking

even the coherence and focused energy to emerge into consciousness. This

unconscious activity works on us, pushing us into actions that seemingly make no

sense, and yet we are unable to get a handle on them or control them.

In The Ego and the Id, Freud offers an account of how this maelstrom of energies

can be made conscious and so can come to be handled by the ego. The suggestion is

that something can become conscious by ‘‘becoming connected with the word-

presentations corresponding to it’’ (1923/1989: 12). The picture Freud proposes

works something like this. The client is bewildered by what is happening to him; he

feels he has control neither over his thought-processes nor over the behaviors that

result from them. In the psychoanalytic dialogue, words are put into play so that

they become accessible to the individual in his preconscious mnemonic system.

These words expand the number of possible ways he can interpret himself. We can

imagine a good therapist who, upon hearing the client’s references to confusing

fears, adds the word ‘‘rage’’ to the mix. In the course of this relatively free play of

words, a particular word might resonate with the client in such a way that some part

of what he is experiencing becomes accessible in a way it never was before. The

word enables the client to focus and give shape to something that is working in him.

The word (or words) let him gain access to what he is undergoing in a way that

opens up a new space of possibilities for interpretation and action. Naming, in this

respect, both focuses and energizes what was initially hidden. It lets something

come to light, and it ‘‘possibilizes’’ in the sense that this illumination opens the

individual to new possibilities of articulating what is at issue. These new

possibilities can play a role in the process of personal transformation as the

individual discovers new ways of interpreting himself and reframing his identity.

The door is opened to greater insight and clear-sightedness in the person’s being-in-

the-world.

In order to understand how naming and language can raise what is initially

obscure to a new level of clarity and possibility, we will probably need to work out a

different conception of language than the one that prevails today. Heidegger talks

about ‘‘poetic language’’ and means by this, of course, the language that appears in

great poetry. But he also tries to preserve the original source of the idea of poetry,

the Greek poeisis, which means ‘‘making’’. In this broader sense of the word, poeticlanguage is language that lets something new come into being. In contrast to the

ordinary language of everyday busyness, where the aim is to designate something

familiar, poetic language is understood as a way of letting something initially veiled

in darkness now shine forth or emerge into presence as the very thing it always


123

(tacitly) has been. Thus, Heidegger says that ‘‘language is not only and not primarily

an audible and written expression of what is to be communicated’’. Instead,

‘‘language alone brings beings as beings into the open for the first time.’’ Poetic

language functions at the deepest level as a naming that lets what-is appear.

Heidegger goes on to say, ‘‘Language, by naming beings for the first time, first

brings beings to word and appearance. Only this naming nominates beings to their

Being from out of their Being. Such saying is a projecting of [a] clearing, in which

announcement is made of what it is that beings come into the open as’’ (1993: 198).

If we think of psychotherapeutic dialogue as poetry, that is, as primal making(poeisis) in language, then we can understand how Freud’s account of finding the

name for something can play a role in healing those who suffer from mental distress.

The dialogical interplay in which two people engage in bringing to light what is

initially inchoate and confused can be seen as a creative act in which new

possibilities of understanding and self-formulation are allowed to emerge into the

light. Heidegger calls this kind of poetic dialogue projective saying, by which he

means that it points forward to the future, sketching out a range of possibilities that

may have never appeared in this way before. Projective saying is, in Heidegger’s

words, a ‘‘renunciation of all the dim confusion in which a being veils and

withdraws itself’’ (1993: 198). For a human being, this means pointing to a different

future where things shimmer in a constantly radiant field of possibilities. The

individual is then exposed to alternative ways of narrating his or her life, and hence

to new ways of being. It should be evident that the creative act of ‘‘making’’ brought

about by poetic discourse goes well beyond anything that might be achieved by

taking a pill. The value of such constructive self-constitution through language

should be apparent.

Conclusion

We are, of course, realistic about the state of health care today, and we acknowledge

that a substantive turn towards the talking cure is unlikely in the era of quick-fix

managed care, and the ubiquity of the DSM and Big Pharma. However, we do not

want to deny the emergence of a growing body of professional criticism among

psychiatrists and health care professionals who are expressing serious concern about

the medical model in psychiatry (e.g., Lewis 2006; Bracken and Thomas 2005;

Blazer 2005; Sinaikin 2010).7 Our aim in this paper has been to contribute to this

critique by suggesting that the client is not a de-contextualized set of symptoms but

an embodied and linguistic way of being whose identity is created and constituted

through dialogical relations with others.

This does not mean that we are dismissing recent advances in pharmacology or

neuroscience, nor does it mean we think that biology and genetics are irrelevant to

issues of mental health. We are mainly supporting the idea that psychiatrists have a

7 Even Spitzer (2007), the so-called architect of the DSM-III, has expressed reservations about the

assumptions of medicalized psychiatry and its tendency to equate the presence of symptoms with a

medical disorder without any reference to social and interpretive context.


123

greater fluency in and a willingness to use the talking cure in their practices in order

to help clients understand themselves and to make sense of what it means to take

medication in the first place. To this end, we agree with Eric Plakun, the Chair of the

APA’s Committee on Psychotherapy by Psychiatrists, who says, ‘‘It is extremely

powerful to have a psychiatrist who can do both the psychotherapy and the

prescribing because it really allows the meaning of medications to come into the

work’’ (Kaplan 2008).

Here, it bears pointing out that the synergistic effects between the talking cure

and medication have been widely and repeatedly demonstrated in outcome studies

where each approach taken independently is less effective than their combined use

(Altshuler et al. 2001; Sinaikin 2010; Solomon 2001; Good 2000). However, we

want to go further by claiming that the talking cure is a vital component to treatment

because it alone can illuminate alternative possibilities for self-creation. By opening

up a space of new discursive meanings and interpretations, the talking cure allows

the client not only to recognize and name his or her self-defeating and unhealthy

ways of being but also to envision alternative ways to construct and narrate his or

her life in the future.

Acknowledgments We would like to thank the two anonymous reviewers at Human Studies for their

insightful comments on this paper. An earlier draft was presented at the Science and Medicine in SocietyConference at the University of South Florida in Tampa, September 2008.

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