Medicine, Healthcare and Philosophy1: 275–277, 1998.© 1998Kluwer Academic Publishers. Printed in the Netherlands.

Review Article

Hans-Georg Gadamer on mental illness – A critical review

Søren HolmDepartment of Medical Philosophy and Clinical Theory, Copenhagen, Denmark

Gadamer, H.G.: 1996,The Enigma of Health.Stanford: Stanford University Press. 180 pages. ISBN:0-8047-2692-2.

A recently published volume, this book containsa collection of the writings of the German philosopherHans-Georg Gadamer on the topic of health andillness. Gadamer is well known for his very importantcontributions to philosophical hermeneutics althoughhis work on health and illness has not received similarattention, and is for instance not mentioned in anyof the essays in the volume of theLibrary of LivingPhilosophersdedicated to Gadamer (1).The Enigmaof Healthis a direct translation of a German collectionwith the same title (2), but it nevertheless seemsapposite to use the English version as the main basisfor this review, since it is probably accessible to alarger proportion of the readership of the presentjournal.

The equilibrium of health

Most readers ofThe Enigma of Healthhave prob-ably felt a certain sense of frustration when readingthrough the volume, because although all the 13 papersin the volume are concerned with health and/or ill-ness, there are very few places where Gadamer gives asustained and closely argued account of his position.The first problem facing the reader is thus to piecetogether a full and coherent account of Gadamer’sideas. In the following I will attempt to (re-)constructsuch a coherent account based on the parts found in thepapers.

The first element of Gadamer’s account of healthand illness is his insistence that health is a state ofequilibrium, and that disease is only a partial depar-ture from this equilibrium. Even in the diseased personmost of the normal processes of equilibrium still goeson. The work of the physician thus becomes helpingto re-establish equilibrium/health. Gadamer shows thatthis state of equilibrium cannot be characterised as a

product or a stable state. The attainment of equilib-rium is a dynamic and continuous process. He uses thepicture of the circus performer walking the tight rope.Here equilibrium is a constant balance between the toolittle and the too much. Both too little effort and toomuch effort can lead to loss of equilibrium. Gadamerclaims that:

The ultimate horizon of all medical practice isdefined by the fact that the fluctuating state ofequilibrium characteristic of health is qualitativelydistinct from that definitive loss of equilibriumwhen everything finally comes to an end. (p. 37)

Within the field of mental illness Gadamer points out,that our mental equilibrium can be disturbed both bythe amount of possibilities surrounding us, and by ourunderstanding of these possibilities. It is, however,never merely that we are overwhelmed by too manyoptions, but that these are seen as threatening withinour horizon of understanding:

That we can no longer cope with being surroun-ded by possibilities represents a breakdown inour capacity to sustain psychological self-balance.This breakdown is not independent of the horizonof the possibilities which surround us, no matterwhether they help to sustain the state of equilib-rium in which we find ourselves or whether theycontribute to destroying it through our ecstaticself-abandonment and fixation on one particularpossibility. (p. 58)

The second element of the Gadamerian account is theobservation that illness is always experienced as a lack.While illness may have methodological primacy inmedicine and may thus seem to have a positive defin-ition, it is really health which is the state that hasontological primacy, and illness is always experiencedas a lack of health, as something which should onlybe given a negative definition. This account of diseasehighlights some special problems facing the psychi-atrist, because in contrast to most other doctors he

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or she is facing patients who do often not experiencethemselves as ill.

The third and final element in Gadamer’s accountis specifically connected with mental illness andthe concept of insight. Gadamer first notices thatthe concept of insight is itself problematic if it isunderstood on the objectifying model relevant toour understanding of external objects. He highlightsthe Heideggerian idea that self-understanding is notsomething we reach by focusing conscious atten-tion on our selves, it presupposes an active engage-ment with something outside ourselves, because self-understanding can only come about through a return tothe self:

We are only able to become aware of ourselveswhen we are fully occupied with something elsethat is there for us; only when we are com-pletely involved in something beyond us can wereturn to ourselves and become aware of ourselves.The ideal of complete self-presence and self-transparency that would correspond to the conceptof nousor ‘spirit’ or the more recent concept ofsubjectivity is something fundamentally paradox-ical. The state of being completely involved insomething, of seeing it, intending it and thinkingit, is necessarily presupposed if there is to be anypossibility of ‘returning’ to oneself. (p. 134)

He further notices that insight or self-understandingis something which is only achieved through effort,and that many mechanisms may block the process.But certain illnesses seem to be characterised by aparadigmatic lack of insight:

As a phenomenon of lived experience insight intoone’s own illness is clearly not simply insight inthe sense of knowledge of a true state of affairs,but rather, like all insight, it is something which isacquired with great difficulty and by overcomingsignificant resistance. We know the important rolewhich concealment of the awareness of ill-healthplays in certain human illnesses and, above all,what an important role this concealment can playin the lived existence of a person. (p. 52)

Gadamer explains this lack of insight within his frame-work of health as equilibrium, claiming that (in somecases) lack of insight can be seen as the persons’attempt to maintain equilibrium in spite of countervail-ing influences. Gadamer thus finally draws together hisviews on insight and mental illness in the followingparagraph:

In mental illness the twofold manner of ‘being athome’ which is constitutive of human life, being athome in the world and being at home with oneself,

is no longer successfully accomplished. Mental ill-ness does not so much involve the loss of specificabilities as the failure to meet a challenge withwhich we are all permanently confronted, that isof sustaining the equilibrium between ouranimal-itas and that in which we identify our vocation ashuman beings. When suffering from mental illnessour condition does not simply fall into an animal-vegetative state; the deforming loss of equilibriumis rather something which peculiarly affects themind. (p. 60)

Here there are clear echoes of Heidegger’s analysis ofanxiety as something which attacks us when the worldsuddenly becomesunheimlichand our being at homein the world is disturbed.

Objections to the Gadamerian account

One obvious objection against Gadamer’s ideas is thatwe today have a far better understanding of the neuralbasis of many mental illnesses than was available atthe time of writing of some of the articles inTheEnigma of Health, and that it is only a matter of timebefore some of the major illnesses like schizophreniaor manic-depressive illness can be fully explained inneuro-biological terms. An understanding of mentalillness through locating the illness to the mind is there-fore obsolete. This objection does, however, seem tomiss the point. Even if we become able to explainthe causation of a specific mental illness in terms ofneurobiological processes, this does not show that thesame causal explanation will make us able to under-stand or predict the specific mental content whichexpresses the disease in a given patient. This is notonly a problem in mental illness, but in any kind ofillness where the symptoms are not purely physical.It may well be the case that there is some commonneural process underlying all cases of paranoid schizo-phrenia, but knowledge of this process is not sufficientto explain the exact content of a patients’ paranoiddelusions, otherwise the content of paranoid delusionsshould have been the same in the Middle Ages andtoday. As long as Gadamers “theory of mental illness”is not an all-embracing causal theory of mental illnessas such, but a theory of the mental content aspect ofmental illness, it is not affected by the objection. Theinitial process leading to mental disequilibrium, forinstance by disturbing the sense of being at home inthe world, could on Gadamer’s theory well be bio-logical in nature, but this would not affect the claimthat the attempt to regain equilibrium could proceedalong the lines described by the theory. This discus-sion, however, uncovers a problem in understanding

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Gadamer’s position. Is he advancing (1) a causal the-ory of the final, underlying causes of mental illness,or (2) a narrower causal theory of how disturbances ofmental life (no matter how they are ultimately caused)can turn into mental illness with lack of insight, or (3)a phenomenological description of important factors inthe illness experience?

This is a very difficult question, but in the end it isprobably most fruitful to view Gadamer’s ideas as (1)an exploration of the disease-concept and its relationto the concept of health in general, and (2) an analysisof the puzzling fact of the lack of illness-awareness ina number of mental (and neurological) illnesses. Thesecond part of Gadamer’s ideas is, in a certain sense,a theory of this class of mental (and neurological) ill-nesses, because it attempts to explain not the illness assuch, but one very prominent and strange feature, i.e.that the person is not aware that he or she is ill.

Possible further developments of Gadamer’sframework

Outside of the context of mental illness Gadamer’sideas about health as a simultaneously precarious andsteady equilibrium, the ontological primacy of health,and the illness experience as (necessarily) an experi-ence of a lack could probably be fruitfully developedand utilised within the branches of medical philosophyfocusing on the concepts of health and disease andon the phenomenology of illness. One very importanttask for such further development will be to analyzeGadamer’s concept of equilibrium in more depth in

order to be able to argue that health as equilibrium isreally ontologically prior to any kind of disease.

Within the context of mental illness Gadamer hasprovided some pointers to how a closer analysis ofthe preconditions of self-awareness may shed lighton the development of mental illness and especiallyon the problem of lack of insight. Further devel-opments of these ideas could be of importance inpsychiatry and psychology, especially the concept ofself-understanding as a return to oneself. Many psychi-atric conditions are characterised by a dis-engagementwith the world which is not only mental. This dis-engagement is, if Gadamer’s analysis is correct, verydysfunctional since it diminishes the active engage-ment with something outside oneself which is a neces-sary precondition for the attainment of self-awarenessand self-understanding.

As it will be evident from the above I think thatthis is a book which merits careful study. There ismuch with which one can disagree, but inThe Enigmaof Health Gadamer presents a number of thought-provoking analyses of concepts that are central to ourunderstanding of health and (mental) illness.

References

Hahn, L.E.: 1997,The Philosophy of Hans-Georg Gadamer(The Library of Living Philosophers, Volume XXIV).Chicago: Open Court Publishers.

Gadamer, H-G.: 1993,Über die Verborgenheit der Gesundheit.Frankfurt: Suhrkamp Verlag.