On the Use and Abuse of philosophy for psychiatry (and on the use of history)

1. Introduction

Contemporary psychiatry is in a paradoxical status. On the one hand, concern for, and denounce of, the hypertrophy of “the psychiatric” and the psychiatrisation of everyday life have grown exponentially. On the other hand, psychiatry itself, both as a discipline and as an institution, seems to be waning. After the closure of large asylums, the global expansion of a psychopharmacological market, with new subjects (such as GPs) competing with psychiatrists for prescription authority, and the alleged assimilation of “the psychic” into “the neuro”, psychiatry is unravelling in front of us. The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM), the bible of psychiatry, epitomises this shift of balance in a markedly neuro-biological and pharmacocentric direction. To its critics, this drive is bound to have dramatic repercussions on the status of the patient and the quality of psychiatric treatment. The reductionist paradigm embodied by the DSM, they argue, entails a depersonalisation and degradation of care, through the encouragement of increasingly concise and routinized clinical encounters, in turn leading to prompt but superficial diagnostic categorization and the almost exclusive recourse to pharmacological treatments, which is accused of shifting the balance to the cure of the symptom at the expense of the person^[1].

The most commonly proposed antidote against the reductionist poison seems to be philosophy^[2], whereby one can distinguish two means of “administration”. Philosophy can have a moderating function or a direct and active one.

In the first case philosophy’s task is to thematise, clarify and mediate different methods, value systems and concepts at use when it comes to (intra-/inter- and trans-)disciplinary conflicts and crises. In the second case, philosophy itself contributes to solving these conflicts and crises by questioning the adequacy of different psychiatric concepts and methods and introducing its own concepts and methods into psychiatry. Instead of describing and mediating the different assumptions about what the patient is within different psychiatric systems, philosophy might provide its own definition of the patient and of mental illness within a philosophical anthropology of personal experience and hereby influence the psychiatric practice^[3]. It is in this last capacity that philosophy would exert a most effective, if not revolutionary influence^[4].

The call to philosophy

The call to philosophy in rescue of psychiatry is not new^[5]. In the mid twentieth century Karl Jaspers (1883-1969) already warned that «the exclusion of philosophy would be disastrous for psychiatry»^[6]. This may be true. What is not granted, however, is that the inclusion of philosophy would automatically prevent the disaster. A brief historical review of some exponents of the so-called phenomenological and anthropological psychiatry, the most consistent example of an attempt to vivifying psychiatry by philosophy in the twentieth century, may help us to remember it^[7].

Of course, the following examples are not intended to be representative of the phenomenological-anthropological school. They should however at least challenge the common perception (the myth?) of a psychiatry effectively alternative to the institution, and essentially irreconcilable with invasive practices and violence, in short: with the disaster. «In the mysterious and disquieting realm of psychiatry (if one believes in the human value and sense of “madness”)», we were told, «no therapeutic violence is ever allowed. An anthropocentric psychiatry, which brackets with a radical epoché any value (or non-value) judgement on the categorial significance of “normality” and “metanormality”, is a psychiatry whose very nature is radically alternative to the institution»^[8].

To find such a profession of faith among adherents to the anthropological psychiatric school is neither surprising nor scandalous. It becomes however troubling when it affects historians, leading them to project the anthropological paradigm championed in scientific-philosophical works to the practices that were supposed to embody it.

Ludwig Binswanger (1988-1966), father of the Daseinsanalyse (existential analysis in the English rendering) is perfect case of this optical illusion, where philosophy and psychiatry are faultlessly matching. Not only the private clinic is depicted as psychiatry’s lost paradise, while he trustfully resorted to the entire therapeutic arsenal available at the time, from insulin choc to lobotomy^[9]. Every trace of compromising stances (such as the promotion of eugenics) has been whitewashed, philosophiae causa, from its curriculum^[10]. Binswanger’s case is almost textbook. The chosen cases epitomise the power of the myth of anthropo-phenomenological psychiatry equally well.

To call it a myth does not mean to impugn the salvific potential of philosophy for psychiatry. Our aim was rather to challenge the idea that philosophy would automatically or even necessarily prevent the disaster (which incidentally Jaspers never claimed, on the contrary^[11]), that a “philosophy-based psychiatry” is essentially a better one. Nor it suggests that philosophy as such is dangerous for psychiatry. To the contrary, the influence of anthropological psychiatry on the reforms of psychiatry in West- but also East-Germany^[12] and its general impact on important critics of psychiatry such as R.D. Laing (1927-1989), Franco Basaglia (1924-1980) or Michel Foucault (1926-1984) are some of many other proofs of philosophy’s emancipatory potential for psychiatry.

Between Imipramine and Heidegger: Roland Kuhn

A line-up on the relations between philosophy and psychiatry is bound to be opened by the character of Roland Kuhn (1912-2005), authoritative Daseinanalyse^[13], he is also known to have discovered the first anti-depressant (Imipramine). Kuhn’s drug-research is presently facing allegations of having been developed and tested on orphans^[14]. The local Swiss administration has recently nominated a commission to investigate on the allegations and clarify their objectivity, and until then one should stick to the presumption of innocence. Even leaving aside the allegations raised against his pharmacological research, we might ask what the role of the daseinsanalytical approach was in Kuhn’s therapeutic design^[15]. Kuhn combined the prescription of medication with a comprehensive diagnostic process thus limiting the prescription of antidepressants to major depression – a visionary position compared to today’s findings^[16]. The flipside of this coin, however, is that his interpretation of depression as an intrinsic feature of the patients’ being-in-the-world appears to be no less essentialist than its biological counterpart: disorientingly close to the endogenous concept of vital constitution it left little room for pathogenic factors outside the patient^[17].

In search for meaning: Viktor Frankl

The present debate on Kuhn’s persona shows how difficult it is to reconcile, even as a mere possibility, an overtly philosophical approach to mental illness with unethical scientific practices – almost as if philosophy immunized against them. The criticism recently raised by the historian Tymothy Pytell against on the Austro-Hungarian neurologist Viktor Frankl (1905-1997), the founder of logotherapy, may help us strengthen this point^[18].

Logotherapy, one of the most popular and widespread forms of existential and phenomenological analysis, is commonly presented as the product of Frankl’s philosophical elaboration of his own concentration camp experience, which would have led him to thematise the importance of finding meaning in all forms of existence, even the most inhuman ones. Pytell questioned this derivation, claiming that logotherapy had instead already been conceived in opposition to Freud’s materialism in the 1920 and then developed under the aegis of the Nazi-sponsored Goering institute from 1936 to 1937. Moreover, Pytell reports brain surgery experiments Frankl conducted in the early 1940s at the Rothschild hospital (a Jewish hospital under Nazi control), before being himself deported to Theresienstadt. These experiments involved attempts to revive Jews who had committed suicide in order to avoid deportation. Whereas others have seen in Frankl’s experiments a heroic effort to subvert the impact of the Nazi politics of extermination, Pytell claims these extreme measures were even consistent with Nazi policies^[19]. This of course was rejected as intrinsically incompatible not only with Frankl’s own experience (as a victim of Nazism) but also with his achievement as a humanist and philosopher^[20].

The logic of the fate: Hemmo Müller-Suur

Pytell’s denunciation of Frankl’s invasive intervention in someone’s will (which he reads as collaborationism) stand in stark contrast to the common critique moved against anthropological-existential approaches to mental illness: therapeutic laxity. The case which best epitomises this charge is certainly Ludwig Binswanger’s case of Ellen West^[21]. In what came to be considered the paradigmatic study of Daseinsanalyse^[22], Binswanger notoriously argued that Ellen West’s suicide was the «necessary fulfilment of the life-meaning of this existence»^[23]. His rationalisation; however, was anything but isolated. In his influential work on delusion Hemmo Müller-Suur (1911-2001) reports the case of a patient (Pest) suffering from delusional and compulsive thought-disorder (Denkstörung) and having being executed by a national-socialist court for paedophiliac sexual abuse^[24]. Müller-Suur’s extensive description of Pest’s experience gives proof of an intense and empathic therapeutic relationship. Müller-Suur conceives of the different psychopathological phenomena as coherent and meaningful parts of Pest’s personality. Referring to Jaspers’ Psychology of Weltanschauungen^[25] and Heidegger’s concepts of “Angst” and “Geworfenheit”^[26], he defined Pest’s personality as “anti-nomic” and refused to categorize his experience as a disease. But despite the proclaimed “existential communication”^[27] with Pest, Müller-Suur comments on Pest’s execution as follows: «Doesn’t this whole life story have a somewhat uncanny and diabolic sense? Is it not as if Pest was rushing ever more erringly and faster towards his predetermined fate?»^[28]. Considering that this “fate” consisted in the execution by a Nazi court one might rather, as Schödlbauer does, call Müller-Suurs use of philosophical concepts as fatal and defeatist^[29].

Conclusions

A common ground in our examples is the holistic approach to human experience. The discussed authors share the tendency to see the evolution of the patient’s experiential (prereflective) structure as an inevitable fate. Not only did they hereby cut their analysis off the social and political context but also off the patient herself, who in the final words of the existential understanding and analysis usually didn’t have much to say and often appears as the poor victim of her own experiences. Klaus Conrad’s (1905-1961) holistic concept of experience in schizophrenia best represents this tendency^[30]. We know that Conrad, a fervent supporter of the regime^[31], overtly refused the possibility that schizophrenia could be caused by an external, social event, relating the dynamics of schizophrenic experience to an endogenous biological process with little chance for psycho- or socio-therapeutic help^[32]. One may ask – and this is not a rhetorical question but a serious one – where the link is between anthropological psychiatry and Nazi politics^[33].

To conclude we would just like to remember that is precisely in the aspects of the social dimension of patients’-experience, user-involved research, and therapy, that today’s philosophy of psychiatry appears to be new and innovative. To give but a few examples: Louis Sass’ study on Madness and Modernism closely links schizophrenic experience to 20^th century avant-garde art and Zeitgeist^[34]. Others, like Thomas Fuchs^[35], Matthew Ratcliffe^[36] or Giovanni Stanghellini^[37] give cogent descriptions of the intersubjective and social constitution of psychopathological experience. Bracken and Thomas advocate a user-involved and -controlled research and practice in psychiatry and the aforementioned concept of value-based practice is centred around the psychiatry-user’s values. Finally, questions of therapy and recovery play an important role in contemporary philosophy of psychiatry^[38].

In short: It is not so much the question if there is or has been a philosophy of psychiatry but what kind of philosophy that was or should be. The history of this ambiguous alliance, we argue, should be taken into account by any attempt to found a genuinely “new philosophy of psychiatry”^[39].

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^[1] The fifth edition of the DSM (2013) raised so many criticism that it would be impossible here to do justice, if only roughly, to the different positions. See, by way of example, D. Healy. Pharmageddon, University of California Press, Berkeley 2012; M.A. Taylor, Hippocrates cried. The Decline of American Psychiatry, Oxford University Press, New York 2013; A. Frances, Saving Normal: An Insider Revolts Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life, Harper Collins, New York 2014.

^[2] The recent literature promoting a closer link between philosophy psychiatry is extremely ample. For a quite representative if not exhaustive summa see K. W. Fulford et al. (eds.), The Oxford Handbook of Philosophy and Psychiatry, Oxford University Press, Oxford 2007.

^[3] We borrowed the scheme from M. Heinze, C. Kukpe, Philosophie in der Psychiatrie, in «Nervenarzt», 77, 3, 2006, pp. 346–349.

^[4] K. W. Fulford, G. Stanghellini, M. Broome, What can philosophy do for psychiatry?, in «World Psychiatry», 3, 3, 2004, pp. 130–135; K. W. Fulford, G. Stanghellini, The Third Revolution: Philosophy Into Practice in Twenty-First Century Psychiatry, in «Dialogues Philos. Ment. Neuro Sci.», 1, 2008, pp. 5–14.

^[5] See D. Denys, How New is the New Philosophy of Psychiatry?, in «Philos. Ethics Humanit. Med.», 2, 22, 2007.

^[6] K. Jaspers, General Psychopathology (1946), transl. vol. II, London, The Johns Hopking University Press, Baltimore 1977, p. 529.

^[7] H. Spiegelberg, Phenomenology in Psychology and Psychiatry: A Historical Introduction, Northwestern University Press, Evanston 1972; A. Kraus, Phänomenologisch-anthropologische Psychiatrie, in H. Helmchen et al. (Eds.), Grundlagen der Psychiatrie, Springer, Berlin, Heidelberg 1999, pp. 578–603.

^[8] E. Borgna, Per una psichiatria fenomenologica, in U. Galimberti, Psichiatria e fenomenologia, Feltrinelli, Milano 1987, p. 23. Our italics.

^[9] C. Marazia, L’internamento dei grandi, in «Medicina e Storia», 2, 2005, pp. 75-92.

[10] Id., Philosophical whitewashing, in «Medizinhistorisches Journal», 46, 2011, pp. 134-154.

^[11] See K. Jaspers, op. cit.

^[12] S. Thoma, Phänomenologisch-anthropologische Sozialpsychiatrie – Wegmarken für eine theoretische Wiederbelebung, in «Psychiatr. Prax.», 39, 08, 2012, pp. 407–409; E. Kumbier et al., 50 Jahre Rodewischer Thesen - Zu den Anfängen sozialpsychiatrischer Reformen in der DDR, in «Psychiatr. Prax.», 40, 6, 2013, pp. 313–320.

^[13] The on-going edition of Roland Kuhn’s seminars gives a comprehensive impression of his philosophical training and his attempt to combine it with psychiatric theory and pratice : R. Kuhn, Münsterlinger Kolloquien, vol. 1-5, Königshausen & Neumann, Würzburg 2013-2015.

^[14] C. Kowalczyk, “Ich will ein Geständnis” - Medikamentenversuche an Kindern in der Schweiz, http://www.deutschlandfunk.de/psychopharmaka-ich-willein-gestaendnis.1247.de.html?dram:article_id=296524.

^[15] For Kuhn’s puzzling connection between psychiatric experience, aesthetics and pharmacological research see R. Kuhn, Psychiatrie mit Zukunft, Schwabe, Muttenz 2004, pp. 62-67.

^[16] I. Kirsch et al., Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration, in «PLoS Med», 5, 2, 2008, p. 45; S. Thoma, Rezension der “Münsterlinger Kolloquien” von Roland Kuhn und Anmerkungen zur aktuellen Debatte um seine Forschung, in «Sozialpsychiatrische Informationen», 46, 1, 2016, pp. 60-62.

^[17] R. Kuhn, Über kindliche Depressionen und ihre Behandlung, in «Schweiz. Med. Wochenschr.», 86-90, 1963, 93, pp. 1-15.

^[18] Pytell had already published some articles in the early 2000s. They were recolted and integrated in T. Pytell, Viktor Frankl: Das Ende eines Mythos?, Studienverlag, Innsbruck 2005. For the enlarged English version see T. Pytell, Viktor Frankl’s Search for Meaning. An Emblematic 20th Century Life, Barghan, New York, Oxford 2015.

^[19] Cit. especially chapter 6.

^[20] See, for instance: K. Biller, J.I. Levinson and T. Pytell, Viktor Frankl: Opposing Views, «Journal of Contemporary History», 37, 1, 2002, pp. 105-113.

[21] For an overview of the literature about this case see J. Schwarz, West, Ellen, Biographisches Archiv der Psychiatrie, in http://biapsy.de/index.php/de/9-biographien-a-z/211-west-ellen (accessed: 9 october 2015).

^[22] L. Binswanger, Der Fall Ellen West- eine anthropologisch-klinische Studie, in «Schweizer Archiv für Neurologie und Psychiatrie», (1944-1945). For the English translation see R. May et al. (eds), Existence. A New Dimension in Psychiatry and Psychology, Basic Books, New York 1958, pp. 237-364.

^[23] Ibid., p. 295.

^[24] H. Müller-Suur, Über Beziehungen und Unterschiede zwischen Zwang und Wahn, in «Z. für Gesamte Neurol. Psychiatr.», 177, 1, 1944, pp. 238–281; see also M. Schödlbauer, Wahnbegegnungen: Zungänge zur Paranoia, Psychiatrie Verlag, Köln 2016, pp. 326–329.

^[25] K. Jaspers, Psychologie der Weltanschauungen, Springer, Berlin 1919.

^[26] M. Heidegger, Sein und Zeit (1927), Niemeyer, Tübingen 1967.

^[27] H. Müller-Suur, op. cit., p. 279.

^[28] Ibid., p. 265.

^[29] M. Schödlbauer, op. cit., p. 328 ff.

^[30] K. Conrad, Die beginnende Schizophrenie: Versuch einer Gestaltanalyse des Wahnsinns (1958), Psychiatrie Verlag, Bonn 2010, is common reference for contemporary philosophy of psychiatry but also the foundation for new insights of recovery from schizophrenia (see J.E. Schlimme, B. Brückner, Entaktualisierung und Orthostrophe, in «Nervenarzt», 86, 7, 2015, pp. 872–883.

^[31] Conrad was a confidant (Vertrauensperson) of the national socialist association of lecturers (NS Dozentenbund) and member of the national socialist association of doctors and of the German Nazi-Party (NSDAP). See M. Sambale, Gestaltpsychologie in der Nervenheilkunde - Eine ideengeschichtliche Untersuchung anhand der Schriften Klaus Conrads, 34–44; see also M. Schödlbauer, op. cit., pp. 324–326.

^[32] K. Conrad, Gestaltanalyse und Daseinsanalytik. Zugleich Bemerkung zu dem voranstehenden Artikel “Problem der abnormen Krise” von C. Kulenkampff, in J. Zutt, E. Strauss (Eds.), Die Wahnwelten (Endogene Psychosen), Frankfurt a. M, Akademische Verlagsgesellschaft, 1963, pp. 288–301; C. Kuhlenkampff, Antwort auf die kritischen Bemerkungen K. Conrads zur Arbeit über das “Problem der abnormen Krise”, in J. Zutt, E. Strauss (Eds.), op. cit., pp. 302–311; C. Kuhlenkampff, K. Conrad, Schlußworte zur Diskussion über das “Problem der abnormen Krise”, in J. Zutt, E. Strauss (Eds.), op. cit, pp. 312–321.

[33] See, for this relationship G. Böhme, Rationalizing Unethical Medical Research: Taking Seriously the Case of Viktor von Weizsäcker, in W. R. Lafleur et al. (eds.), Dark Medicine, Rationalising Unethical Medical Research, Indiana University Press, Bloomington 2007, pp. 16-29. See also J. Meyer, R. Seidel, Die psychiatrischen Patienten im Nationalsozialismus, in Brennpunkte der Psychiatrie. Psychiatrie der Gegenwart, vol. 9, Springer, Heidelberg 1989, pp. 387-388.

^[34] L. A. Sass, Madness and modernism: insanity in the light of modern art, literature, and thought, BasicBooks, New York 1992.

^[35] T. Fuchs, Depression, Intercorporeality and Interaffectivity., in «J. Conscious. Stud.», 20, 7-8, 2013, pp. 219–238.

^[36] M. Ratcliffe Selfhood, Schizophrenia, and the Interpersonal Regulation of Experience (draft), in

https://www.academia.edu/13585253/Selfhood_Schizophrenia_and_the_Interpersonal_Regulation_of_Experience (Accessed: 10 december 2015).

^[37] G. Stanghellini, Disembodied Spirits and Deanimated Bodies: The Psychopathology of Common Sense, Oxford University Press, New York 2004.

^[38] J. E. Schlimme, M. A. Schwartz, In Recovery from Schizophrenia: Regaining Social Cover – A Phenomenological Investigation, in «Psychopathology», 46, 2, 2012, pp. 102–110.

^[39] N.F. Banner, T. Thornton, The new philosophy of psychiatry: its (recent) past, present and future: a review of the Oxford University Press series International Perspectives in Philosophy and Psychiatry, in «Philos. Ethics Humanit. Med.», 2, 9, 2007.