Hermeneutic Labor in Medicine and Psychiatry
Hermeneutic Labor in Medicine and Psychiatry
Ellie Anderson has discussed the notion of “hermeneutic labor” in the context of feminist scholarship in a wonderful paper, ‘Hermeneutic Labor: The Gendered Burden of Interpretation in Intimate Relationships Between Women and Men,’ forthcoming in Hypatia.
She writes:
“… hermeneutic labor is the burdensome activity of a) understanding one’s own feelings, desires, intentions, and motivations, and presenting them in an intelligible fashion to others when deemed appropriate; b) discerning others’ feelings, desires, intentions, and motivations by interpreting their verbal and nonverbal cues, including cases when these are minimally communicative or outright avoidant; and c) comparing and contrasting these multiple sets of feelings, desires, intentions, and motivations for the purposes of conflict resolution. Hermeneutic labor is related to emotional labor because it works on the emotions—and, more broadly, the emotional domain of interpersonal life. Yet it is distinct from emotional labor because it pertains to explicit processes of interpreting emotions (as well as desires, intentions, and motivations) through cognitive processes, such as deliberating and ruminating. Naming ‘hermeneutic labor’ permits us to distinguish its harms from those of related forms of care labor. Indeed, many of the harms that feminists point out in analyses of the undue burden of emotional labor placed on women may actually be describing the harms of hermeneutic labor.”
And
“… hermeneutic labor primarily involves patient, deliberative reflection, and is generally undertaken in solitary rumination and/or in conversations outside of the situations on which it labors, as in conversations with friends or counselors. Hermeneutic labor reflects on social encounters after they occur, and prepares plans for future encounters. This may include reflecting on how they made one feel—and whether that feeling was appropriate to the situation—as well as reflecting how others may have felt in the situation, and whether one should respond to others differently in similar situations in the future. It also often involves attempts to infer another’s mental and emotional state and make judgments about their personality by synthesizing multiple impressions one has received from another person over time. Emotional labor is the nurse extending a warm smile and squeeze of the hand as an elderly patient recounts a story from their past that the nurse has heard many times already; hermeneutic labor is the nurse wondering on the ride home whether her response was appropriate, and whether next time she might be able to tell the patient that she’s heard the story before without hurting the patient’s feelings.”
I encourage you to read the original article for the details of her argument (which I find persuasive). It seems to me, however, that the concept of hermeneutic labor can also prove useful in talking about certain sorts of harms that we encounter in medicine, psychiatry, and psychology.
It is telling that Anderson already makes a few references to clinicians as a way of illustrating hermeneutic labor. We have seen her example of the nurse. At other points she writes about hermeneutic labor by comparing women to psychotherapists: “In short, women serve both as informal therapists for men and as informal couples’ therapists for the relationship.” And at another place in the text “… this situation leads to women’s becoming informal therapists for men partners and for the relationship, but this results in their disempowerment and dissatisfaction.” The analogy makes sense given that the task of interpretation is a vital element of psychotherapy.
It is uncommon for us, however, to recognize and talk about clinicians as undertaking hermeneutic labor, as a form of labor that is expected of them. And when clinicians fail to perform this labor, or fail to perform it sufficiently well, this has detrimental effects where the hermeneutic burden is then shifted onto the patients. In fact, patients may not only be left with the hermeneutic burden of making sense of their own problems, but they may also be burdened with the task of figuring out how to tidily package and present their concerns to their clinicians in a manner that they are taken seriously. A good illustration comes from a twitter thread by Maia Bittner (@maiab) in which she presents her cheat sheet on how to interact with doctors. It illustrates patients having to go to great lengths just so that they don’t “fuck up going to the doctor.” It shouldn’t require this degree of preparation to go see a doctor, but unfortunately it does (especially for marginalized folks). The distribution of hermeneutic labor here is not as it should be!
Hermeneutic labor has additional relevance to psychiatry. A lot of work on the importance of the hermeneutic approach to psychiatric problems has been done in the field of phenomenological psychopathology. For instance, Stanghellini & Aragona (2016) discuss the hermeneutic framework for psychopathology in this book chapter, and write:
“… subjective experiences are not simply “given”; they are not objects that can be simply itemized in operative diagnostic criteria. Mental symptoms are the product of a complex hermeneutic process involving a recursive interpretation between two poles: the patient’s self-interpretation of what he/she is feeling and the clinician’s interpretation of what the patient is trying to communicate. Due to different personal, familial, and sociocultural conceptual categories and idioms of distress, the patient may perceive, interpret, and express differently what he/she is experiencing (cp. Berrios 2013b; Aragona and Marková 2015). Similarly, another interpretative act “is performed by the listener who must sometimes interpret the speaker’s meaning by asking the speaker and himself “what does he mean by that?” This problem, which plagues psychopathological research and clinical practice, becomes even more acute in using standardized assessment, since when interviewees respond to questionnaires, they might have very different understandings of the questions, and this may lead to the inaccurate conclusion that different individuals or groups have similar experiences or beliefs. An interview is a linguistic event. It is not a behavioral-verbal interchange simply mediated by language. Rather, it happens in language” (Stanghellini 2013, p. 326). Accordingly, subjective mental states may be opaque to its owner and errors in translation may always occur; nevertheless, this hermeneutic status of mental symptoms is constitutive, and for this reason a hermeneutic approach to psychopathology is not a philosophical surplus but a necessary requirement in psychiatric and psychological trainings. In fact, the acknowledgment of the hermeneutic co-construction of mental symptoms “implies, in practice, that the coding of each item of an interview always requires an (often laborious) process of interpretation—rather than a pseudo-objective simple ‘ticking’” (Stanghellini 2013, p. 326).” (my emphasis in bold)
That is, mental health problems and psychological difficulties are not natural objects of inquiry. They are experienced and reported and understood and treated through essential acts of interpretation. When this fundamental insight is ignored, and when psychiatric clinicians have little to offer beyond assessing symptoms and offering a formal DSM/ICD diagnosis, an important shortcoming occurs: the hermeneutic labor that was owed is not undertaken.
I have previously talked about diagnosis and self-alienation, and I wrote:
“The situation now is that most people who see a clinician for mental health problems leave with their folk understanding of psychiatric distress intact (or reinforced) because all the implicit assumptions around psychiatric diagnoses are almost never examined and corrected.”
We can now understand this as a failure of undertake the requisite hermeneutic labor.
See also: Stories That Trap Us