PsychiatricMental Health Outcomes

Kutney

An Examination of PsychiatricMental
Health Outcomes From the Perspectives of
Logical Positivism and Phenomenology
Ann M. Kutney

The current philosophical paradigm in psychiatry is based in logical positivism, as outcomes are viewed as objective and scientifically verifiable. This approach, although making important contributions to the field, fails to acknowledge outcomes from the
perspective of the client. A growing movement within the mental health field is promoting the use of phenomenology and the
lived experience, which provides new opportunities for defining outcomes from the clients perspective. The purpose of this article
is to briefly review the main tenets of both philosophical perspectives and to demonstrate how these perspectives influence the
conceptualization of outcomes in psychiatricmental health nursing practice and research. Finally, a proposal is made for clinicians and researchers to adopt an integrative model, a blending of the two viewpoints, to capture the most complete experience of
the client and to define the most appropriate outcomes. J Am Psychiatr Nurses Assoc, 2006; 12(1), 22-27. DOI: 10.1177/
1078390306286443
Keywords: mental health outcomes; psychiatric nursing; mental illness; philosophy

The predominant philosophical view within a discipline shapes the nature of treatment outcomes that are
accepted and valued by that discipline. The current
philosophical paradigm in psychiatry is based in logical positivism, and hence, valued outcomes are those
that are objective and scientifically verifiable. This approach, although making important contributions to
the field, fails to acknowledge outcomes from the perspective of the client. A growing movement within the
mental health field is promoting the use of phenomenology and the lived experience, which provides new opportunities for defining outcomes from the clients
perspective.
This article will address psychiatricmental health
treatment outcomes at the client level. The philosophi-

Ann M. Kutney, RN, MSN, is a predoctoral fellow at the Center

for Health Outcomes and Policy Research for the University of
Pennsylvania School of Nursing, Philadelphia; akutney@nursing.upenn.edu.
This project was supported by research fellowship grant
T32NR0714 from the National Institute of Nursing Research, National Institutes of Health.
The author thanks Angela Gerolamo, Nancy Hanrahan, Ryan
Lee, Mindy Zeitzer, and the editors of the Journal of the American
Psychiatric Nurses Association for their thoughtful comments in
the development of the manuscript.

22

cal perspectives of logical positivism and phenomenology will be used to frame different views of outcome
measurement. A discussion of logical positivism will
highlight the underpinnings of current outcome measurement, whereas phenomenology will be used to represent a more patient-centered philosophy of outcomes. The purpose of this article is to briefly review
the main tenets of both philosophical perspectives and
to demonstrate how these perspectives influence the
conceptualization of outcomes in psychiatricmental
health nursing practice and research. Finally, a proposal is made for clinicians and researchers to adopt an
integrative model, a blending of the two viewpoints, to
capture the most complete experience of the client and
to define the most appropriate outcomes.
LOGICAL POSITIVISM
The French philosopher Auguste Comte developed
positivism to establish a pure scientific philosophy in
which all knowledge results from experience (Miller,
1999). Logical positivism was a name subsequently
adopted by members of the Vienna Circle, a wellknown group of philosophers and scientists, including
Alfred Ayer, Moritz Schlick, Rudolf Carnap, and Karl
Menger, in the early 20th century to define their
unique position (Ayer, 1959).

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PsychiatricMental Health Outcomes

The major tenet of logical positivism is that information is meaningful only if obtained through scientifically verifiable observations. Knowledge in the logical
positivism tradition is derived from sensory-based experiences, such as sight, sound, and touch. The logical
positivism perspective believes in a single reality that
is experienced by all people (Baker, 1992). The use of
the scientific method and formal logic, through the process of observation, hypotheses creation, and experimentation, allows verifiable conclusions about reality
to be made (Kitchener, 2004). Although logical positivism is not considered an active movement in the philosophical world today (Schumacher & Gortner, 1999;
Tolman, 1992), its influence can still be readily felt in
the realm of psychiatry and mental health.
LOGICAL POSITIVISM AND PSYCHIATRIC
MENTAL HEALTH OUTCOMES
In a reflective, historical account, Sabshin (1990)
documents the major turning points in 20th-century
American psychiatry, with an emphasis on the adoption of positivist ideals. In the years after World War II,
the field was driven by psychotherapy, with little interest in empirical methodologies. Because of the disciplines lack of connection with science, as well as a lack
of objective outcomes, stakeholders became skeptical of
the field and its contributions. On the verge of disappearance, psychiatry began to move toward an empirical, positivist philosophy in the late 1970s based on this
dire need to be seen as a recognized member of the scientific community. The positivist approach to outcome
measurement was fueled also by advancing discoveries
of the biological etiology of some mental illnesses, as
well as the development of psychotropic medications.
The creation of objective procedures and assessments,
as well as classification systems (i.e., the Diagnostic
and Statistic Manual of Mental Disorders manuals),
was evidence of a new paradigm.
As a consequence of these advances, clinicians consistently discounted the subjective experience of the
patient. Psychiatry rejected clients as a source of data
based on an institutionalized distrust of individuals
and their ability to report validly and reliably on their
own mental conditions and the scientists inability to
verify independently such reports (Baker, 1992, pp. 1011). Because the clients experience was viewed as scientifically unreliable and unverifiable, psychiatry
adopted a pure, objective approach to the assessment of
outcomes. However, it was a presumed fact that the scientists interpretation was true. This assumption was
possible because logical positivists believe in an objec-

tive reality that is absolutely true, and with the proper

methods, reality may be known (Baker, 1992).
In the examination of mental health outcomes from
a logical positivist perspective, the client is viewed in
terms of objectively measured actions that can be verified in reality. Psychological phenomena are viewed in
terms of variables rather than in terms of people, as
this allows for an objective language. . . . It was uncritically and universally accepted that these variables
were the same variables for all subjects (Baker, 1992,
p. 10). The objective measurements chosen to capture
outcomes are behaviors or events that are believed to
be experienced by all clients but in different degrees of
severity. Other characteristics of outcomes framed in
this perspective include the psychometric properties of
reliability and validity. Reflective of their positivistic
roots, reliability is the concept that a measurement
taken by different observers or at different times will
produce the same result, whereas validity speaks to
how well the method captures the intended outcome
(Slade, Thornicroft, & Glover, 1999).
These universal, objective variables are visible in
many of the psychiatric measures being used in practice today (American Psychiatric Association, 2000).
Outcome measurements in psychiatricmental health
practice frequently entail the use of scales and surveys.
For example, the Brief Psychiatric Rating Scale (BPRS)
uses a 5-point Likert-type scale in which the clinician
assesses the severity levels of certain behaviors. Only
recently has the clients subjective experience been introduced in outcomes research; however, remaining
true to its empirical roots, the clients experience has
been reduced to a quantifiable scale. The Behavior and
Symptom Identification Scale (BASIS-32) is an example of a subjective client-completed survey, which
grades the level of difficulty patients experience with
their symptoms. Other examples of outcomes within
the logical positivism perspective include number of
hospitalizations, costs of care, and functional and
occupational status.
As a demonstration of a study using positivist-based
outcomes, Drake, Xie, McHugo, and Shumway (2004)
examined 3-year outcomes of 51 patients with bipolar
disorder and substance use disorder who received dual
diagnosis treatment in the New Hampshire state mental health system. The outcome assessment included
the use of the BPRS, substance use, and quality of life
scales. Other quantitative measures included counts of
hospital stays, days of independent living, imprisonment and periods of homelessness. During the 3 years,
only slight improvement was noted in the bipolar
symptom assessments, whereas substance abuse con-

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Kutney

ditions, living situation, social interaction, and quality

of life demonstrated significant improvement.
All outcome measurements based in logical positivism have quantifiable, verifiable results and are sought
by the public, providers, payers, and policymakers
alike. These graded approaches to outcomes measurement, such as the BPRS and BASIS-32, however, compromise the understanding of a patients lived experience by limiting the description of symptoms to a
quantifiable scale. In this manner, the unique complexity of the clients experience is lost.
PHENOMENOLOGY
Budding from its roots in existentialism, the
phenomenological movement was formally organized
by Edmund Husserl, a German philosopher, in the
early 20th century (Becker, 1992). This philosophical
view is a systematic method of studying the lived experience, or the conscious human experience of a person
experiencing the phenomena of everyday events. Although several branches of this philosophical position
exist, Husserls view of phenomenology as an epistemology, or way of knowing, will be used in this brief
overview. Two basic components of phenomenology are
the experience of everyday events and intentionality.
Philosophers in the Husserl tradition of phenomenology hold that listening to an individuals experience
of events in the everyday world, or lifeworld, with all
theory and assumptions aside, is an invaluable source
of knowledge (Welch, 1999). The process of holding all
theory, assumptions, and prior knowledge aside is
termed the bracketing of existence (Chessick, 2001).
Each person has his or her own exclusive experience;
however, when combined, this range of unique experiences generates common themes that enable
phenomenologists to illuminate essential, universal
structures in life (Becker, 1992). It was within this process of bracketing and theme extraction that Husserl
hoped to help the method gain scientific recognition
(Welch, 1999). In this sense, phenomenology attempts
to unite subjectivity and objectivity in the pursuit of
understanding the world.
In close connection to the experience of everyday
events, intentionality is also a core principle of the
phenomenological tradition. Intentionality refers to
the relationship between persons and the conscious
awareness of objects or events in their experience
(Husserl, 1962). It is within the context of this relationship that people create meaning and are able to understand the relationships with the world surrounding
them.
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PHENOMENOLOGY AND PSYCHIATRIC

MENTAL HEALTH OUTCOMES
Phenomenologists believe strongly in the interconnected relationship of the mind and the body. Traces of
the phenomenological tradition can be seen in psychotherapy treatment modalities, in which the clinician interprets the clients experiences and aids the client in
expanding his or her awareness of thoughts and
behaviors.
A psychiatricmental health outcome in the phenomenology perspective stems directly from how the
etiology of mental illness is conceptualized by this philosophy. In the eyes of a phenomenologist, mental illness results when a detachment occurs between an individual person and his or her environment.
Phenomenologists place great emphasis on the establishment of the therapeutic relationship between the
clinician and the client, similar to psychiatricmental
health nurses. It is within this relationship that the client is able to rediscover his or her reality through the
sharing of the clients experiences. In the
phenomenological perspective, outcomes are based on
the clients subjective experience. Therefore, characteristics of individual outcomes in this perspective are undefined and are unique to each client. In the process of
evaluating psychiatricmental health outcomes after
an intervention, a clinician would assess changes in the
clients understanding of his or her reality and experiences, as well as in the clients sense of control over his
or her life. However, as common themes begin to
emerge from a collection of individuals, statements
may be made that become increasingly reflective of
reality.
Phenomenology outcomes are ascertained primarily
through listening to the clients description of his or her
experience, with minimal application of theory or assumptions by the clinician. For example, the Diagnostic
and Statistical Manual of Mental Disorders, Fourth
Edition is commonly used to organize information and
possible diagnoses during a clinical encounter
(Chessick, 2001); however, phenomenologists would reject this practice, as it introduces assumptions and presuppositions about the client. However, within the current structure of health care, pure phenomenological
outcomes are not viewed as legitimate, defensible
measures in the evaluation of quality and costeffectiveness.
Campbell (2004) explored families experiences of
behavioral family therapy and used a
phenomenological approach to assess outcomes. The
study examined the lived experience of 10 families that
received the intervention as part of a training program

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to disseminate the behavioral family therapy modality

in the United Kingdom. Semistructured, loose interviews that aimed to ascertain the families thoughts
about the therapy were conducted. Common themes
emerged from the interviews, which demonstrated an
increased disposition toward receiving mental health
services. Families also reported reduced stress levels
because of improved communication. As the author
also notes, a causal link to behavioral family therapy
cannot be made because of the philosophical nature of
the methodology. The families, however, attributed the
positive change to the skills learned in therapy process.
LOGICAL POSITIVISM AND
PHENOMENOLOGY: A VALUABLE
COMBINATION
Both logical positivism and phenomenology seek
knowledge and an understanding of the world but are
divided in their ideas of approach and methodology.
The attributes of these perspectives present both
strengths and limitations in the assessment of mental
health outcomes.
The empirical, scientific methods of logical positivism, based on observable facts, are especially important
in todays market-driven health care system to document measurable outcomes. Quantifiable, convenient
methods to assess outcomes are daily necessities in the
busy clinical setting. Outcomes measured in the positivist tradition allow for readily interpretable, quantitative comparisons to be made between treatments and
therapies. The use of the scientific method also allows
for cause-and-effect relationships to be established,
which is becoming increasingly important for reimbursement and research funding (Babiss, 2002;
Chambless et al., 1998). A limitation to the logical positivist stance, however, lies in the question, How is it
possible to capture the true nature and experience of a
client afflicted with mental illness and limiting the
experience of suicidal ideations or hallucinations to a
scale?
The introduction of phenomenology to the assessment of mental health outcomes allows the clients perspectives of his or her experience to be understood, as
well as the meanings that have been attached to those
events. The comprehension of these experiences by the
clinician or researcher aids in the development of individualized outcomes. The addition of phenomenological outcomes also provides richer, contextualized
data on which to make treatment decisions. The detailed data that a phenomenological qualitative interview provides highlight the unique nature of the progress and continued needs of the individual client.

However, a strict phenomenological approach would

not allow us to establish cause-and-effect relationships,
especially in light of what is now known about the etiology of mental illness. As discoveries continue to be
made about the biological correlates of mental illness,
clinicians have a natural inclination to empirically
measure the phenomena of mental illness, including
treatment outcomes. Also, in the consideration of the
possibility that mental illness may skew consciousness
and experience, how would outcomes then be measured
in the phenomenological tradition? The former risk is
inherently associated with this approach; however,
phenomenologists believe in the clients pure, lived
experience of reality, without making the assumption
that the clients experience of reality is altered
(Chessick, 2001).
Psychotherapy efficacy studies have included outcome measures that reflect positivist and
phenomenological perspectives but most often independently. Psychotherapy outcomes are often measured by pre- and posttherapy questionnaires. For example, Watson, Gordon, Stermac, Kalogerakos, and
Steckley (2003) compared the effectiveness of processexperiential and cognitive-behavioral psychotherapy
in patients with depression. Sixty-six participants
with major depression were assigned to either processexperiential or cognitive-behavioral therapy and received 1 hr of therapy weekly for 16 weeks. Measures
included several quantitative instruments and inventories to assess changes in depression level, interpersonal distress, self-esteem, psychological symptom distress, dysfunctional attitudes, and coping style. For
example, changes in clients levels of symptom distress
were measured through the use of the Symptom
Checklist-90-Revised (Derogatis, Rickels, & Roch,
1976) scale, a 90-item self-report instrument. Processexperiential and cognitive-behavioral therapy were
demonstrated to have similar effects on outcomes
based on statistically testable, numerical differences in
the mean scores of clients in each group. The findings of
this study might have been improved with the addition
of phenomenological-based outcomes. This methodology would have allowed for a more complete understanding of how the therapies affected the participants
symptoms. A phenomenological approach would allow
also for a discussion of the clients experience of the
process of therapy, thereby allowing for possible
differences to be highlighted between the two
modalities.
Psychotherapy outcomes have also been measured
with phenomenological methods. Gallegos (2005) conducted a qualitative study to explore the lived experience of symptom relief in psychotherapy as perceived

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by clients experiencing depression and anxiety. Three

clients who reported experiencing symptom relief from
psychotherapy were selected to participate in a narrative interview. Giorgis (1985) descriptive
phenomenological method was used for the analysis.
The results illuminated the clients individual reasons
for participating in psychotherapy, which become important in conceptualizing treatment options. In addition to exposing the contributors of symptom relief for
individual participants, the researcher extracted
shared themes that were found within the interviews.
These common descriptions allow for a deeper understanding of what contributes to symptom relief and
adds to the knowledge of feelings that might be shared
by clients universally. A more comprehensive understanding of the client, however, could have been afforded by the addition of positivist-based outcomes.
The additional use of a quantitative instrument, such
as the SCL-90, would allow for possible differences in
symptom relief to be objectively quantified and
statistically tested for differences. Positivist-based
outcome measures also provide readily interpretable
data for stakeholders.
CONCLUSION
The prevalence of mental illness and the tremendous multifaceted impact it has on our country has
been well documented in recent years (U.S. Department of Health and Human Services, 1999). As the
meaning of mental illness varies across cultures and
social contexts, the benefit of being able to view mental
illness and the associated outcomes of its treatment
through several lenses is becoming increasingly more
essential. Even though the movement of logical positivism has generally fallen out of favor (Schumacher &
Gortner, 1999; Tolman, 1992), its effects still resonate
throughout psychiatry and mental health. This approach has led to significant advances in the field, including improved understanding of mental illness and
the development of methods to assess the effectiveness
of the fields interventions. However, the lived experience of a client with mental illness is often not a factor
in developing outcomes of care. Building on the valuable contributions of both perspectives, a blend of the
logical positivism tradition and phenomenology, even
in the most severely mentally ill clients, would provide
the most holistic picture possible of the client and his or
her surrounding system.
After or during the course of an intervention, such as
psychotherapy, clinicians would obtain quantitative
scores from selected instruments, as well as openended questions that would allow for a fuller and more
26

meaningful understanding of the clients quantitative

responses. This focus on the clients feelings and attached meanings to his or her functioning will allow the
clinician to discern the goals the client has for his or her
own everyday living. The phenomenological approach
also builds our understanding of how a phenomenon
may be universally experienced, thereby creating opportunities to improve treatments and therapies. The
philosopher Karl Jaspers (1963) has suggested a similar blending within psychiatry; however, the combination of these two philosophical perspectives is particularly relevant to nursing. Nurses focus on the whole
client from both objective and subjective levels and are
well suited to utilize a blend of the logical positivist and
phenomenological traditions in the assessment of outcomes. Cutliffe and Goward (2000) suggest that the
specialty of mental health nursing is strikingly similar
to the tradition of phenomenology, namely, the shared
value of the importance of the interpersonal
relationship.
In the assessment of outcomes with clients, it is important to remain cognizant of the clients subjective
experience, which is often overlooked. Having the ability to view psychiatricmental health outcomes
through these lenses will arm the clinician and the researcher with the knowledge to define the optimal
outcome for the client.
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