Philosophy, Psychiatry, & Psychology

In A Logic in Madness, Aaron J. Hauptman (2015) presents the case of Mr. A, a college-age man suffering from the unexpected and cruel severance of a romantic relationship. This breakup caused Mr. A to become severely depressed, harboring a desire to starve himself. However, Mr. A adamantly refused any sort of pharmacotherapy for his condition. Being someone who has “a doggedness with rationality” (p. 304) and who cares deeply about being logical, he offered several arguments and reasons for his refusal. One of these was: “I am depressed for a very good reason and if, because of that, I have these feelings then it is right for me to have these feelings” (p. 304). He further regarded drug therapy as “dishonest,” “despicable,” and “disloyal” (p. 304).

Mr. A’s case beautifully showcases several intersecting questions at the heart of philosophy of psychiatry and psychiatric practice. Here, I focus upon only one: ‘what should be done about Mr. A’s situation?’¹ Although Hauptman raises a related question: ‘Is Mr. A suffering from a disease, or from heartbreak?’, the question about what should be done may or may not be linked to Hauptman’s conceptual question in more or less complex ways, and is arguably the more urgent question for Mr. A, his clinicians, his parents, and his friends.

As I understand it, Mr. A has three main options:

1. (1). receive no treatment;

2. (2). receive pharmacotherapy (what I will also call ‘drug therapy’ or ‘antidepressants.’ This is considered an ‘external’ or ‘direct’ manipulation of his brain chemistry.); or

3. (3). receive psychotherapy i.e., some sort of ‘talk therapy’).

The tension that drives this case is that clearly no treatment is bad, because it is the option that carries the largest risk of self-starvation, but Mr. A steadfastly refuses drug therapy. So much of the case is painted as a Scyllan and Charybdian choice between (1) and (2). Oddly (it seems to me), psychotherapy is not introduced as an option in Hauptman's discussion until later. I found this puzzling, insofar as many consider it textbook knowledge that certain forms of psychotherapy [End Page 317] are equally effective as medication (Holmes 2001, 234–5; Kaplan and Sadock 2007, 961; see also Hollon and Ponniah 2010). Granted, equal effectiveness becomes more shaky in cases of severe depression (see discussion in Biegler 2011), but there is still evidence for sometimes equal effectiveness in this context (DeRubeis et al. 2005), and certainly psychotherapy stands a better chance of effectiveness than no treatment at all. I am curious about what institutional, economic, and other factors led to this delayed introduction, and whether Hauptman would think that such factors should be combatted.

My curiosity is coupled to my main aim here: to present a novel consideration in support of psychotherapy.² Because psychotherapy is the outcome that Hauptman calls “a success in many regards” (2015, 305), I am in broad agreement with him. I am not sure, however, as to whether our agreement would extend to the specific consideration I present here.

Notably, I do not think my consideration here is necessarily the most important one in this decision, especially because the issue of forced treatment and violation of autonomy loom very large. But I hope that it may serve as an additional way to shed light on the merits of psychotherapy in Mr. A’s case. Furthermore, I believe it is a consideration that Mr. A himself might have found appealing and conceptually useful.