Phenomenological Psychiatry

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Phenomenological Psychiatry
Osborne P. Wiggins, Ph.D. and Michael Alan Schwartz, M.D.

In Encyclopedia of Phenomenology. Edited by Lester Embree, Elizabeth A. Behnke, David Carr, J. Claude Evans, Jose Huertas-Jourda, Joseph J. Kockelmans, William R. McKenna, Algis Mickunas, Jitendra Nath Mohanly, Thomas M. Seebohm, and Richard M. Zaner. 1997, Kluwer Academic Publishers.
Modern psychiatry, as represented by Emil Kraepelin (1856-1926), and phenomenology, as developed by Edmund Husserl, began around the same time, namely, during the last decades of the 19th century. Moreover, psychiatry and phenomenology have always shared a common goal: they have both sought detailed descriptions of human experience. This communality of goals has repeatedly led psychiatrists to turn to phenomenology for aid in explicating mental life. For many psychiatrists it has seemed that phenomenology offered a method that could help them better understand and conceptualize the experiences of their patients. As a result, psychiatrists have utilized various phenomenological approaches just as phenomenologists have explored subjects in psychiatry.
The history of this relationship has remained ambiguous, however. Frequently a gap has yawned between the broad theoretical perspectives adapted from phenomenology and the needs of clinical practice. Furthermore, psychiatrists -- who are often trained in the biological and natural sciences -- may feel disinclined to delve deeply into explorations of the subjective when these explorations appear to them to remain too abstract or metaphysical. And, returning the compliment, phenomenologists have usually exhibited a profound reluctance to ascribe centrality to biological and naturalistic perspectives. In the post-World War II years, impressive progress in empirical research has provided physicians with powerful means for diagnosis and treatment, for example, with psychopharmacology; because psychiatrists are always pragmatists at heart, these new insights have tended to supplant phenomenological insights.
More recently, the relationship has grown more complicated, and these complexities offer hope of a revitalized cross-fertilization between psychiatry and phenomenology. On the one hand, empirical research in psychiatry continues at an even more rapid pace. On the other hand, many physicians and patients are more aware of the gaps, inadequacies, and even untoward consequences of the one-sidedness of these new developments. This has spurred a turn towards holistic medicine, wellness, and environmental medicine that is more congenial to phenomenological views. Moreover, there is a growing recognition that phenomenological and neurobiological perspectives can no longer oppose one another; when properly conceived, each will strengthen the other. We shall first sketch a brief history of the relationships between phenomenology and psychiatry. Subsequently, we shall delineate possible directions that future inquiry might take.
The main value of phenomenology for psychiatry has historically consisted in phenomenology's careful descriptions of the many facets of human existence. On the level of clinical practice, psychiatrists who are schooled in phenomenology have learned to explore the subtleties and nuances of their patients' experiences. On the level of research and theory, phenomenological psychiatrists have been able to conceptualize invariant features of on the concrete situatedness of persons through embodiment, culture, and history, has made psychiatrists more aware of the complexities of human existence.
The first influence of phenomenology on psychiatry is found in the work of Karl Jaspers. Jaspers began his career as a psychiatrist, turning to philosophy only later. The first article indebted to phenomenology was concerned with morbid jealousy (1910). His early book, Allgemeine Psychopathologie (General Psychopathology, 1913), was decisively shaped by the ideas of Husserl, Wilhelm Dilthey, and Max Weber, among others. Drawing on Husserl's Logische Untersuchungen (1900-1901), Jaspers developed his own phenomenological method. This phenomenology was designed to define the basic concepts of psychopathology, such as "abnormal mental life. Moreover, phenomenology, because of its emphasis "delusion" and "hallucination." Jaspers' phenomenology resembled Husserl's in being descriptive, intuitive, and presuppositionless. But because psychopathology pertains to the patient's experiences, Jaspers views understanding (Verstehen) and empathy (Einfühlung) as essential components of the method. He did diverge from Husserl by explicitly rejecting eidetic method. Jaspers saw his own phenomenology as empirical.
Jaspers' phenomenological approach influenced psychiatrists in wht came too be known as the "Heidelberg school." This school included Hans Gruhle, Kurt Schneider, and Willy Mayer-Gross. Schneider assisted Jaspers with rewriting and expanding the Allgemeine Psychopathologie (fourth edition) during World War II. The fourth edition incorporated notions from Jaspers' philosophy of existence.
Mayer-Gross carried the phenomenological orientation to Great Britain in 1933. His textbook, Clinical Psychiatry (1969, 3rd edition) influenced numerous British psychiatrists. By then, however, Jaspers' phenomenology was viewed as empirical in contrast to Husserl's. Moreover, Husserl's phenomenology came to be misperceived as a mere precursor to Martin Heidegger's analysis of Dasein as imported into psychiatry by Ludwig Binswanger. Jasper's contributions to psychopathology are usually regarded as definitive in Great Britain. Furthermore, present-day British work in the field tends to deny Husserl's influence on Jaspers.

Under the leadership of Aubrey Lewis, the Maudsley Hospital in London disseminated Jaspersian phenomenology to the English-speaking world. The American psychiatrist Paul R. McHugh trained there. McHugh, in collaboration with Phillip R. Slavney has done much to advance Jaspersian and other forms of phenomenological psychiatry in the United States. At the Tavistock Institute in England, R. D. Laing introduced an existential-phenomenological approach to schizophrenia. While this approach draws on a number of existentialists, it is mainly to Jean Paul Sartre. Liang also studied interpersonal aspects of mental disorders. He is perhaps best known for his criticisms of psychiatry, especially his challenges of the standard sanity/madness distinction.

In Germany and elsewhere in Continental Europe, other important schools of phenomenological psychiatry have developed. The most significant figure in the Continental appropriations of phenomenology is probably the Swiss psychiatrist, Ludwig Binswanger. Binswanger's phenomenology is nourished by his extensive clinical experience. He searched his entire life for a proper form of phenomenological conceptualization and method. First influenced by Husserl, Binswanger subsequently employed central features of Heidegger's analytic of Dasein. In his last works, under the influence of Vilmos (Wilheim) Szilsi, Binswanger again turned to Husserl's ideas.

In Switzerland the most important follower of Binswanger was Roland Kuhn. Kuhn developed a phenomenological conception of the Rorschach test. He combined psychopharmacology with psychotherapy and in fact invented imipramine, which even today is considered a standard drug for the treatment of depression.

In Germany most of Binswanger's students worked in the Department of Psychiatry at Heidelberg. Heinz Häfner applied Binwanger's approach to patients with personality disorders (such individuals are called "psychopaths" in Germany) and Karl P. Kisker to patients with schizophrenia. Herbutus Tellenbach extended Binswanger's concepts to the world of the melancholic. Tellenbach constructed a typology of depressives, focusing on pr-morbid characteristics, e.g., an extreme tendency towards orderliness. He inspired Alfred Kraus to study existential types and role theory.

Wolfgang Blankenburg developed a phenomenological understanding of characteristic features of chronic schizophrenics and described the loss of taken-for-grantedness (Selbstverständlichkeit).

Earlier in Heidelberg there were physicians interested in the field of psychosomatic medicine. An anthropological approach was created by the internist, Viktor von Weizsäker. Influenced by Max Scheler's reflections on biological psychiatry, von Weizsäker's conception of the Gestaltkreis (formative cycle) posited an interaction between perception and movement. Also influenced by Scheler was Viktor von Gebsattel. Von Gebsattel developed his ideas in association with Binswanger, Eugène Minkowski, and Straus. He adopted what he called an "anthropological-existential" framework for investigating such topics as the world of the compulsive, depersonalization, and addictions and perversions. Herbert Plügge has written a number of essays in "medical anthropology" that are focused on various dimensions of health and illness and on the experiences of one's body.

In the last two decades, the phenomenological tradition at the University of Heidelberg has sought to incorporate empirical investigations and neurobiological
perspectives, Werner Janzarik has explicated a comprehensive "structural dynamic" theory. This theory is geared to providing a holistic approach that will make both biological and psychopathological data relevant to practicing clinicians. Christoph Mundt has investigated several concepts of intentionality, including the most recent ones, eg., Daniel Dennett's. In both theoretical and empirical studies he applies these concepts to schizophrenia. As the present director of the Psychiatric Clinic at the University of Heidelberg, Mundt is interested in revitalizing the phenomenological tradition there, but he insists on doing so in conjunction with empirical investigations of populations of patients. In this regard Mundt has voiced sharp criticisms of the "autistic" tendencies in past phenomenologists.

Jürg Zutt in Frankfurt has developed an "understanding anthropology" (verstehende Anthropologie) aimed at overcoming mind-body dualism. From this point of view he has contributed several insights into the psychopathology of the lived body. Gerhard Bosch, a student of Zutt's, has studied autism from the perspective of a "phenomenological anthropology." He employs Husserl's analysis of intersubjectivity in order to explicate the defect involved in the autistic child's social encounters.

Erwin W. Straus along with von Gebsatiel, Binswanger, and Zutt, founded the journal Der Nervenarzt in 1930. Straus was trained as a psychiatrist and neurologist, but he also possessed a profound knowledge of classical authors such as Aristotle, Augustine, Goethe, and Shakespeare. From the University of Berlin Straus emigrated to the United States in 1938. He taught psychology at Black Mountain College in North Carolina, engaged in research at Johns Hopkins University, and in 1946 moved to the Veterans Administration Hospital in Lexington, Kentucky. At Lexington in the 1960s, he helped disseminate phenomenology to Americans through his conferences on "Phenomenology: Pure and Applied."

Straus was convinced that abnormal mental conditions could be adequately understood only as deformations of normal experience. He also insisted that scientific psychology, especially in its behavioristic forms, furnished only misconceptions of normal mental functioning. These two convictions led him to undertake anew the study of normal experience, primarily sensory experience, but to undertake it in a manner different from that of traditional scientific psychology. Straus first called his own approach "anthropological" and later "phenomenological." In the area of psychopathology he devoted specific studies to obsessions, compulsions, hallucinations, disorders of time in depressive states, and the pseudo-reversibility of catatonic stupor. His broader concern, however, was the pathology of 1-world relationships.

Kurt Goldstein (1878-1965) was a biologist and physician who developed a gestaltist conception of the human organism. Goldstein's influence on Aron Gurwitsch and Maurice Merleau-Ponty led these two younger phenomenologists to investigations that bear on psychiatric problems. Goldstein's own descriptions of the breakdown of organization and the organism's "catastrophic" responses remain highly relevant today.

In Dutch psychiatry the two most prominent figures have been H. C. Rümke and Jan Hendrik Van Den Berg. Rümke has warned of the danger involved in the loss of scientific and objective criteria in phenomenological psychiatry. Calling for a genuinely "scientific psychology," he has studied the experiences of happiness, compulsion, and affective contact. Rümke's sensitive description of the psychiatrist's "praecox feeling" in the presence of schizophrenic patients remains highly relevant. J. H. van den Berg is perhaps best known for The Changing Nature of Man: Introduction to a Historical Psychology (1975). Also of interest is A Different Existence: Principles of Phenomenological Psychopathology (1974).

In Switzerland Medard Boss has carried Heideggerian views directly into psychiatry, especially in the areas of psychotherapy and psychosomatic medicine. Boss's writings apparently have the approval of Heidegger himself. Heidegger personally participated in some of Boss's seminars, and Boss has published extensive records of these under Heidegger's own name. Gion Condrau has continued to elaborate a Bossian approach to psychotherapy, also drawing directly on Heidegger.

Eugène Minkowski, a native of Poland who settled in France, was strongly influenced by Henri Bergson. Minkowski may be regarded as the first psychiatrist to take seriously the notion that a mentally ill person is fully human and should be treated as a fellow human being. Minkowski lived with mentally ill people and sought to understand them on their own terms. Central to his understanding of mentally ill persons is the notion that for them access to the future is blocked. In 1929, Minkowski helped found the group L'Evolution psychiatrique, which published a journal by that name.

After World War II, Henri Ey worked with Minkowski to revive L'Evolution psychiatrique. In 1972, Herbert Spiegelberg wrote of Ey, "his is the most thorough and original utilization of phenomenological philosophy in French psychiatry." Drawing on concepts from evolution, Ey has developed an "organo-dynamic" model of psychopathology; he thus seeks to integrate consciousness and brain processes. Starting first from a phenomenology of normal mental
life, he attempts to understand mental illnesses as "destructurations" of consciousness. Of special interest is Ey's reinterpretation of the unconscious.

Paul Ricoeur's study of Freud, De I'interprètation: Essai sur Freud (1965), established strong ties between psychoanalysis and hermeneutics. This work also sets forth a hermeneutical critique of Husserlian phenomenology, especially connected with Freud's understanding of the unconscious. Ricoeur's writings led some people to reevaluate the scientific status of psychoanalysis. On this topic, an interesting counterweight to Ricoeur's book is Adolph Grunbaum's The Foundations of Psychoanalysis: A Philosophical Critique (1984).

Among Japanese psychiatrists, Bin Kimura is the leading representative of phenomenological and existential approaches. His investigations of the "in between" (the mood or atmosphere between two people) utilizes a theme in Japanese culture that allows hm to explicate aspects of the doctor-patient or therapeutic relationship.

American psychoanalysts, such as Harry Stack Sullivan (1892-1949), have introduced much needed social perspectives on mental illness. They view the self and its personal identity as constituted through intersubjectivity. Their psychology is thus "interpersonal" rather than "intrapsychic."

Henri F. Ellenberger has written an important historical study: The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry (1970). Ellenberger criticizes the narrow (i.e., theory-based) view of the unconscious and emphasizes that there is more to the field than Freud. As one of the coeditors of Existence: A New Dimension in Psychiatry and Psychology (1958) Ellenberger helped bring phenomenological and existential approaches to psychiatry and psychology to the attention of Americans.

Rollo May (1909-1994) was another coeditor of Existence. He also coedited other compilations of essays that in the 1950s and 1960s helped familiarize American readers with phenomenological and existential psychiatry. In his own early writings, such as Psychology and the Human Dilemma (1967), May sought to clarify for an American audience the links that the new psychiatry and psychology bore to Kierkegaard, Husserl, Tillich, Sartre, and other European thinkers.

Irving Yalom's Existential Psychotherapy (1980) offers an account of mental problems as arising from conflicts rooted in the basic "givens of existence" - namely, death, freedom, isolation, and meaninglessness.

Otto Dörr-Zegers has carried the Heidelberg tradition of Blankenburg and others to Spain and Latin America. Dörr-Zegers' work has also been strongly influenced by Hans-Georg Gadamer and Heidegger. In Spain phenomenology has been represented primarily by Ramon Sarró, P. Lain Entralgo, and J. J. Lopez Ibor. Lopez Ibor, in his book, Angustia vital (Vital anxiety, 1952), draws mainly on Ortega y Gasset, Scheler, and Heidegger. He remains more willing than most phenomenologists to extend the field to include psychopharmacology and biology.

During the last thirty years a growing number of French psychiatrists have been systematically developing phenomenology by incorporating German and American insights. Arthur Tatossian spearheaded this development in Marseille. In order to explicate the subjective experiences of patients, these writers draw on the ideas of Binswanger, Blankenburg, Kraus, and other German psychiatrists. Their recent work connects Binswanger's conception of inner life history with a narrative model of mental illness derived from John Straus and Larry Davidson. For a broader understanding of the relationship between story and personal identity Naudin draws on the work of Wilhelm Schapp, a student of Husserl. Other members of this new French School include Jean-Michel Azorin, S. Giudicelli, D.J. Pringuey, Marc Geraud, Marie-Claude Lambotte, and Yves Pelicier.

If we turn to imagining directions of collaborations between phenomenology and psychiatry in the future, we can conceive of at least three. Two of these are contributions phenomenology can make to psychiatry: (1) A philosophical anthropology through which mental disorders can be comprehended and (2) methods for explicating human existence in great detail. Both of these contributions should include detailed investigations of the healthy human being as well as the ill, in contrast to the preoccupation of mainstream psychiatry with illness alone. In addition, psychiatry can contribute to phenomenology by (3) furnishing examples of unusual human experiences that can stimulate and inform phenomenological investigations.

Elements of a philosophical anthropology can be gleaned from Husserlian and Schelerian phenomenologies and from the philosophy of existence – namely those of Jaspers, Heidegger, Gabriel Marcel, Sartre, Merleau-Ponty, and Ricoeur. From a psychiatric point of view, however, the limitations that pervade phenomenology and existentialism consist in the fact that they remain too idealistic, either they put aside or ignore the physic-biological dimensions of human life, or, as in the case of Heidegger, they scorn approaches that ascribe centrality to biology. Scheler remains the sole exception to this criticism. Jaspers and Merleau-Ponty appear at first glance to provide exceptions to it. But while Jaspers does allot a place for biology, he insists on a rigid dualism that separates the biological from the existential. Merleau-Ponty's philosophy of the lived body should definitely be accorded a primary place in psychiatric anthropology, but ultimately even he attributes too little importance to the human body as explained by biology and neurophysiology for his position to prove adequate. The potential relevance of philosophical biologists and philosophical anthropologists, including Hans Jonas (1903-1993), Helmuth Plessner, Adolph Portmann, Arnold Gehlin, and Marjorie Grene, has not been sufficiently appreciated. Their importance lies in the centrality that they accord to human biology and in their opposition to traditional mind-body dualism. Furthermore, these thinkers analyze the interaction between society and biology in ways that have yet to be incorporated into either phenomenology or psychiatry.

It should be recognized that while Jonas, Gehlen, Plessner, Grene, and Portmann provide the larger organic context, this context must be filled in with contemporary neuroanatomy and neuroscience. Kenneth Schaffner and other philosophers of biology are relevant to this task.

(2) Methods for explicating human existence in great detail are needed in order to appreciate sufficiently the complexity of mental disorders. A phenomenological method that is scientifically rigorous, nuanced, and securely based on evidence could provide the basic concepts for psychopathology; such methods could specify the differences, for example, among delusions present in schizophrenia, mania, and delirium. In addition, a carefully developed hermeneutical method is needed to explore the life histories of individual patients. Here, the narrative structure and temporality of human existence as studied by Paul Ricoeur and David Carr would prove crucial.

(3) Psychiatry and other disciplines within medicine can furnish examples of unusual human experiences that can stimulate, inform, broaden, and challenge phenomenological investigations. Merleau-Ponty's and Gurwitsch's uses of Goldstein studies provide instructive illustrations of how phenomenology benefits. Oliver Sacks and Alexander Romanovich Luria (1902-1977) show how richly explicated clinical case histories deepen our appreciation of what it means to be human.

Several journals regularly publish articles from phenomenological, existential, or anthropological perspectives. Among them are PPP-Philosophy. Psychiatry.
and Psychology (United States); Journal of Phenomenological Psychology (United States); Journal of Humanistic Psychology (United States); Review of Existential Psychology and Psychiatry (United States); Zeitschrift für klinische Psychologie und Psychotherapie (Germany); Der Nervenarzt (Germany); and Daseinanalyse, Phänomenologische Anthropologie und Psychotherapie (Switzerland).

For Further Study

Bosch, Gerhard. Der frühkindliche Autismus. Berlin: Springer-Verlag, 1962; Infantile Autism: A Clinical and Phenomenological-Anthropological Investigation Taking Language as the Guide. Trans. D. and I. Jordan. Berlin: Springer-Verlag, 1970.

Boss, Medard. Grundriss der Medizin und der Psychologie. Bern: Verlag Hans Huber, 1971; Existential Foundations of Medicine and Psychology. Trans. Stephen Comay and Anne Cleaves. New York: Jason Aronson. 1979.

De Koning, Andre J. J., and F. A. Jenner, eds. Phenomenology and Psychiatry. New York: Grune & Stratton, 1982.

Ey, Henri. La conscience. Paris: Presses Universitaires de France, 1963; Consciousness: A Phenomenological Study of Being Conscious and Becoming Conscious. Trans. John H. Flodstrom. Bloomington. IN: Indiana University Press,
1978.

Heidegger, Martin. Zollikoner Seminare. Ed. Medard Boss. Frankfurt am Main: Vittorio Klostermann, I957.

Kraus, Alfred. Sozialverhalten und Psychose Manisch-Depressiver: Eine existenz- und rollenanalytische Untersuchung. Stuttgart: Enke, 1977. "Methodological Problems with the Classification of Personality Disorders: The Significance of Existential Types." Journal of Personality Disorders 5 (1991), 82-92.

May, Rollo. Ernest Angel, and Henri F. Ellenberger, eds. Existence: A New Dimension in Psychiatry and Psychology. New York: Simon & Schuster, 1958.

McHugh. Paul R., and Phillip R. Slavney. The Perspectives of Psychiatry. Baltimore: Johns Hopkins University Press, 1986.

Psychiatry and Phenomenology (papers by Gion Condrau, Alfred Kraus, Jan Hendrik van den Berg, and Dieter Wyss; Introduction by Edward L. Murray), The Fourth Annual Symposium of the Simon Silverman Phenomenology Center
[1986]. Pittsburgh: Duquesne University, 1987.

Ricoeur, Paul. De l'interprétation: Essai sur Freud. Paris: Editions du Seuil, 1965; Freud and Philosophy: An Essay in Interpretation. Trans. Denis Savage. New Haven, CT: Yale University Press, 1970.

Spiegelberg, Herbert. Phenomenology in Psychiatry and Psychiatry. Evanston, IL: Northwestern University Press, 1972.
Spitzer Manfred, Friedrich Uehlein, Michael A. Schwartz, Christoph Mundt, eds. Phenomenology, Language, and Schizophrenia. New York and Heidelberg: Springer Verlag, 1992
Tellenbach, Hubertus, Melancholie. Berlin: Springer-Verlag. 1961; Melancholy. Pittsburgh: Duquesne University Press, 1972.
van den Berg, Jan Hendrik. A Different Existence: Principles of Phenomenological Psychopathology. Pittsburgh: Duquesne University Press, 1980.
Wiggins, Osborne P., Michael A. Schwartz, and Georg Northoff. "Towards a Husserlian Phenomenology of the Initial Stages of Schizophrenia." In Philosophy and Psychopathology. Ed Manfred Spitzer and Brendan A. Maher. New York: Springer-Verlag, 1990, 21-34.
Yalom, Irvin D. Existential Psychotherapy. New York: Basic Books, 1980.