This essay is a response to proposals to integrate patient-subjective or idiographic data into future versions of nosologies such as the DSM and the ICD. It argues that a nosology is not a suitable vehicle for disseminating psychopathological-phenomenological research results throughout the field. Drawing on the work of Ludwig Binswanger, it examines, on the basis of four postulates, how he applies the Husserlian concept of intentionality in psychiatry and thus arrives at a psychopathological phenomenology. For each individual postulate, we then look in depth at the implications for the current debate around DSM. The conclusion we come to is that, both because of the objective of phenomenological research and because of the complexity of the kind of information involved in findings based on that research, it is impossible to integrate these findings into a nosology without deviating from either them or the nosology itself.
As was the case with all previous versions, the recent publication of a new version of the Diagnostical and Statistical Manual of Mental Disorders, DSM-5 (APA, 2013) has rekindled the debate around nosology. This time around, several researchers have called for the integration of patient-subjective data into future versions: Elizabeth Flanagan, Larry Davidson and John Strauss call for the integration of empirically derived, patient-subjective characteristics in the DSM (Flanagan, Davidson & Strauss, 2010), and the Dutch psychiatrist Jim van Os calls for the integration of a dimensional-diagnostic system into new versions, so as to add an idiographic component to the diagnostic alongside the nomothetic component (Van Os, 2013). This argument has caught our attention all the more because we have read with great interest the reports of the phenomenological research work done by our colleague Larry Davidson in the field of schizophrenia and psychosis (see Davidson 1994, 2002; and Davidson, L., Saka, M., & Stayner, D., 2004). The efforts our Dutch colleague Jim van Os has also made to renew Dutch mental healthcare have not escaped us (Van Os, 2014). One might be forgiven for thinking that, of all people, researchers in the field of psychopathological phenomenology would welcome this proposal to add patient-subjective to nosologies. In our view, however, a nosology is not a suitable vehicle for disseminating the results of psychopathological-phenomenological research throughout the field. And that is the position we argue for in this proposition.
Before we embark on this enterprise, we set two boundary conditions. First, we will interpret the term ‘phenomenological’ in an exclusively Husserlian way, in order to protect ourselves against the changing meanings of this concept that we encounter in the literature. However, the changing meanings of ‘phenomenology’ are not the only threat to the success of our project. Though we have clearly indicated how we interpret the term phenomenology, our view could still be vulnerable to the danger that it will get lost in the multitude of publications that have been published in the last century in the field of phenomenology and psychopathology. We could, for example, unintentionally get bogged down in an attempt to provide a historical overview of these publications, thus duplicating what others have already made a great of (Spiegelberg, 1972; Broome et al., 2012). Or, if we had in mind only an informed criticism of DSM-5, we could get bogged down in a repetition of arguments that have already been rehearsed extensively by other authors (Halling & Goldfarb, 1996; Andreassen, 2007; Francis, 2013; and Greenberg, 2013). Instead of all that, we take the work of just one psychopathological phenomenologist, Ludwig Binswanger, as a starting point. We know, after all, that he tried very carefully to apply Husserlian phenomenology to a psychopathological phenomenology.1 We focus in this connection on those passages in Binswanger’s oeuvre in which he tries to translate the Husserlian concept of intentionality to the psychopathological practice of psychiatry.
2 Ludwig Binswanger’s Psychopathological Phenomenology
It goes without saying that the extensive work of the famous Swiss psychiatrist Ludwig Binswanger was largely inspired by Husserl’s phenomenological philosophy. He was nothing if not clear about that himself, and Spiegelberg (1972) divides Binswanger’s works into four phases that point to the same source of inspiration: 1) the pre-phenomenological, 2) the Husserlian, 3) the Heideggerian, and 4) the second Husserlian. For us, the central question when it comes to the study of Binswanger’s work is this: How did he translate Husserl’s phenomenology to psychopathology? The answer to this question can be sought in the concept of Intentionalität and in two markers that Binswanger brings to bear in his oeuvre, namely:
For Binswanger, intentionality is about how a person orients themselves towards the world.
As he sees it, intentionality can be made psychopathologically fertile only if the problem of time (das Zeitproblem) is brought into psychiatry.
In keeping with Binswanger’s aforementioned marker in his indication of the importance of the concept of intentionality for psychiatry, we have then brought to the fore the main objective(s), which we name here and which we will then discuss extensively in the light of our analysis of DSM-5:
Intentionality: orientation of the person in the world:
Psychopathological phenomenology aims to bring phenomenological clarity to psychiatric concepts
Psychopathological phenomenology is both descriptive and subjective.
Psychopathological phenomena cannot be described in abstraction from the person who experiences them.
Intentionality—the problem of time in psychiatry:
Psychopathological phenomena cannot be described in abstraction from the inner consciousness of time and disruptions to it.
3 Intentionality—Person and World
Binswanger attached great importance to the value of intentionality as a theme for psychopathology. At the request of the Schweitzerische Gesellschaft fűr Psychiatrie, he devoted an entire presentation to this in Zurich in 1922. He entitled it “Über Phänomenologie”. The goal he had in mind here was to familiarise the audience with the concept of intentionality and its implications for psychopathology. When he wrote the preface to an anthology of some of his lectures 25 years later (Binswanger, 1947), he expressed the relationship between the preface and the lecture as follows:
„Das Augenmerk des Lesers sei nur noch ausdrűcklicher, als es in jenem Vortrag geschah, auf die Intentionalität als das Eigenwesentliche des Bewusstseinsleben gelenkt; denn der von Husserl der Psychologie gemachte Vorwurf, das << ihr Erbteil die Blindheit fűr die Intentionalität >> sei, besteht auch heute noch zu Recht …“2 [The reader’s attention should—even more explicit than it was in the lecture—be directed to the intentionality as the essential essence of the life of consciousness; for the accusation made by Husserl of psychology that ‘her inheritance is the blindness for intentionality’ is still valid today …]3
The first part of this lecture is an introduction to static phenomenology, and here Binswanger offers notes on the phenomenological concepts of Intentionalität, Wesensschau, acts of consciousness, Gegenstand, and phenomenological and eidetic reduction. He then discusses in detail the implications of intentionality for psychiatry, in which three objectives merit our particular attention.
4 Postulate 1—Psychopathological Phenomenology Aims to Bring Phenomenological Clarity to Psychiatric Concepts
„Da Psychopathology Erfahrungs-oder Tatsachenwissenschaft ist, wird sie sich nie zur Anschauung von reinen Wesen in absoluter Allgemeinheit erheben wollen und können. Sie erwartet aber von der rein phänomenologische Klärung ihrer Grundbegriffe eine Förderung und Klärung ihrer eigenen Forschung.“ [Since psychopathology is experiential or factual science, it will never want to and cannot elevate itself to the conception of pure beings in absolute universality, but it expects the purely phenomenological clarification of its basic concepts to promote and clarify its own research.]
What does psychopathological phenomenology expect to achieve? In other words, what goal does a psychopathological phenomenologist have in mind? This question is related to Binswanger’s first postulate. Psychopathology is always an experiential or factual science, in the sense that the psychopathologist studies the patient’s experiences, which present themselves as facts for the psychopathologist´s consideration. However, studying the patient’s experiences does not in itself make the psychopathologist a phenomenologist. After all, the way in which the psychopathologist makes their observations is still based, as it is with every human being, on mundane or natural sensory perception, and thus cannot be used for phenomenology. This natural-sensory means of perception—Husserl calls it the natürliche Einstellung—should be abandoned in order to allow a purely phenomenological analysis of the essence (rein phänomenologischen Wesensschau). The need to abandon natural-sensory perception lies in the fact that for the phenomenologist everything that is observed in this natural way is not apodictic—that is, cannot lead to an irrefutable discernibility. The transition from this natural perception of the facts to a purely phenomenological analysis of the essence takes place in two steps. First, the psychopathologist will have to make the transition from “the way in which reality occurs” to them (realen Dasein), to the possibility of indicating the pure essences of what they perceive (reinen Wesenssein). They can make this transition by declaring inapplicable all the scientific knowledge they have about the phenomenon under observation. Thus, when they study a patient’s compulsion issues, they take their distance from both their theoretical knowledge about compulsion (such as knowledge of intrusions, of the structure of compulsion, of the epidemiology of compulsion, of the inclusion criteria for obsessive compulsive disorder in DSM-5, and so on), and from their strategic knowledge regarding treatment (such as knowledge about SSRI, exposure coupled with response prevention, and so on). Thus, this knowledge is certainly regarded, not as worthless, but as something that gets in the way of achieving an analysis of the essence—that is, as what stops the psychopathologist from gaining insights into what they really see themselves. This step is of course the same as what Husserl called the phänomenologische Epoché, the methodical means by which the phenomenologist can come to their own unique I, their unique life of consciousness, which, because of its intentional character, focuses on the object of study in that moment. It allows them to focus on things themselves—that is, on the manner in which the phenomenon appears to them. The second step that is needed to get from a natural perception to the purely phenomenological analysis of the essence, concerns the necessary transition from individual factuality—for that is how this phenomenon appears to this psychopathologist—to a general essence. The method for doing this is eidetic reduction, whereby the phenomenologist will try to rid the phenomenon of every individual property in order to be able to describe its essence—its core. Thus Binswanger tells us about this two-step process that it will not be possible to find an absolute generality in psychopathological phenomenology, and that this is also not what is intended. A complete reduction, and thus the achievement of absolute psychopathological generalities, is in itself impossible, precisely because psychopathology is experiential science. When the psychopathological phenomenologist aims for as open-minded and unbiased a description as possible of the pathological phenomenon they are studying, this ‘act of describing’ implies, for instance, that they will have to make a choice of words. This choice of words will not be unbiased. That is, any wording must go through the ‘grid of the language’, this making a complete reduction impossible (Mooij, 2012). For this reason, a phenomenological research method cannot presuppose a complete reduction (Van de Pol & Derksen, 2014; Karlsson, 1993; Giorgi, 2009). However, our initial question also becomes even more pressing: if it is not possible to get to absolute psychopathological generalities in accordance with the phenomenological way, then what is its utility in the first place? Binswanger tells us here that this utility lies precisely in a phenomenological elucidation of psychopathological terminology, and thus in the promotion and elucidation of its own research. The psychopathological phenomenologist does not aim to establish absolute generalities, but to elucidate psychopathological terminology.
But has this psychopathological terminology not been elucidated for quite some time by now, in 2018? Has the DSM itself not defined what is meant by various psychopathological terms? We must answer both questions in the negative. Indeed, entering into agreements within a classification system such as the DSM improves communication among researchers and clinicians about psychiatric disorders, in the sense that they each appear to know from each other what they are talking about. Suppose we say of a client in the Netherlands that he has a major depressive disorder (DSM code 296.22), and this client emigrates to the United States halfway through their treatment and continues it with an American colleague, this colleague will have the same understanding of the DSM codification as we do here in the Netherlands. This was certainly not the case in Binswanger’s day, as we can see from his study, Melancholie und Mania (1960), in which he actually avoids using the term depression, because of the different meanings it had in his day.4 And indeed, everyone who has contributed to all versions of DSM has tried to arrive at reliable ratings, at a nosology that could offer clinicians and researchers around the world a common language. One might think that all these efforts have meant that psychopathological terminology has already been elucidated by now, in 2018. And yet even the creators of DSM-5 have now formulated new research objectives precisely because of the level of reliability of these classifications, which is still regarded as insufficient. They have been motivated by the conclusion that the objective of establishing homogenous populations for the purposes of treatment and scientific research in previous versions of the DSM has actually meant that too-narrowly specified diagnostic categories were formulated that were not compatible with clinical reality, the heterogeneity of symptoms within disorders, or the significant overlap of symptoms between different disorders. They thus indicate that the historical ambition to achieve diagnostic homogeneity through progressive subtyping within categories of disorder no longer makes sense, just as most somatic disorders in people are psychic multi-level heterogeneous disorders ranging from genetic risk factors to symptoms. Categorical classifications confront us with problems. It was considered too early to propose alternative definitions for most disorders, but the creators of the DSM do foster neuroscientific and comorbidity research that can, over time, lead to a more fully dimensional description of most disorders.5 The psychopathological phenomenologist will certainly be able to agree, in view of their own findings that, instead of a categorical nosology, a more dimensional description of psychiatric terminology is needed. However, they expect to find this dimensional description not only in the fields of research that the creators of DSM-5 envisage: the cognitive neurosciences, brain imaging, epidemiology and genetics.6 For the psychopathological phenomenologist, psychiatry is first and foremost an experiential science, and they want to return to things themselves. Consciousness is intentional—it is a consciousness of something—and what is not given to consciousness lacks ontic legitimacy. There is therefore no ‘outside the consciousness’, and no access to reality outside consciousness (Mooij, 2012). This is why the psychopathological phenomenologist investigates only what is given in patients’ consciousness, and nothing more. It is only this that has ontic legitimacy, and there is thus no access to a psychopathological reality outside the patient’s consciousness. Only from the phenomenological investigation of the patient’s consciousness—an investigation that gives space to notions of meaning, subjectivity and patient experience—does the psychopathological phenomenologist expect psychiatric terminology to be elucidated and clarified.
Given how it has been applied within psychopathology, phenomenology has long been playing this role whereby it elucidates psychiatric concepts, and it does so still today. A recent example of this is the research by Josef Parnas and Dan Zahavi (Zahavi & Parnas, 2003), who showed from the standpoint of phenomenology that there are a number of problems with the explanatory model for infantile autism, which states that infantile autism has to do with the lack of a ‘theory of mind’ (the ‘theory of mind’ is the ability to ascribe mental states to oneself or to be able to interpret, predict and explain behaviour in terms of mental states). From their phenomenological research they both reject the assumption underlying this explanatory model, namely that intersubjectivity and self-awareness both have to do with a theory of mind. And not only that: this same research offers a number of alternative explanations that may offer a better understanding of the structure of intersubjectivity and self-awareness, and thus perhaps also a better understanding of autism itself. They argue that the problem we run into in infantile autism is the lack, not of a ´theory of mind’, but of an immediate, pre-reflective or implicit understanding of the meaning of social interaction. A second example of the ability of phenomenological research to clear up the conceptual confusion in psychiatric terminology, is found in the work of Dan Zahavi on empathy and mirror neurons (Zahavi, 2012). Since the discovery of the so-called ‘mirror neurons’ (neurons in the premotor cortex which are activated not only when the subject is carrying out a purposive action, but also when the subject observes the same actions being carried out by other individuals), various authors have, according to Zahavi, claimed that the effect of these mirror neurons would be in line with the so-called Husserlian theory of empathy. On the basis of an analysis of Husserl’s entire oeuvre, he shows, however, that this claim holds up only to a degree, and that it is largely based on an oversimplification of what Husserl found in his studies of empathy.
5 Postulate 2—Psychopathological Phenomenology is Both Descriptive and Subjective
„Psychopathologische Phänomenologie ist nicht deskriptive oder << subjektive >> Psychopathologie; jedoch greifen beide in der praktischen Forschung dauernd ineinander.“ [Psychopathological phenomenology is not descriptive or “subjective” psychopathology; however, both are constantly interlinked in practical research.]
From the foregoing discussion of Binswanger’s first postulate on the meaning of intentionality for psychiatry, it is clear that the second postulate follows logically from it: psychopathological phenomenology is both descriptive and subjective, and both constantly overlap with each other in research practice. With this postulate, Binswanger opens up a new question. How does psychopathological-phenomenological research take place in his work? First of all, that research, Binswanger tell us here, is descriptive: the psychopathologist describes the phenomenon being studied. He thus joins the philosophical tradition that can be traced back to the philosophy of Wilhelm Dilthey, who from his postulate, “Die Natur erklären wir, das Seelenleben verstehen wir”7, tried to design a descriptive psychology oriented towards understanding, assuming that what can only be understood, can only be described (we will refer to the work of Dilthey in which he described all this, as the Ideen for short). In his 1925 summer lectures on phenomenological psychology, Husserl paid attention to Dilthey’s Ideen and described this work as “eine genial, wenn auch unvollkommen ausgereifte Arbeit, die sicherlich in der Geschichte der Psychology unvergessen bleiben wird” [a brilliant, though not fully mature work that will surely be remembered in the history of psychology] (Husserl, 1925).8 The great importance that he saw in this lay especially for Husserl in Dilthey’s conclusion that what is needed is a purely descriptive psychology that, despite the ‘simple’ description could arrive at the highest explanatory performance in a form all its own, namely one that Dilthey indicated with the word Verstehen.9 As the attentive reader may already have noticed from the foregoing quote from Husserl, despite his laudatory words for Dilthey, he certainly also criticised his descriptive psychology. He called it not only a brilliant but also an “unvollkommen ausgereifte Arbeit.” Dilthey’s descriptive psychology came up short in Husserl’s view, too short, because it by-passed the fundamental distinction between acts of consciousness and their Bedeutung. That is, description alone is not enough and can lead only to an endless series of descriptions of people who have been studied by descriptive psychologists. In addition to description, an analysis of the essence is needed, and only that way can one get to a generalisation, in a certain (though not an absolute) form of examined phenomena, and to laws that explain the life of the psyche.10 Binswanger thus aligns himself, in his lecture on the importance of intentionality for psychiatry, with these views of Husserl on descriptive psychology, and argues that, in their research practice, psychopathological phenomenologists go about their work descriptively, with the aim of coming to an analysis of the essence of the psychopathological phenomena they examine, with the aim in turn of arriving at generalisable knowledge regarding these psychopathological phenomena. Here, the descriptive method of the psychopathological phenomenologist diverges from that of the nosology in DSM-5. Admittedly, DSM-5 also aims with its categorial or dimensional descriptions to foster scientific research and hence generalisable knowledge. In this regard, the DSM and phenomenologists share the same objective. However they go about this in a different way. The DSM is limited to formulating only descriptions of mental disorders and sees this as a sufficient basis for scientific research and generalisable knowledge, in contrast to the psychopathological phenomenologist, who does not see this act of describing as a sufficient basis for generalisable knowledge, but from the premise that it is only the meaning of the essence of these psychic phenomena that can make it possible to generalise research findings. The same criticism that Husserl made of Dilthey, namely that collecting descriptions regardless of the analysis of their essence can only lead to an endless series of descriptions, can also be made by present-day psychopathological phenomenologists of the creators of DSM. This objection would then be as follows: apart from phenomenology, making psychopathological descriptions, or versions of the DSM or of any nosology, is an infinite torment of the mind, in the sense not only that it is an infinite project, but also that it will lead to the pathologising of normalcy and the risk that it eventually seems that every person has a mental disorder (Van de Pol & Derksen 2014; Horwitz & Wakefield 2007). Both the creators of a nosology and psychopathological phenomenologists will hold that it makes no sense to engage in psychopathology without a scientific basis for speaking of a disorder. For the makers of a nosology such as the DSM this basis is ‘statistics from empirical research’. For Binswanger as a psychopathological phenomenologist, however, it can be found only in the phenomenological doctrine of intentional consciousness. Binswanger states this position in the following quote:11
Just as physical medicine, as a ground or basis for indicating a physical symptom as a symptom of a disease, indicates the ‘organism’ and can rely on a highly developed science of the organism, so must psychiatry—the so-called medicine of the soul—be able to rely on a science on the basis of which a failure in the soul can be indicated. The only science, however, that could offer that to us even up to today is found in the teachings of Husserl on intentional consciousness: the doctrine of the intentional structure of the consciousness organism.
However, the research of the psychopathological phenomenologist deviates in a second way from that of the creators of DSM-5. This distinction has to do with the personal perspective. Psychic phenomena can be described from any personal perspective—the first, the second and the third—and this means, as it were, that there are three entry points to psychic reality. The personal perspective in the nosology of DSM-5 is a third-person perspective; that of the psychopathological phenomenologist Binswanger, a first-person perspective, when he bases his investigative measures on the concept of intentionality. For instance, where DSM-5 speaks of hallucinations as though we are dealing with the definitive form of an object of some kind, the psychopathological phenomenologist investigates, along with their patient, the experience, the structure, and the meaning of this ‘hallucinatory existence’ as it is given to the patient. This different starting point naturally has considerable implications. The third-person perspective spurs the researcher to collect data on large groups of people, so that they can then analyse these statistically. The first-person perspective, on the other hand, encourages the psychopathologist to be in direct contact with the patient, so that they can investigate together how the phenomenon is given to the patient’s subjectivity. It is advisable to think here about Binswanger’s concept of subjectivity, since he not only emphasises this concept in the lecture we are discussing here, but also discusses it extensively in his first book, Einführung in die Probleme der allgemeinen Psychologie, which came out in the same year (1922) he gave that lecture in. In the book, he speaks of the ‘problem of subjectivity’12 as the problem that psychology has to solve. For him, this problem of subjectivity can equally be referred to as the problem of consciousness, regarding which he notes right away, however, that the fundamental problem of psychology is not so much generating a theory of consciousness, but that psychology must make ‘the immediate experience of consciousness’ the central object of study. This ‘immediate experience by the subject’ must be recognised, according to Binswanger, as something unique, as something that differs utterly from the notion of ‘objectivity’, and must be evaluated as a separate problem. The problem of subjectivity, or of the subject’s immediate experience, is for Binswanger a crucial theme that belongs within psychology, but that is nevertheless utterly denied and ignored by the scientifically deployed psychology of his time. Or, as he himself puts it, scientific psychology has no problem of subjectivity, has no problem of immediate experience—it has only the problem of nature, and thus of objectivity. It is undeniable that for Binswanger, in his long working life, the theme of subjectivity remained central. For instance, he discussed the relationship between subjectivity and language in a lecture in 1946 in which he stressed that subjectivity or human consciousness is inseparable from language, and that human subjectivity exists in language, without being completely reduced to it (Frie, 1997).13 There is, moreover, a certain development to be found in his thinking; whereas in the 1920s he investigates subjectivity especially in its relation to the person, in his late work he speaks more and more of the “transzendental-konstituierende Subjektivität” or of a “Leistendes Leben”—that is, of a Husserlian understood transcendental Ego, understood in the Husserlian sense, that constitutes a world and a self (Blankenburg, 1994).
This problem of subjectivity for psychiatry has not been resolved to this day. Let us delve into the discussion on subjectivity that took place in the winter edition of the American journal Psychiatry in 2010, in the context of the issuance of the new versions of the DSM and ICD. This discussion was initiated by Elizabeth Flanagan, Larry Davidson and John Strauss with their paper on the need to integrate what they call ‘patient-subjective data’ into the DSM and the ICD (Flanagan, 2010). They argue that with the improvement from DSM-II to DSM-III, ´the baby was thrown out with the bathwater’; the attempt by the creators of the DSM to replace subjective clinical interpretations of mental disorders with objective—and for researchers, reliable—descriptions of signs and symptoms, meant that it was not only the subjective impressions of the clinician that disappeared into the background, but also the subjective experiences of the person with the mental disorder. They then cite two reasons why the subjective experiences of the patient are a valuable tool for research into mental disorders. First, these subjective patient experiences can be a valuable source of information in the search for the underlying operative mechanisms in mental disorders. Second, this source of information yields new information, as what appears to be objective and observable on the outside, is by no means always equal to what the patient experiences on the inside. For these reasons, Flanagan and her colleagues propose to the creators of new versions of the DSM and the ICD to integrate into new edition empirically derived, patient-subjective characteristics. The utility they are thus aiming for is to increase the accuracy of the diagnostic categories and in so doing to facilitate the empathy of clinicians, which could lead to improvements in therapeutic relationships. There were two responses to this proposal of Flanagan’s and her colleagues in the same winter edition of Psychiatry—one from the creators of the new DSM-5,14 and the other from the creators of the new ICD.15 The response from the creators of the new DSM-5 is as follows. Regier et al (2010) include a marginal note on the use of patient-subjective data in DSM. They argue that subjectivity is a variable that varies from person to person, thus making it impossible to come up with definitive criteria that would apply to any disorder. However, they agree with the recommendation from Flanagan and her colleagues to involve patients in the DSM working groups, which they also did. Cuthbert & Insel (2010) are sceptical of Flanagan’s proposals, and do not see how these could contribute to solving today’s major nosological problems, which, as they see it, are excessive co-morbidity, the heterogeneity of disorders, and an increase in the use of the Not Otherwise Specified (NOS) diagnostic categories. Anne Lovell (2010) responded for the creators of the new ICD. She finds in the recommendation from Flanagan and her colleagues an echo of the more common recommendation from the research field, regarding the conceptualisation of psychiatric disorders, that a ‘twin-track’ approach be opted for in which patient-subjective and causally-scientific data are combined. Lovell attaches considerable importance to subjective data, but that does not automatically imply for her that criteria that have been derived from patient-subjective data should be integrated into diagnostic categories in the DSM or the ICD. It does mean for her, though, that patients should be involved as much as possible in the creation of revised versions of the DSM and the ICD. We thus see that the responses from both the creators of DSM-5 as ICD11 are the same: they reject the integration of patient-subjective data into nosology, but embrace the recommendation to involve patients in the working groups around the creation of a nosology.
6 Postulate 3—Psychopathological Phenomena Cannot be Described in Abstraction from the Person Experiencing Them
„Anstatt über seinen Zusammenhang mit andern seelisch-abnormen Erscheinungen und seine Entstehungsbedingungen zu reflektieren, sucht er nur solche Merkmale auf, die dem betr. Erlebnis selbst immanent, in ihm selbst vorfindbar sind. So wird in erster Linie bei jedem Einzelerlebnis der ‚persönliche‘ Hintergrund sichtbar, auf dem es sich abspielt; anders ausgedrückt: in jedem Einzelerlebnis gibt die erlebende Person etwas kund, durch jedes schauen wir in die erlebende Person hinein. Jedoch stehen wir hier noch ganz am Anfang, da uns eine psychopathologisch-phänomenologische Personalcharakteristik noch fehlt.“ [Instead of reflecting on its connection with other psychic-abnormal phenomena and its conditions of origin, he only seeks for those features that are inherent to the experience itself and can be found in itself. Thus, in the first place, the individual “personal experience” makes the “personal” background visible on which it is played. In other words: in every single experience the experiencing person gives something, through each we look into the experiencing person. However, we are still at the very beginning because we still lack a psychopathological-phenomenological personality theory.]
This third postulate of Binswanger’s on the importance of the concept of intentionality for psychiatry has to do once again with the research method used. Here he compares the research method used by the psychopathological phenomenologist with that used by the descriptive psychopathologist. The difference that he then outlines between both methods has to do with the fact that the psychopathological phenomenologist, in contrast to the descriptive psychopathologist, can never describe a psychopathological phenomenon in abstraction from the person experiencing it. Or, as Antoine Mooij (Den Boer, Glass & Mooij, 2008) puts it: Here, Binswanger broadens the Husserlian concept of ‘intentionality’, in which consciousness focuses on a Gegenstand, to a person who focuses on the world/contents. Binswanger also argues that psychopathological phenomena cannot be described in abstraction from the person experiencing them. For example, a formal description of a hallucination is inadequate if the modification of the subjective mode of being (as a person) is not involved. A number of questions come to us when we let this statement sink in. What does Binswanger mean exactly by descriptive psychopathology? Is the DSM an outgrowth of descriptive psychopathology such as that which Binswanger characterises here? And if it is, in what respect does the psychopathological phenomenology of the kind promoted by Binswanger deviate from the form of descriptive psychopathology we find in the DSM?
What does Binswanger mean exactly by ‘descriptive psychopathology’? First of all, he is referring here to a psychopathology that wishes to describe the psychopathological free of theory, based on what the patient says about it.16 The descriptive psychopathologist thus focuses their attention on what the patient says, on their words (for example, on the answer given by the schizophrenic patient to the question, “Do you also hear voices?”, which might be as follows: “No, I don’t hear voices, but at night amusement arcades open up, to which I would like to get permission to get into”). The descriptive psychopathologist then bases judgements on this account (such as “this person suffers from acoustic hallucinations” or “this person has a bizarre way of speaking”). This judgement is then used as the basis for drawing conclusions or making concepts, which are accommodated under a category of illness (e.g. “this patient suffers from schizophrenia, and a bizarre way of speaking is part of this”). Several conclusions and concepts of this kind can be accommodated under the same illness category (e.g. the symptoms of schizophrenia include acoustic hallucinations and a bizarre way of speaking); the way a judgement is formed here involves subsumption. Thus a theory of the development of a disorder comes into being, on the basis of which a symptom can be explained. Descriptive psychopathology leads in this way to a series of judgements, conclusions and concepts that are based on patient accounts, and all of which will be accommodated within a system of categories of illness, a hierarchical system of characteristics, a classification, and a nosology. Binswanger seems never to speak out explicitly against such a hierarchical system, and in the lecture under discussion here he himself indicated that the psychopathological phenomenologist and descriptive psychopathologist depend on and need each other. The psychopathological phenomenologist needs the products of descriptive psychopathology to have something to go on. And conversely, the descriptive psychopathologist needs the psychopathological phenomenologist for the elucidation of their concepts. Nevertheless, we would like to state that Binswanger throughout his working life also struggled with this categorical system, more specifically, with the diagnostic boundaries that can result from it and sometimes can be too narrow, and, on the other, with the artificial character of descriptive constructs that for him are far removed from the living reality of the entire state of being human. The study of the phenomena themselves was for him a more fruitful way than the study of artificial constructs such as categories of illness. We find examples of this in his discussion of melancholy (Binswanger, 1960), in which he found the delimitation between endogenous and exogenous depression too narrow,17 or in his study of the flight of ideas (Binswanger, 1933),18 in which he indicates that establishing the psychiatric-diagnostic judgement that someone is suffering from the flight of ideas, may give the appearance of clarity, but in its structure and basis in the person whom the judgement is about, is still by no means clear. His primary psychiatric interest lay especially—instead of diagnoses or labelling things with a word label and then giving it a psychopathological-theoretical construction—in understanding what we are actually talking about with all those psychopathological phenomena, and understanding what they are from the starting point of the entire state of being human as a totality (Binswanger, 1957).19
Is the DSM an outgrowth of descriptive psychopathology such as that which Binswanger characterises here? Unfortunately, this question is too complex to give a simple yes or no answer to. There are certainly similarities between the hierarchical system of descriptive psychopathology and editions of DSM. Both feature categories of illness, including various concepts that are accommodated systematically and hierarchically; in short, in both cases we have to do with a categorical, diagnostic system. Like the previous editions, DSM-5 is just such a categorical diagnostic system. However, more than they did in previous editions, the creators recognise the limited character of such a categorical-diagnostic approach. They mention a number of disadvantages of categorical diagnostics including the impossibility of distinguishing mental disorders on the basis of natural boundaries, the resulting need for intermediate classifications (such as schizo-affective disorder), the high co-morbidity between disorders, the limited usefulness of the search for the antecedents of mental disorders, and the lack of specificity when it comes to treatment (APA, 2013).20 Van Os (2014) adds two drawbacks to the list, namely a faulty relationship between the care need and a DSM classification, and the distance between DSM classifications and the patient’s story. Increasingly, therefore, the need for a new diagnostic system is mentioned in scientific publications. Thus Van Praag and his colleagues (Van Praag et al, 1990) call for a functional-diagnostic system under which classifications would have to be broken down into their constituent parts—what they call the ‘psychological dysfunctions’, and about which they note that these are not classification-specific—in order then to link the treatment plans to the analysis of these functions rather than to the classifications themselves. A variant of this has already been proposed for quite some time by many authors. Today it is called the “cross-cutting dimensions method” (Persons, 1986; Costello 1992; Van Os et al., 1999 and 2014). Using this dimensional diagnostic system, a number of disease-category transcending symptom domains can be formulated, whereby alongside the nomothetic, also an idiographic component is added to the diagnostics and treatment plans are associated with the care needs resulting from these symptom domains rather than with classification. Alternative possibilities to replace the thinking in categories of illness are the Research Domain Criteria project (RDOC) of the National Institute of Mental Health (Cuthbert & Insel, 2010) and the approach whereby psychopathology is seen as a network of symptoms with mutually causal mechanisms (Kendler, 2011 and 2012). Particularly the dimensional diagnostic system seems to point, for the creators of DSM-5, in a valuable direction for the future. For these reasons a section 3 has been included in DSM-5, in which possible models for dimensional diagnostics are introduced in order to stimulate further research. Through this reformulation of research objectives, the APA wants to remain central, with DSM-5, to the development of dimensional-classification approaches that, as it expects, will in the next few years supplement or replace the current categorical approaches.21
A second major similarity between DSM-5 and descriptive psychopathology is that, because of the method used, both result in a psychopathological system of categories of illness that is separate from the persons who have the ‘illness’. Or the system is purely nomothetic. The unilaterally nomothetic character of the DSM has certainly been the subject of discussion. Thus we read in Frances (2013) that, with the advent of DSM-III, the understanding of the whole patient—both because of the way in which DSM III was formulated and because of how the manual was misused22 —was reduced to the filling out of a checklist, a ‘diagnostic inflation’ that he brands as the worst result of DSM III and about which he also indicates that he, along with his fellow creators of DSM IV, should have reined in more fully with explicit measures. Others see in the unilaterally nomothetic character of DSM-IV grounds for increasing the gap between clinicians and researchers, and thus declare that, its ambition notwithstanding, DSM IV serves the purposes of researchers more than it does those of clinicians (Phillips, 2005). Van Os (2014) argues that, because DSM-5 is purely nomothetic, the idea is propagated that patients in the same diagnostic category are equal, thus strengthening the scientifically unproven idea that there are psychiatric ‘diseases’ and making it possible to stereotype people. It suggests that each ‘illness’ needs special treatment, for which separate professional guidelines, separate patient groups and separate ‘treatment pathways’ are needed.23 The World Psychiatric Association has stated that an idiographic component must be added to current nomothetic psychiatric diagnostics to be able to come to a complete diagnostics (IGDA Workgroup, 2003).
Similarities between descriptive psychopathology, as Binswanger described them, and DSM-5 thus include thinking in categories of illness and describing psychopathological disorders in abstraction from the person. However, there are also large differences between DSM-5 and descriptive psychopathology. For example, there are differences in the extensiveness of the descriptions involved. Bleuler’s Dementia Praecox oder Gruppe der Schizophrenien (1911/2014) does show a system of information that has a significant overlap with DSM-5 (information is organised around the same themes, such as symptomatology, differential diagnostics, the course of an illness, and so on), but Bleuler, as a descriptive psychopathologist, adds a significant dimension to it. He describes symptoms as deviations from normality and orders symptoms under the psychological functions that have been disrupted in the schizophrenic patient, such as the ‘einfachen Funktionen’ (including association and affectivity), the ‘intakten Funktionen’ (largely in patients) such as orientation in time and place) and the ‘zusammengesetzten Funktionen’ (as the will, the person, and the relationship to reality). Time and again he tries to describe the way in which this function in the patient has changed in comparison to what is customary. Thus the description that Bleuler uses is not only more extensive than that which we know from the DSM classification, but it is also presented in a different way. For Bleuler as a descriptive psychopathologist, the arrangement of information takes place by way of the logical coherence between normality and abnormality, while in the case of DSM-5 it happens, as we know, through statistical research. We posed ourselves the question of whether DSM-5 is a form of descriptive psychopathology. Here is our answer: We can certainly say that DSM-5 is a form of descriptive psychopathology, in view of its great similarity with descriptive psychopathology, even if the two of them cannot simply be equated just like that, given, for instance, the differences between them in terms of extent and the principle of information arrangement used in each case.
This brings us to our next question: in what way is the psychopathological phenomenology of the kind promoted by Binswanger different from the form of descriptive psychopathology we find in DSM? For the answer to this question we have to go back to Binswanger’s paper Über Phänomenologie, in which he mentions two significant differences: one in focus, and one in how feasible it is to study psychopathological phenomena in abstraction from the person experiencing them.
The first difference has to do with the focus of the psychopathologist. Whereas the descriptive psychopathologist highlights the words of the patient to create a system of disease categories through subsumption and judgement, the psychopathological phenomenologist focuses on the patient’s experience. They try to imagine as lively as possible that which the words indicate, and to turn away from the sound of a word and its meaning, and to turn, rather, to the experience the words are related to. This experience is for the descriptive psychopathologist ‘the matter itself’, the ‘Gegenstand’, the only source of reliable information about the psychopathological phenomenon. This act of imagining the patient’s experience in as lively a way as possible, of immersing oneself in what the words indicate, reminds us of what in our day is called empathy. Yet Binswanger does not explicitly use the concept of empathy, perhaps because of the vagueness that in his view surrounded the concept; a vagueness in both the theoretical, phenomenological sense and the everyday sense. From a theoretical perspective, there was already, when he gave his lecture in 1922, a broad spectrum of theories on empathy. Binswanger mentions a number of examples in his Allgemeine Psychology (1922): ‘Assoziationstheorie’, ‘Analogieschlusstheorie’ (Dilthey and Fechner, among others), ‘Einfühlungstheorie’ (Lipps) and ‘Wahrnehmungstheorie’ (Scheler). But also from a phenomenological perspective, the concept of empathy needed a lot of attention in order to become clear. For Husserl, with whose phenomenology Binswanger felt a close affinity, the phenomenological study of the concept of Einfühlung was a life-long occupation that lasted from 1905 to 1937 (Zahavi, 2012). Finally, for Binswanger, even in everyday language the concept of empathy had an ambiguous meaning, which he described at length in his case study, Ilse (Binswanger, 1957). Only when these various turns of phrase and the related phenomenal, intentional and pre-intentional modes of being-with-each-other (Miteinandersein) and being-together (Mitsein) were fully analysed, would it be possible, as Binswanger saw it, to bring clarity to the concept of empathy. Until that time, because of its vagueness, the concept of empathy was unusable for him, and, since he envisaged bringing clarity to psychiatric terminology with his psychopathological phenomenology, his reticence in using the term empathy is understandable. Finally, there is still another reason that may have played a role in Binswanger’s reticence in using this term, namely the wish to distinguish his psychopathological phenomenology in an important respect from Jaspers’s Allgemeinen Psychopathologie (Jaspers, 1913/1965), which was also referred to as phenomenological in the Husserlian sense. Jacob used the concept of empathy as a concept that set the limits of nosology: psychosis starts where empathy is no longer possible (Jaspers, 1913/1965; Ghaemi, 2003), and the weightier psychiatry starts where psychological clarity stops and it is no longer possible to speak of intelligible cohesion (Den Boer, Glas, & Mooij, 2008). Binswanger was of the opinion that psychiatry had to get rid of Jaspers’s dichotomy between empathisable and non-empathisable psychic life, on the one hand because the scientific value of this dichotomy, given the vagueness of the term empathy, was low and, on the other, because the empathic possibilities are purely subjective and vary in accordance with the researcher’s empathic skills (Binswanger, 1957).
The second difference concerns the feasibility of studying a psychopathological phenomenon in abstraction from the person experiencing it. For the statistical form of descriptive psychopathology we find in DSM, a psychopathological phenomenon can certainly be studied in abstraction from the person experiencing it. The researchers base their statements about psychopathological phenomena on the statistical analysis of groups of people that meet certain characteristics. Essential in the phenomenological approach to psychopathological phenomena is that the psychopathological phenomenologist never immerses themselves in a single isolated phenomenon, but that this phenomenon always plays out against the backdrop of an I, a person. In other words, Binswanger always sees the phenomenon as an outward sign or a notification that a person is well grounded in one way or another. The person involved expresses themselves in the specific phenomenon, and the other way round: we see inside the person through the phenomenon. For Binswanger, a psychopathological phenomenon is inextricably linked with a person; speaking of psychopathological phenomena in abstraction from the person experiencing it is not possible for the phenomenologist (Den Boer, Glas, & Mooij, 2008). For this reason, Binswanger argues that psychiatry is in urgent need of an adequate, general characterisation of personalities that can provide the psychiatrist with clear, basic phenomenological concepts with which they can grasp the essence of a person. He regards such a characterisation as less than readily available at the time of this lecture, with the exception of the book by Alexander Pfänder entitled Psychologie der Gesinnungen (Pfänder, 1913 and 1916). In this work, Pfänder argues that it is incorrect to conceive of the psychic subject who focuses actively on a Gegenstand as a single point, as though they were not divided up further. For him, the psychic subject is a divided whole: the experiences are always the experiences of a psychic subject, but at the same time they do not always occupy the same position within this subject. That is why the psychic subject cannot be conceived of as a single point, but has a certain range of different positions. Pfänder goes on to recognise other positions than a self (that itself also consists of several positions) and an I-centre, which he conceives as a middle point of the soul and that has the function of guiding the self. As the I-centre guides the self, the psychic subject becomes a person. For the rest, in his Psychologie der Gesinnungen, Pfänder does not aim to give a full characterisation of the self. He therefore omits its constituent elements, as well as the numerous existential, dynamic and causal relationships in which the components of the total itself are bound up with the I-centre and the psychic subject. He interprets such a discourse as a theory of the structure of the human personality, while, in Psychologie der Gesinnungen, he did not want to describe such a theory, but only the structural schema of this human personality. Pfänder’s structural schema of the human personality now becomes an occasion for Binswanger to broaden the concept of intentionality from a psychic subject focusing on Gegenstanden to a person focusing on the world. Psychopathological phenomena cannot be studied in abstraction from the person experiencing them. Psychopathology cannot do without a theory of the structure of the human personality. That is, it cannot do without a theory of intrapsychic architecture (Derksen, 2007–1, 2007–2, 2008, 2009, and 2014).
7 Intentionality: The Problem of Time in Psychiatry
Herzog (1994) declares that Binswanger changed his views on the concept of intentionality throughout his life in a number of ways, including a change that emerged from his meeting and friendship with Eugène Minkowski. This meeting took place at the same congress in Zurich where he, on 25 November 1922, gave his lecture, “Űber Phänomenologie”, which we discussed above. The fact is that Binswanger gave this lecture in connection with Minkowski’s own lecture, “Etude psychologique et analyse phénoménologique d’un cas de mélancolie schizophrénique”, and was struck by Minkowski’s insights, which were inspired by Henri Bergson’s philosophy, on the experience of time and on psychopathology. Herzog (1994) tells us that, in this lecture, “drängte Minkowski zu einer Erweiterung des Intentionalen” in order to give a new dimension to Bergson’s concepts of ‘élan vital’ and ‘durée vécue’—a dimension in which the concept of intentionality could be made psychopathologically fruitful. Binswanger was of this same opinion, which led him, in various case studies of schizophrenia, melancholy and mania, to pay considerable attention to changes in the consciousness of time, such as in the case studies of schizophrenia by Ellen West, Jürg Zünd, Lola Voss, Suzanne Urban (Binswanger, 1957), the case studies of melancholy by Cécile Münch and David Bürge, and the case studies of mania by lsa Strauss, Dr Ambühl and Olga Blum (Binswanger, 1960). He made the analysis of the disturbances in the consciousness of the patient a regular part of his psychopathological phenomenology. Binswanger encountered a similar kind of attention to the problem of time in psychopathology, on the part of two colleagues he was friends with, Erwin Straus and Victor von Gebsattel. However, Binswanger realised fully that this time problem called for a deepening of what he had conceived of as intentionality only with the publication of the lectures given by Heidegger on Husserl’s ‘Zur Phänomenologie des inneren Zeitbewusstseins’ (Hua X) in 1928. After reading it, he had to conclude that the concept of intentionality in Husserl went much farther than it did in Brentano’s work, and that one could therefore no longer stick with Husserl’s presentation of intentionality in the Logical Untersuchungen or with his own version of it in his Einführung in die Probleme der allgemeinen Psychologie from 1922.24 And so we come to Binswanger’s fourth postulate on the concept of intentionality: psychopathological phenomena cannot be described in abstraction from the inner consciousness of time and disruptions to it.
8 Postulate 4—Psychopathological Phenomena Cannot be Described in Abstraction from the Inner Consciousness of Time and Disruptions to it
Binswanger put his thoughts most explicitly into words with the appearance of Husserl’s Zur Phänomenologie des inneren Zeitbewusstseins in his publication Melancholie und Manie (1960). He found it remarkable that Husserl understood the concept of ‘time’ as proceeding from intentionality—in other words, that Husserl examined ‘how temporal objectivity and noematic temporal subjects (past, present, future) constitute themselves in the subjective consciousness time’. The constituent moments in the construction of these topics in time (past, present, future), which Husserl called the structural schema of “retention—presentation—protention” were for Binswanger the subject of psychopathological research: with psychopathological phenomenology it was a matter, with regard to the inner consciousness of time, of revealing the ‘deficient modes of these three constituent moments in construction, and their interaction’. In the two case studies on melancholy (Cécile Münch and David Bürge) Binswanger locates this deficiency in melancholic self-reproach (‘if only I had’, ‘if only I had not’): this self-blame “shows only empty possibilities” (Leerintentionen), and it is a matter of protentive acts (the past has no possibilities) that focus on the past, either, that is, it is a matter of “exchanging the retention with the protention”,25 whereby ‘not only the entire process, the entire streaming or continuity characteristic in the formation of time, but also the whole stream of consciousness, of thinking in the first place, is disturbed’. In the case studies on mania (Elsa Strauss, Dr Ambühl and Olga Blum), Binswanger holds that the disturbance of the intentional construction of temporal objectivity appears in two respects: on the one hand in the failing continuity between meaning and thinking, and on the other in the failing continuity of appresentations (which he calls a failure of the appresentations that are anchored in the inner life history).26 In his case studies on schizophrenia (Binswanger, 1957), Binswanger approaches the problem of time not so much in a transcendental-phenomenological way (in the Husserlian sense), but rather in an existential-ontological way (in the Heideggerian sense); the concept of “Zeitlichkeit” here means not the experience of or consciousness of time, but a self-formation-of-time by the Dasein an sich, a ‘Zeitigung’. Here we can see clearly that the problem of time is a fixed part of Binswanger’s Daseinsanalyse and that no matter which viewpoint he took in his psychopathological phenomenology—whether transcendental-phenomenological or existential-ontological—a psychopathology in abstraction from inner time-consciousness for him was fruitless. The inner consciousness of time is, moreover, the foundation for the stream of consciousness, the continuity of thought, and the continuity of appresentations, and the disruption of these—that is, the Zeitproblem, just as with Minkowski (albeit in a way that is otherwise elaborated)—is a latent source of psychopathogenesis.27
Although we do not want to subscribe fully to Binswanger’s position that psychopathological phenomena cannot be described in abstraction from the disturbances of an inner consciousness of time as understood in a Husserlian way, we must also point out that, in his application of Husserl’s phenomenology of the inner consciousness of time, Binswanger does not always proceed in a Husserlian way. It is beyond the scope of this article to analyse all the differences in this respect. However, one difference that we do want to mention has to do with his “un-Husserlian” use of the term retention. To illustrate the improper character of this usage, we must first of all elucidate a distinction that Husserl used in his phenomenology of time: that between primary and secondary memory, or primaire Erinnerung and Wiedererinnerung. Primary memory is retention, it binds itself immediately to the perception of the Now, the primal impression, and its function is to fix in consciousness, or better yet in the retentive consciousness, a past object in time, to ‘represent’ it, but then as ‘just passed’, before it sinks back and fades into an emptying of that retentive consciousness. Secondary memory concerns memory that does not directly seize the primal impression, but reproduces it (we remember a melody, for instance, that we last heard in a concert), and can, logically, make its appearance only after emptying the retentive consciousness—otherwise, the memory would not be secondary but primary. Well, when Binswanger speaks, when it comes to the case studies by Cécile Münch and David Bürge, for instance, of melancholy self-reproach (“If only I hadn’t set out on the train ride”, or “If only I hadn’t lent that money”), he is speaking of retention, with which the protention is exchanged. However, if primary memory—retention—were actually involved here, then that would imply that Cécile Münch, who, five months after the fateful train accident in Münchenstein, was admitted to the Bellevue clinic in Kreuzlingen, had a continuous retentive consciousness of this train accident for those five months—something that is not impossible but unlikely. That would also imply that David Bürge, who for a year kept up his melancholic self-reproach about the money he had lent out, had a continuous retentive consciousness of his guarantee for that year—something that is also theoretically not impossible but unlikely. Indeed Husserl did not exclude the theoretical possibility of a constant retentive consciousness: “Auf die Begrenztheit des Zeitfeldes ist im Diagramm keine Rücksicht genommen. Dort ist kein Enden der Retention vorgesehen, und idealiter ist wohl auch ein Bewusstsein möglich, indem alles retentional erhalten bleibt (Husserl, 196628 ).” But we should note the emphasis that Husserl puts on the word ‘idealiter’: this is an ideal, theoretical possibility, and not a real, emerging one. If we had to do with a retention that lasted such a long time, then from a psychopathological perspective it was not so much the alleged exchange with protention that was the most noteworthy, but rather the representation for so long of the primal impression, in other words, the fact that it took so long to empty the retentive consciousness. It is more likely that, in the case of both patients, what is involved is secondary memory, Wiedererinnerung—a repeated self-reproduction over a long period of the fateful event. For Husserl it was natural that these protentions should occur in these secondary memories: “… jede Erinnerung enthält Erwartungsintentionen, deren Erfüllung zur Gegenwart führt” (Husserl, 196629 ). It would indeed be all the more remarkable to him that both patients should retain the same empty, unfulfilled protentions for such a long time in their Wiedererinnerung. For in the secondary memory it is not only that these protentions renew themselves, but also that their state of being unfulfilled also changes: “… die wiedererinnernde Prozess erneuert erinnerungsmässig nicht nur diese Protentionen. Sie waren nicht nur auffangend da, sie haben auch aufgefangen, sie haben sich erfüllt, und dessen sind wir uns in der Wiedererinnerung bewusst“ (Husserl, 196630 ). It is a matter here, not of retention that is exchanged for protention, such as Binswanger states, but of protentions that are present in the secondary memory, the Wiedererinnerung. It is not so much the presence of these protentions in the secondary memory that is a sign of the disturbance, but the fact that these protentions remain unfulfilled for such a long time in that secondary memory. In any event, whether it is said that it took too long to empty the retentive consciousness, or that the protentions remained unfulfilled for too long in the secondary memory, both descriptions are, for the case studies of melancholic depression that are cited by Binswanger, a more Husserlian explanation for the delay in the thinking and consciousness stream than the suggested protention that is exchanged for the retention.
With the publications by Binswanger and his contemporaries about the experience of time and disturbances to it, a new tradition in psychopathological research was started, and to this day the experience of time in specific patient populations is investigated through various types of research. For example, there is the research by Wessel van Beek on disturbances in the experience of time among suicidal patients (particularly disturbances in the ability to focus on the future) and the therapeutic options for undoing these disturbances (Van Beek, Berghuis, Kerkhof & Beekman, 2011). Although Thomas Fuchs, of Heidelberg University Hospital, indicates that Binswanger, along with Minkowski, Straus, von Gebsattel and Tellenbach established a unique tradition in the psychopathology of temporality that others have been able to build on to the present day, he also differentiates aspects in which this tradition needs to be continued and expanded (Fuchs, 2013). First of all, the publications up to now are often not clear when it comes to the distinction between the different levels of the experience of time, in particular with regard to the micro-level on the one hand (the inner consciousness of time, as Husserl has described it), and the ‘life-historical’ level on the other, while it is precisely that distinction that is essential to the ability to distinguish between psychotic and neurotic disturbances of temporality. In addition, many of these publications about psychopathological disturbances of the experience of time, just as we saw with Binswanger, are often analysed from an individual perspective, while psychopathology should, in an analysis of disturbances in the experience of time, also involve the social aspect of synchronisation and desynchronisation—that is, intersubjective temporality. It can be stated with certainty that research into temporality and psychopathology has continued actively to this day, that important new discoveries have been made on the basis of that research, such as the relationship between temporality and self-awareness, the role of desynchronisation (falling out of shared time) in the development of psychopathology, and the importance that ‘conative momentum’ (the energy that comes from the instincts, affects, needs, emotions) has for the experience of temporality and the self. Thus we now know the concept of ‘explicit time’—that is, the phenomenon in subjectivity where the usual implicit mode of experiencing time turns into an explicit experience of time as a result of the ‘sudden’: something such as a shock or a sudden loud noise, a painful loss, or disappointment or shame. Whereas this phenomenon was already known in Binswanger’s time, the changed experience of time that Cécile Münch and David Bürge had can largely be explained on that basis. Thus it seems to be important to extend Binswanger’s theorem regarding the importance of involving the experience of time in psychopathological-phenomenological research, by adding to it the current state of knowledge. This renewed statement would then go as follows: psychiatric phenomena cannot be described in abstraction from: 1) the implicit experience of time, both passive-synthetic (Husserl) and conative-affective, 2) the explicit experience of time and the life-historical level of the experience of time, and 3) intersubjective temporality as expressed in the degree of synchronisation and desynchronisation.
In response to proposals to patient-subjective or idiographic data to integrate data in future versions of nosologies such as the DSM and the ICD, we take the view that a nosology is not a suitable vehicle for disseminating psychopathological-phenomenological research results throughout the field, however much we also value and even pursue these research results. However, the reasons why we take this position are different from those of the creators of DSM-5 or the ICD for refusing the proposal to integrate patient-subjective data into nosologies. The DSM side rejected this proposal for two reasons: 1) subjectivity would preclude generalisability and thus patient-subjective data would not fit in a nosology (Regier et.al., 2010)31, and 2) patient-subjective data would not contribute to solving the big nosological challenges of co-morbidity, the heterogeneity of disorders, and the increase in the use of NOS categories (Cuthbert & Insel, 2010). The ICD side also rejected this proposal, but for a third reason, namely: patient-subjective data are important, as is integration of this knowledge with the knowledge that comes from causal-scientific research, but that in itself does not mean that this integration should take place within a nosology (Lovell, 2010). Based on the previous discussion of Binswanger’s application of the Husserlian concept of ‘intentionality’ within psychopathology, we can add here two new reasons for rejecting this proposal.
One could say that a pooling of results from different psychopathological research initiatives within one nosology is permissible, at least as long as the purpose of both research approaches is the same. Well that seems to be the case at times, if we compare the efforts of the creators of DSM-5 to those of the psychopathological phenomenologist. After all, both the creators of DSM editions and the psychopathological phenomenologist try, for instance, to ‘elucidate psychiatric concepts’ (postulate 1) or to ‘describe’ (postulate 2), even if they do so in completely different ways. Whereas the creators of the DSM use comorbidity or neuroscientific research as a method to that end, the phenomenologist uses the phenomenological research on the consciousness of patients, on subjectivity, and on the coherence of meaning in the experience of patients in order to elucidate psychiatric concepts. In other words, the goal of both approaches to psychopathology seems the same, but the method used to achieve that goal is different. However, the goals of both approaches seem similar to each other only at first glance. When we ask about the ultimate goal—that is, why both parties want to elucidate psychiatric concepts, we do indeed discover a difference in their goals: the creators of nosologies want this elucidation for the sake of facilitating research, or of reducing co-morbidity, or cutting the number of Not Otherwise Specified classifications made, while a psychopathological phenomenologist pursues the elucidation of psychiatric concepts for the sake of a better understanding of the patient’s experience in the case of various mental disorders, or in more general terms for the sake of a better understanding of the functioning of subjectivity and possible disturbances in it. Even when it is a matter, then, of elucidating psychiatric concepts, both of these approaches to psychopathological research have a different final goal. It happens to us in the same way as when we talk about descriptiveness (postulate 2): both approaches to research want to describe mental disturbances, and seem to be pursuing the same goal, even if they use a different personal perspective (the one a first-person, the other a third-person, perspective); however, both want this description for the same set of different goals. The demand for the ultimate goal of both psychopathology-approaches in both cases leads inevitably to a finding of differences in objective; and therewith for those for whom an agreement of at least the objective is applicable as the most important condition for integration of patient-subjective data in nosologies, the proposal of Flanagan and colleagues is already rejected.
In our discussion of Binswanger´s third postulate—that mental phenomena cannot be studied in abstraction from the person experiencing them—we ran into a second major stumbling block to the integration of patient-subjective and idiographic data into the DSM and the ICD: the kind of information that the psychopathological phenomenologist pursues is a complex cluster of person, context and psychopathological phenomenon. That is why it has always been a commonly heard objection of phenomenologists regarding DSM, that it does not make symptomatic behaviour understandable, because it ignores the individual context and experience of the patient (see, for example, Halling & Goldfarb, 1996). The same is true of the fourth postulate—that psychic phenomena cannot be studies in abstraction from disturbances to inner time-consciousness. Although in our discussion of this postulate we determined that Binswanger had misunderstood Husserl’s phenomenology of the inner consciousness of time, and that his postulate, in view of present-day phenomenological knowledge concerning temporality was framed too narrowly, this postulate still also calls for an examination of symptomatic behaviour in conjunction with the personal context and constitution of the experience of time, which leads irrevocably to a kind of information that coheres in a complex way. The latter meant that he found himself forced to make case studies, in which the symptomatology in the sense-connection with time, person and world was examined. Of course such a symptom analysis leads to complex research results, and it is therefore difficult to imagine how such information can be integrated into the DSM or the ICD, without also deviating significantly from the structure of these nosologies, or the complexity of the research results. We could also formulate this question otherwise: Binswanger intended with his psychopathological phenomenology to diagnose a person, while a nosology aims only to classify disorders. Thus we find a second objection to the proposal by Flanagan and Van Os to integrate patient-subjective and idiographic data in future versions of DSM.
Although it would thus be both illogical and improbable—both because of the different goals and because the different sorts of information cannot be united—to imagine that a psychopathological phenomenologist such as Binswanger would like to see his research findings into the leading nosologies of a given epoch, he would of course welcome the underlying plea for the dissemination of phenomenological research findings in the field: he did, after all, devote himself to that end his entire life. Will contemporary practitioners of less descriptive and more interpretive-hermeneutical forms of psychopathological phenomenology reject such an integration of phenomenological data into dominant nosologies as well and for the same reasons? We think they should do that, but it is up to them to answer that question. Whatever their answer, psychopathological phenomenology—both descriptive and interpretative-hermeneutic—must certainly continue its research into normal psychic life and possible disturbances to it. This investigation into subjectivity still offers, to this day, many important and valuable insights for our field, and these deserve to be disseminated among everyone working in psychiatry, whether as a researcher or a clinician, because they allow them to face patients with more empathy and trigger, moreover, the formation of hypotheses regarding the underlying operative mechanisms of psychopathology. However, a nosology is not the right vehicle for this dissemination of insights. Other resources such as manuals, journals, conferences, education and multidisciplinary cooperation seem better suited to that end.
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Binswanger makes a point of choosing “psychopathological phenomenology” over “phenomenological psychopathology” to indicate, on the one hand, that this is a phenomenology that does not pretend to scale the heights of “pure essences”, and, on the other hand, that it distinguishes itself from what others (to wit, Karl Jaspers) have referred to as descriptive psychopathology (see Binswanger 1947, p. 33).
See Binswanger (1947), p. 7.
Translations of German quotes are made by authors themselves.
See Binswanger (1960), p. 10.
DSM-5—APA, 2013, pp. 12 and 13.
Ibid., p. 5.
Dilthey 1894, published in 1990, Gesammelte Schrifte, Bd.V; quote on p. 144.
Husserliana, IX, p. 6, lines 26–28.
Ibid., p. 10, lines 10–17.
Ibid., 9.13, lines 8–28; see also De Mul 1993, § 4 of Chapter 5.
Binswanger 1960, ‚Melancholie und Mania‘, p. 79.
See Binswanger 1922, pp. 102–107.
See Binswanger (1955), p. 350. Here Binswanger quotes the German linguist Wilhelm von Humboldt (1767–1835): “Der Mensch ist nur << Mensch >> im Miteinander-Sprechen …”. Once again he quotes Humboldt in this connection in (1959), Sprache, Welt und Bildung—Sprachspiegel 3–4, p. 65: “Der Mensch ist nur Mensch durch Sprache; um aber die Sprache zu erfinden, musste er schon Mensch sein.”
From the APA DSM-5 Task Force, in collaboration with the APA Division of Research, the response was from Darrel Regier, Emily Kuhl, David Kupfer and James McNulty; from the National Institute of Mental Health, there was a response from Bruce Cuthbert and Thomas Insel. See Regier, Kuhl, Kupfer & McNulty, 2010; and Cuthbert & Insel, 2010.
From the WHO International Advisory Group for the Revision or ICD-10 the response came from Anne Lovell—writing, by the way, under her own name. See Lovell 2010.
In his lecture, Binswanger refers, by way of illustrating this aspect of descriptive psychopathology, to Bleuler’s Dementia Praecox oder Gruppe der Schizophrenien (1911) and calls the descriptive portions of it “das glänzendste Beispiel” of what he refers to as a descriptive psychopathology.
See Binswanger 1960, p. 20.
See Binswanger 1933, p. 1.
See Binswanger 1957, p. 66.
DSM-5, section III, pp. 733–737.
DSM-5, p. 13.
A. Frances (2013), Terug naar normaal [Back to Normal], pp. 81 and 82, and pp. 88 and 89.
J. van Os (2014), De DSM-5 voorbij [DSM-5 Is Done With], pp. 30–32.
L. Binswanger (1960), Melancholie und Mania, p. 79.
Ibid., p. 27: „Wenn sich die freie Möglichkeit in die Vergangenheit zurückzieht, besser gesagt, wenn die Retentio sich mit der Protentio verwechselt, …“.
With the term ‘Appräsentation’, Binswanger is referring to Husserl’s fifth Cartesian meditation (Hua I, 1950), § 49–58, and in particular to the intentionality of the experience of the other (Fremderfahrung), also called ‘Appräsentation mit dem Sinn alter ego. He defines ‘Appräsentation’ as what is needed for a physical presentation of the other, and what blends into oneness within the meaning of the experience of the strange, the experience of the alter ego.
Although Binswanger elaborates the time problem in psychiatry differently from Minkowski, we find that he greatly appreciates how his friend and colleague Eugène Minkowski treated this problem of time in psychiatry. His admiration for Minkowski’s work was without doubt significant. And the admiration was mutual: Binswanger admired Minkowski’s treatment of the Zeitproblem in psychiatry—see Melancholie und Mania, p. 38: “Die Art und Weise, wie Minkowski diese Grundthese auf seinen Kranken anwendet, ist heute noch lehreich und, ich möchte sagen, wegen ihrer Neuheit genial.” For his part, Minkowski (1933) admired Binswanger’s treatment of the Raumproblem in psychiatry—see Le temps vécu, p. 365, where, at the beginning of the chapter on the psychopathology of lived space (l’espace vécu), he writes: “Ici je me borne avant tout à contribution personnelle; mais je signale la remarquable mise au point de mon ami Ludwig Binswanger <<Das Raumproblem in der Psychopathologie …>>.”
P. 31, footnote 1.
P. 52, lines 27 and 28.
P. 52, lines 30 and 34.
Of course, Binswanger does not agree with a similar objection pursuant to Husserl’s doctrine of intentional consciousness; as he sees it, provided that the conditions of the phenomenological method of reduction and analysis of the essence are met, inferences from such research are indeed entirely generalisable.