Phenomenological psychiatry was founded as a discipline in a precise place, at a precise time, and for a precise purpose. Four psychiatrists – Eugene Minkowski, Ludwig Binswanger, Erwin Straus and Victor von Gebsattel – met in 1922 at a meeting of the Swiss Society for Psychiatry in Zurich. They were unhappy with both psychological and organic approaches to psychiatry prevalent at the time, and decided to launch an alternative programme. They called this ‘phenomenological’ because they were aware of the new philosophical school of philosophy instituted by Husserl’s Logical Investigations (1) published in 1900/1901 and believed that a philosophically-based psychopathology, loosely beholden to Husserl’s innovations, was the way forward.
All sorts of misunderstandings about the term ‘phenomenological psychiatry’ have accrued in the intervening century, but the core venture – to fashion a non-biological, non-psychological understanding of what it is to be mad or mentally ill in other ways – has lingered on. In fact the same doubts about the correctness of a purely biological, or a purely psychological approach, or even a combination of these, favoured in North America and known as the ‘biopsychosocial model’, are as pressing today as they were in 1922.
This book covers the ground in exemplary fashion. The editors are all relatively junior psychiatrists who themselves experienced the same dissatisfaction with the state of psychiatry at the beginning of the 21st Century that the tetrad referred to above had in the 1920’s. The selection of authors, the particular extracts from these authors, and the framing philosophical discussion, are all illuminating. The book is of primary interest to psychiatrists, whose acquaintance with this literature is probably cursory, as it is seldom taught, and hardly referred to in the standard textbooks that they read. It should also appeal to philosophers, thinkers of all sorts, those who have been or are mentally ill, and, indeed, anyone who takes an interest in psychiatry and psychology.
The richness of the book is such that it is difficult to know what themes to draw attention to. I shall concentrate on two, which get lost in the very comprehensiveness of the book. One is the confusion surrounding the term ‘phenomenological’ and hence the heterogeneous nature and non-Husserlian provenance of most of the extracts selected. The other is the contemporary relevance of the extracts. In short: What has ‘phenomenology’ as a philosophical school of thought, and the Husserlian version in particular, got to do with so-called ‘phenomenological psychiatry’? and, What does the future hold for ‘phenomenological psychiatry’, squeezed between its two powerful competitors – clinical psychology and biological psychiatry?
On the first point – the problematic terms phenomenology and phenomenological – confusion reigns because the philosophical school of phenomenology was itself heterogeneous and because some psychiatrists deemed ‘phenomenological’ in this book arrived at their notions about psychopathology independently of any philosopher who was part of the philosophical school of phenomenology. A third level of confusion obtains in addition, because some so-called ‘phenomenological psychiatrists’ used the term ‘phenomenon’ in a completely non-philosophical way to mean little more than its everyday use as a class of experience. I shall take these points in turn.
Husserl was the originator of the school of phenomenological philosophy, though not of course the term ‘phenomenology’ itself in a technical, philosophical sense, which is in the title of Hegel’s greatest book. But Scheler and Heidegger are now regarded as equal contributors to the school, certainly so in Spiegelberg’s (2) masterly historical account of the movement. Setting aside other major philosophers in the early and middle decades of last Century – Hartmann, Merleau-Ponty, Sartre, for example – who held some views in common with these three, and who are also known as phenomenological philosophers, the differences between Husserl, Scheler and Heidegger themselves are so great that the very notion of a phenomenological school of philosophy is hard to credit.
This means that to call someone a ‘phenomenological psychiatrist’ one should first ask which phenomenological philosopher was their mentor. Binswanger, for example, started as a Husserlian, then came under Heidegger’s influence, then turned back to Husserl; von Gebsattel espoused Scheler’s views. But Minkowski’s ‘maître’ was Bergson and hardly mentioned phenomenology, whilst Straus barely quotes any philosopher except Aristotle. So, even amongst the original gang of four, phenomenological philosophy, Husserlian or not, was not the critical influence.
What does link nearly all the contributors, however, is an interest in, and an attempt to apply, philosophy of some sort to psychopathology. With the exception of Conrad, who was concerned to show the relevance of Gestalt psychology rather than philosophy, and Jaspers, who actually became a philosopher after four years as a psychiatrist, but whose overall approach to psychopathology is rather anti-philosophical, perhaps a better label for the movement tracked in this book would be philosophically-oriented psychopathology or philosophical psychopathology.
To confound matters still further, the term ‘phenomenon’ in psychiatry is generally taken to mean a psychopathological entity, such as delusion, hallucination, or, in an article included in the book, by Jaspers, pseudo-hallucination. [A pseudo-hallucination is a perceptual experience which falls somewhere between the normal experience of something as independent of the perceiver and externally located, and something dependent on the perceiver and located in the mind]. All such ‘phenomena’ are hypothetical constructs by a ‘normal’ person of what someone in an anomalous state of mind experiences or thinks, and ‘pseudo-hallucination’, with which Jaspers chooses to illustrate the whole notion of ‘phenomenon’, is dubious even as a class of psychopathological experience. Jaspers, whose book General Psychopathology was first published in 1913, and whose centenary is being celebrated this year in conferences and articles, is fêted by psychiatrists of all sorts of orientation for supposedly bringing ‘phenomenology’ to the world of psychiatry. In fact, he ‘de-philosophised’ the term, and turned ‘phenomenological psychiatry’ into a crude technique for identifying symptoms and signs in psychiatry in the same way as they are processed in general medicine.
In summary, ‘phenomenological psychiatry’ is, in the main, a philosophically-beholden approach to psychiatry, which treats in utter seriousness, what the mad, neurotic, and even people compromised by their indulgence in damage-inflicting behaviours (gamblers, fasters, drinkers), say or do as variations in the extant ontological framework of contemporary life. Such variations are neither deemed pathological, as biological psychiatrists would have it, nor regarded as outliers on some normal curve of mental functioning, as clinical psychologists suppose. The label ‘phenomenological’ for this psychiatric movement is misleading, as has been shown. The psychiatrists involved, whose views are well presented in this book, were, to be pedantic, rather philosophical psychopathologists, their philosophical influence being largely 20th Century philosophy, amongst which phenomenology was one of the major innovations.
What of the contemporary relevance of all this? and what of the future with respect to the dual constraints exerted by clinical psychology and biological psychiatry?
One criticism levelled at phenomenological psychiatry is its lack of therapeutic potential. Unlike a biological or clinical psychological approach, where there is a smooth transition from an assessment to either drug treatment or psychotherapy of some sort, an exposition of a schizophrenic’s sense of space or a depressive’s experience of time is not obviously beneficial to anyone but a philosophically curious psychiatrist.
Another negative point of view which might strike a reader of this book is the sheer diversity of what has been written under the umbrella term phenomenological psychiatry, to which I alluded earlier. The reader might also note the dearth of Husserlian applications to psychopathology, despite his being the stimulus to the entire venture. In addition, one might well wonder which of the numerous philosophers whose work has been applied, exemplified by the extracts in this book, is to be preferred in this exercise. Scheler even turned the table on philosophers themselves, with his view (3) that some philosophical systems were only true of psychopathological states of mind, and Minkowski (4) stated quite specifically that the depressive condition was a living exemplar of a materialist philosopher’s credo and the schizophrenic condition an incarnation of an idealist’s.
My view on the supposed therapeutic nihilism, and rather scattergun approach of phenomenological psychiatry (i.e. any philosophical psychopathology is better than none), is as follows.
Drug treatment in psychiatry, some of it very effective, was all discovered serendipitously. No-one ever sat down with assured knowledge of the nature of some condition and devised rational drug treatment, because no such knowledge existed in the 1940’s, 1950’s and 1960’s when effective antidepressants, antipsychotics and mood-stabilisers were discovered. In the case of psychotherapy, whether psychoanalytic or cognitive, benefit is claimed in a variety of conditions, which is surprising because the model of depression which is espoused, and for which most benefit is alleged, bears little resemblance to the nature of depression built up by the phenomenological psychiatrists in this book, nor would one expect the two sets of models to coincide, because, as I said earlier, the phenomenological approach is anti-psychological. If, however, the phenomenological approach is correct, and I believe that it is the right way forward, as schizophrenia and depressive psychosis, at least, on even casual acquaintance, can be seen to involve an ontological break with contemporary world formation, then a phenomenological / philosophical account of the two conditions appears to be called for. Effective drug treatment can then be put down to a particular alteration in the chemical status of the brain, which in a yet unknown way alleviates the nature of the targeted condition. The efficacy of psychotherapy, which is anyway nowhere near curative, can then be attributed to a combination of placebo effects and cognitive restructuring, neither of which validates the model which the psychologist adheres to. If anything, because of the dire side-effects of otherwise beneficial drug treatment, and because of the dubious link between the cause of improvement with psychotherapy and the model of the condition which is supposed to justify the therapy, what psychiatry is crying out for is an approach that will resolve the nature, once and for all, of schizophrenia, depressive illness, and a host of other conditions, and, by example with general medicine, will then rationally direct the search for appropriate treatment. Throughout the 20th Century the cart has always been put before the horse in this respect. Because antipsychotics worked, and because they blocked the neurotransmitter dopamine, then schizophrenia must be caused by dopamine excess; or because cognitive restructuring ameliorated a mild depressive illness, then all sorts of depressive illnesses were caused by faulty cognitive attitudes. I am optimistic that at least some of the contributions of phenomenological psychiatrists will be picked up by psychiatrists of the future and used as the building blocks for safer and more rational treatment than is the case now.
As to which of the various ‘phenomenological’ views will survive the test of time this seems to me to be in the hands of philosophers. If Husserl’s overall philosophy is more correct as an account of the 21st Century human than Scheler’s or Heidegger’s, for example, then so be it, or if, as I believe, Scheler’s and Cassirer’s give the more accurate account of the ‘normal’, contemporary human, then clearly a Schelerian / Cassirean – psychopathology should be pursued. The psychiatrists included in this book were smart enough to realize that philosophical psychopathology was the way forward, but were not purporting to be great philosophers themselves, and had to take on trust the truth of their mentors’ systems.
In conclusion, a marvellous book, even for someone like me who has immersed himself in this literature for 30 years. Buy it, whoever you are, and dip into its richness.