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From the Problem of the Nature of Psychosis to the Phenomenological Reform of Psychiatry. Historical and Epistemological Remarks on Ludwig Binswanger’s Psychiatric Project

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Medicine Studies

Abstract

This paper focuses on one of the original moments of the development of the “phenomenological” current of psychiatry, namely, the psychopathological research of Ludwig Binswanger. By means of the clinical and conceptual problem of schizophrenia as it was conceived and developed at the beginning of the twentieth century, I will try to outline and analyze Binswanger’s perspective from a both historical and epistemological point of view. Binswanger’s own way means of approaching and conceiving schizophrenia within the scientific, medical, and psychiatric context of that time will lead us to grasp the epistemological stakes at the origins of his project of reforming psychiatry by means of phenomenology. I will finally attempt to upgrade and update Binswanger’s project in light of the current reappraisal of phenomenology within the ongoing debate on psychopathology engaged by studies in the field of science and philosophy of mind.

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Notes

  1. Binswanger’s doctoral dissertation was focused on The Psychogalvanic Phenomenon in Association Experiments (Binswanger 19071908).

  2. At that time, Ludwig Binswanger was very interested in Freud’s theory (in his doctoral dissertation, there are several references to Freud’s Interpretation of Dreams, The Psychopathology of Everyday Life, and Fragments of an Analysis of a Case of Hysteria (cf. Binswanger 19071908). Thanks to Bleuler, at Burghölzli, Binswanger could meet some of the main exponents of the psychoanalytical movement in Switzerland, like Karl Abraham (1877–1925), Franz Riklin (1878–1938), Max Eitingon (1881–1943), and Herman Nunberg (1884–1970). Binswanger met Freud for the first time with Jung, in Vienna, in 1907. Freud had already known Binswanger’s uncle, Otto Binswanger, during the 1890s, and had already recommended the Bellevue to some of his own patients. Thenceforth, Ludwig Binswanger maintained with psychoanalysis a constant dialogue, which will initiated several encounters and discussions with Freud and his group. In 1909, for instance, he contributed to the first issue of the journal created by Freud and Bleuler, the Jahrbuch für psychoanalytische und psychopathologische Forschungen, with the analysis of a case of hysteria that he had treated by means of Freud’s method during his internship in Jena (Binswanger 1909). The articles and conferences he will draw up during the 1920s, and in part also during the 1930s, attest not only to Binswanger’s interest in Freud’s doctrine, but also to a personal relationship with Freud, a relationship that finds expression in a 30-year-long correspondence (Binswanger and Freud 1992).

  3. One of the reasons of the historical approach to Ludwig Binswanger’s work in Germany is the fact that in 1986 the archive material of the Bellevue—the sanatorium led over four generations by the Binswanger family—has been left to the archives of the University of Tübingen. After the publication of the monograph of Max Herzog in 1995 (Ludwig Binswanger und die Chronik des Klinik « Bellevue » in Kreuzlingen. Eine Psychiatrie in Lebensbildern, Berlin: Quintessenz), the University of Tübingen, in collaboration with the “Institut für Ethik und Geschichte der Medizin”, launched a project aiming to inventory and organize the archive, which is now open to researchers. Among the most recent works, see Moses and Hirschmüller (2004) (on the first generation of the sanatorium), and Akavia and Hirschmüller (2007).

  4. In this regard, it would be interesting to analyze the history of the ways in which psychiatrists, in the different European and non-European countries, received and developed the Daseinsanalyse’s program. It is a history that is strongly connected with the philosophical, social, and political involvements of psychiatry along its history. We could just mention, for instance, the way in which Binswanger’s thought was developed or exploited by the various “anti-psychiatric” movements during the 1960s and the 1970s. Regarding the present, we limit ourselves to mention, as institutional reference, the “Daseinsanalytisches Institut für Psychotherapie und Psychosomatik” in Zurich, which was promoted by Medard Boss (1903–1990), a psychiatrist who became acquainted with Ludwig Binswanger during the 1930s, and who later further developed Binswanger’s approach according to a theoretical direction closer to Heidegger’s philosophy. The Institute now directs the review of the “International Federation of Daseinsanalysis”: Daseinsanalyse. For a recent conceptual history of Daseinsanalyse, see Charbonneau (2010), and Cabestan and Dastur (2011), three authors who founded, in 1993, the “École Française de Daseinsanalyse,” a group that gathers together psychiatrists and philosophers.

  5. We just limit ourselves to mention here some of the most recent international studies: Courtine (1992), Herzog (1994), De Monticelli (1994), Passie (1995), Besoli (2006), Gros (2009).

  6. One should not forget that the most part of the works composed by Binswanger between 1910 and 1930 were published in such journals the “Zeitschrift für die gesamte Neurologie und Psychiatrie”, the “Monatsschrift für Psychiatrie und Neurologie”, or the “Schweizer Archiv für Neurologie und Psychiatrie”, which corresponded to the main feature of the European academic psychiatry of the time, according to which psychiatry and neurology were intimately interwoven. The first chair in psychiatry in Germany was created for Griesinger in Berlin in 1864. This was followed by the creation of associate or ordinary professorships in Göttingen in 1866, Zurich in 1869, Vienna in 1870 and 1875, Heidelberg and Leipzig in 1877 and Bonn in 1881. Only in 1906 did psychiatry become a recognized subject in the medical examination in Germany. Thus, in the second half of the century, psychiatric research moved increasingly from asylums to universities. (Hirschmüller, Whitrow 1999, p. 400). As regards psychiatry in Switzerland, historians have emphasized the strong influence of the German model during the second half of the nineteenth century (Ellenberger 1951; Walser 1971, 1972, 1976).

  7. The problematization of the “objectivity” of science, or the “scientificity” of knowledge, is currently on the agenda of the most recent studies in history and philosophy of sciences. According to the historical perspective of Lorraine Daston and Peter Galison—just to mention one of the most influential studies in this field—the science of nineteenth century struggled for an “objectivity,” which presented itself as a fight against “subjectivity.” Science was therefore intended as the search for empirical proofs, as the attempt at having access to nature’s law by means of “experience” intended as empirical observation (Daston and Galison 2007). It is a position, which is still strong in medical sciences and psychiatry at the beginning of the twentieth century, also in that innovative current of psychopathology that tried to leave room for the historical and subjective character of the psychopathological manifestations. It is worth recalling, in this regard, the arguments advanced by Bleuler and Jung in their defense of Freud’s theory, arguments that we are going to present below.

  8. In his Verteidigung und kritische Bemerkungen on psychoanalysis (1910), Bleuler answers point by point and with detailed references to the criticisms that many psychiatrists had addressed to Freud at the beginning of the century. This essay is therefore also quite interesting from a historical and bibliographical point of view.

  9. Also, Alphonse Maeder (1882–1971), another member of Bleuler’s group, in a French presentation of Freud’s theory in 1909, maintained that Bleuler and Jung had “demonstrated the existence and the pathogenic action [of Freud’s complexes] in dementia praecox” (Maeder 1909, p. 97).

  10. But also the Diagnostische Assoziationsstudien—whose subtitle was Beiträge zur experimentelle Psychopathologie—were considered by Jung as an experimental confirmation of Freud’s theory (Jung 1906–1910).

  11. The problem of the nature of schizophrenia was the main concern of psychiatry at the beginning of the twentieth century. The term “schizophrenia” was coined by Bleuler in 1911 in order to oppose Kraepelin’s negative model of dementia praecox with the idea of a positive configuration of the pathological. In effect, the nosological category of dementia praecox was intended by Kraepelin—in the sixth edition of his Lehrbuch der Psychiatrie (1899)—according to the models of, respectively, Antoine Laurent Jessé Bayle’s (1799–1858) general paralysis or “dementia paralytica” Bayle 1822 and Karl Ludwig Kahlbaum’s (1828–1899) catatonia (Kahlbaum 1874), namely, two pathological entities that had been analyzed from an organicist point of view and that had been clinically defined on the basis of their chronicity and fatal outcome. The first formulation of the term “dementia praecox" appeared under the French form of “démence précoce” in the second edition of the Traité des maladies mentales (1860) of the French psychiatrist Benedict-Augustin Morel (1809–1873). By this term, Morel intended a deterioration of the intellectual functions affecting young adults, and he inscribed this process within the context of the theory of “degeneration” (“dégénérescence”). The category of “démence précoce” was reformulated in the Latin form (“dementia praecox”) in 1891 by Arnold Pick (1851–1924), a Czech psychiatrist who described it as a chronic disorder quite similar to what Ewald Hecker (1843–1909) in 1871 had defined as “hebephrenia,” namely, a disorder occurring at puberty, which would begin by melancholy and whose terminal state would be an irreversible damage to the mental faculties. The dementia praecox was widely accepted thanks to the previously mentioned Lehrbuch by Kraepelin, in which the German psychiatrist grouped catatonia, hebephrenia, and paranoiac demence—which until then had been considered separately—in only one nosological entity. (Cf. Garrabé 1992; Berrios 1996).

  12. For a brief historical and bibliographical account on the history of the concept of psychosis, see Shepherd and Zangwill 1986 (pp. 39–40).

  13. According to Berrios, “as a result of the decline of classical nineteenth-century psychology, the conceptual foundation of descriptive psychopathology had become suspect and required buttressing. Phenomenology, with its emphasis on subjectivity and descriptivism, became the ideal partner. […] Jaspers’ youthful eloquence made it appear as if phenomenology had been put to work, at least on the concrete problem of describing and understanding symptoms. A comparison of the clinical meaning and usage of these symptoms before and after 1913 [the year in which the first edition of Jaspers’ General Psychopathology was published] shows, however, that the ‘phenomenological’ treatment did not alter them at all” (Berrios 1992, p. 321).

  14. For futher information about Bleuler’s reception of freud, see De Ridder and Corveleyn 1992; Hell and Baur 2006 and Dalzell 2007. cf also Hell et al. 2001; Scharfetter 2001.

  15. This expression corresponds in part to Michel Foucault’s concept of “epistemological model” or “epistemological configuration” (Foucault 1963, 1966), in that it refers epistemology not to the most evident level of knowledge (intended as “connaissance”), thesis and contents, but to its “unconscious,” that is the level which establishes what is “scientific” or not in a given epoch (“savoir”). From this perspective, it would be possible to explain how similar theses and theories could actually be grounded on different epistemological basis. Nevertheless, differently from Foucault, here I do not have the ambition to conclude that between two different epistemological frameworks there is a break. So I do not intend to maintain that Binswanger’s new criteria for scientificity would constitute an “epistemological break” as regards the psychiatric knowledge of his time. I would rather aim at showing that actually Binswanger’s phenomenological approach is strongly connected to some insights developed on the basis of that knowledge.

  16. Kierkegaard is actually one of the most constant references in all Binswanger’s work. Yet, in spite of such an imposing presence, the role of the Danish philosopher on Binswanger’s thought has been almost completely neglected by the critical literature. In this regard, I permit myself to refer to my recent paper on “Kierkegaard’s Influence on Binswanger’s Work” (Basso 2012).

  17. According to Heidegger, the “analytic” of the ontological (“existential”) structures of Dasein (“being-there”) is only the preliminary condition for approaching the “question of Being” (“Seinsfrage”), that is the problem of the “Fundamentalontologie”. In fact, Heidegger’s “Daseinsanalytik” is grounded on what he calls the “ontological difference” between Being and the ontic beings as “beings-at-hand” (“Vorhandensein”). This analytic should not be confused therefore with an “ontic” analysis and understanding of “man”, like the analysis given by psychology or psychiatry. This is why Heidegger will criticize Binswanger’s project of Daseinsanalyse, in particular during the philosophical seminars he delivered between 1959 and 1969 in Zurich (Heidegger 1987).

  18. see in particular Goldstein 1934; Weizsäcker 1940

  19. I believe this is the ethical core of the phenomenological approach of psychiatry, an ethics that cannot be separated from the epistemological reflection that motivates it. In other words, in philosophical psychiatry, philosophy does not shape psychiatry from the outside with precepts already given, but rather it takes the form of an epistemological reflection that cannot be separated from the concrete and historical medical knowledge that urges it and serves as a testing ground. It could be worth, in this respect, recalling the “philosophical biology” outlined by Georges Canguilhem (1904–1995) in his thesis on The Normal and the Pathological, whose ideas are also connected to Goldstein’s medical thinking. According to Canguilhem, “if we can speak of normal man as determined by the physiologist, it is because normative men exist for whom it is normal to break norms and establish new ones” (Canguilhem, 1972, 1989, pp. 164–165). That is why the concept of biological normativity, for humans, is in the last analysis an ethical concept (Debru 2011, p. 2). Now, interestingly, at this point, Canguilhem takes as an example the idea of pathological normativity as it had appeared in the field of existential psychopathology, thereby mentioning the insights of one of the most meaningful French psychiatrists of the first half of the last century, Eugène Minkowski (1885–1972): “The normal man is not a mean correlative to a social concept, it is not a judgment of reality but rather a judgment of value; it is a limiting notion which defines a being’s maximum psychic capacity. There is not upper limit to normality” (Canguilhem 1972, 1989, p. 119) cf. in particular Minkowski 1938. It is exactly on this basis that Canguilhem could conclude that, on these conditions, “we find it sufficient to replace ‘psychic’ with ‘physical’ in order to obtain a very correct definition of the concept of the normal which the physiology and medicine of organic disease use every day without caring enough to state its meaning precisely” (Ibid).

  20. Harrington’s expression: “reenchanted science” evokes explicitly Max Weber’s remark according to which a certain kind of mechanistic science had “disenchanted the world.” The main thesis of Harrington’s study is that in the early decades of the twentieth century, a part of German-speaking scientists, for instance the Gestalt’s psychologists, the neuropsychiatrist Kurt Goldstein, or some “life philosophers” such as Ludwig Klages—just to mention a few—“did not believe that the process of disenchantment through science was destined to continue. Instead, these men—biologists, neurologists, and psychologists—argued that a continuing commitment to responsible science was compatible with an ethical and existentially meaningful picture of human existence. […] These scientists argued, in varying ways, that a transformed biology and psychology—one that viewed phenomena less atomistically and more ‘hollistically’, less mechanistically and more ‘intuitively’—could lead to the rediscovery of a nurturing relationship with the natural world” (Harrington 1996, p. XVI).

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Basso, E. From the Problem of the Nature of Psychosis to the Phenomenological Reform of Psychiatry. Historical and Epistemological Remarks on Ludwig Binswanger’s Psychiatric Project. Medicine Studies 3, 215–232 (2012). https://doi.org/10.1007/s12376-012-0076-x

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