Whereas the first generation of phenomenological psychiatrists was critical of the objectifying and reifying attitude of biological psychiatry, the second generation expanded the scope of their criticism to also target institutional structures and societal issues and was particularly concerned with the marginalization of the mentally ill.
Consider first the case of R.D. Laing (1927–1989). In his work, Laing was not only drawing on the contributions of earlier generations of phenomenological psychiatrists such as Boss, Binswanger, and in particular Minkowski, whose work Laing praised as “the first serious attempt in psychiatry to reconstruct the other person’s lived experience” and as “the first figure in psychiatry to bring the nature of phenomenological investigation clearly into view.”Footnote 13 Laing also engaged with the philosophical work of figures such as Husserl, Heidegger, Schutz, Merleau-Ponty and in particular Sartre. He co-authored a book on Sartre, and Laing’s early book The Divided Self was at the time of its publication in 1960 one of the most accessible introductions to phenomenological ideas in English.Footnote 14
Laing describes his own efforts as both a type of social phenomenology and as a form of existential phenomenology. It is an attempt to study “inter-experience,” i.e., the origins of experience in relation, as well as to “characterize the nature of a person’s experience of his world and himself.”Footnote 15 One of the aims of existential psychiatry is to “discard any preoccupations which prevent one seeing the individual patient in the light of his own existence.”Footnote 16 In fact, and here Laing is very close to Minkowski, the aim is not simply to describe particular experiences, but rather to situate these experiences within the context of the patient’s whole being-in-the-world. And as Laing adds, the “mad things said and done by the schizophrenic will remain essentially a closed book if one does not understand their existential context.”Footnote 17
To think that one can somehow obtain a better understanding of another person by translating a personal-level understanding into the impersonal terms of a sequence or system of it-processes, is for Laing nothing but an illusion.Footnote 18 Just as one will never find consciousness by looking through a microscope at brain cells, one will never find persons by studying them as though they were mere objects.Footnote 19 In fact, the idea that an unbiased scientific understanding of the other requires one to be objective in the sense of depersonalizing the person into an “object” of study is a fallacy that has nothing to do with proper science.Footnote 20
Persons are centers of experience and origins of actions that exist in social fields of reciprocal influence and interaction. We are not self-contained monads but are constantly interacting with others. Our interaction can be validating, confirming, enhancing, but it can also be invalidating, undermining, and constricting. Indeed, the fact that others can play a destructive role follows from our very interdependence.Footnote 21 One way to objectify and dehumanize the other is by invalidating the other’s experiences, by labelling them as mad and abnormal, by treating the other as an object-to-be-changed, as someone bereft of agency, as someone who is invaded and controlled by destructive psychopathological mechanisms.Footnote 22 But as Laing then remarks “[P]eople who experience themselves as automata, as robots, as bits of machinery, or even as animals... are rightly regarded as crazy. Yet why do we not regard a theory that seeks to transmute persons into automata or animals as equally crazy?”Footnote 23
If we are to understand schizophrenia, we need, according to Laing, to consider “the whole social context in which the psychiatric ceremonial is being conducted.”Footnote 24 Laing does not deny the existence of schizophrenia, but as he writes, the
label is a social fact and the social fact a political event. This political event, occurring in the civic order of society, imposes definitions and consequences on the labelled person. It is a social prescription that rationalizes a set of social actions whereby the labelled person is annexed by others, who are legally sanctioned, medically empowered, and morally obliged, to become responsible for the person labelled.Footnote 25
Laing further claims that the person labelled as insane and forcibly admitted to a mental institution is invalidated as a human being in a more complete and radical manner than anywhere else in society.Footnote 26
Laing’s ideas gradually moved him from advocating a more humane psychiatry to questioning the very basis of psychiatry itself. Although he personally disowned the label “anti-psychiatry,” his ideas came to provide the intellectual bedrock for the anti-psychiatric movement.Footnote 27 Even after the decline of the anti-psychiatric movement, Laing’s ideas continued to be influential in the user movements and came to play a role in the development of therapeutic communities that sought to involve the patients in decision making.
For Laing, a self-critical psychiatrist should recognize to what extent the psychiatric examination and the very classification of a person as a psychiatric patient is an exercise of control and power.Footnote 28 To look and to listen to a patient and to see “signs” of schizophrenia (as a “disease”) and to look and to listen to him simply as a human being are to see and to hear in two radically different ways.Footnote 29 In the context of therapy, existential phenomenology is the attempt to reconstruct the patient’s way of being himself in his world, and in order for that to happen, the psychiatrist must have the plasticity to transpose himself into a strange and alien view of the world, only thus can one arrive at an understanding of the patient’s existential position.Footnote 30 Laing is consequently calling for the psychiatrist to employ empathy and put her own “personality into play.” Something he repeatedly faults Kraepelin for not having done.Footnote 31
One book often referenced by Laing is Erving Goffman’s Asylums. Essays on the Social Situation of Mental Patients and Other Inmates. Goffman’s book was published in 1961, the same year as Foucault’s Madness and Civilization. Both theorists share much common ground in their focus on how closed disciplinary organizations shape the identity and self-perceptions of the inmates. But whereas Foucault considered how pervasive systems of thought influenced and enabled concrete practices, Goffman focused on microstudies of the concrete encounters between specific individuals.Footnote 32
Goffman (1922–1982) was not trained as a phenomenologist. He was a sociologist who had graduated from the University of Chicago and who belonged to the tradition of symbolic interactionism inaugurated by G. H. Mead. But Goffman’s approach was early on described as phenomenological by other sociologists (e.g., Parson 1968), and the fact that his focus was very much on the communicative exchange and face-to-face interaction between embodied individuals who share time and space together makes it natural to compare his work to that of Schutz, who is indeed the phenomenological thinker most explicitly and extensively discussed by Goffman.Footnote 33
Asylums is a participant-observational study of the mental patients at the St. Elizabeth’s Hospital in Washington, DC. This was the largest mental hospital in the US, and the very institution where Walter Freeman a few years earlier had started practicing his “transorbital lobotomy,” where steel instruments resembling icepicks were hammered into the brain of the patient through the eye socket; a procedure that Freeman eventually promoted as a cure for serious mental illness, chronic pain, insomnia, and nervous indigestion. Posing as an employee of the hospital for a year, Goffman offers a detailed ethnographic study of the patients’ social life. The hospital is, to use Goffman’s term, a total institution. It is an all-encompassing institution where the normal structures and compartmentalization of daily life have been abolished. Work, recreation, and sleep are all conducted at the same place following a tightly regulated schedule under constant supervision.Footnote 34 Focusing in particular on the effects of coercion and control, Goffman depicts the mental hospital as a thoroughly authoritarian system where the patients through processes of humiliation, deprivation, and abuse are stripped of their identity, dignity and self-esteem and forced to “engage in activity whose symbolic implications are incompatible with” their pre-existing conception of self.Footnote 35
Although Goffman did not explicitly propose public policy changes in his study, the book became an important source of reference for critics of psychiatric practice and led to modifications of treatment programs through its citation in legal briefs and judge’s rulings.Footnote 36 As Weinstein recounts, Asylums was cited in a number of cases at the federal level that established precedents for mental health policy. One of the cases, Wyatt v. Aderholt was a landmark case in the patients’ right movement and granted the patients right to privacy, the right to have visitors, to live in humane physical environments and have individualized treatment plans.Footnote 37
Goffman was subsequently criticized for focusing too much on the hospital as a place for the social control of the deviant and abnormal, and for overlooking its therapeutic and rehabilitative goals, but more than any other work by a social scientist, it was Goffman’s book that “sensitized psychiatrists and public officials to the antitherapeutic consequences of hospital treatment, the negative effects of labelling on patients’ sense of self-worth, and the loss or curtailment of legal rights resulting from institutionalization.”Footnote 38
Less known than Laing and Goffman, but ultimately far more influential when it came to policy change was the Italian psychiatrist Franco Basaglia (1924–1980). Drawing directly on phenomenology in his theory and practice, he was to give name to what became known as the Basaglia Law, which many consider the most radical mental health legislation ever passed.
After having graduated in medicine in 1949, Basaglia continued studying philosophy and psychiatry, and became increasingly attracted by phenomenological philosophy and by the classical tradition of phenomenological psychiatry. He was particularly inspired by the work of Husserl, Minkowski, Binswanger and by Sartre, whom he met on several occasions. Basaglia considered himself a phenomenologist, and roughly a third of his collected works deal with the application of phenomenology to psychiatry.Footnote 39
In 1961, the same year that saw the publication of not only Goffman’s Asylums and Foucault’s Madness and Civilization but also of Fanon’s Wretched of the Earth—books that Basaglia was thoroughly familiar with, indeed it was Basaglia’s wife Franca Ongaro who translated Asylums into Italian—Basaglia left his university position in Padua and took up the directorship of the mental asylum in Gorizia, where he would remain until 1968. In contrast to the university clinics and the private clinics where research was conducted and psychotherapy performed, the Italian public psychiatry at that time operated under an outdated and heavily stigmatizing mental health legislation. The main function of the mental asylums, which at that time contained almost 100.000 inmates, was to lock away patients considered a danger to themselves or to society. Once inside the asylums, the patients were stripped of their civil rights and the decision on whether and when to release them was entirely up to the director of the asylum.Footnote 40
The asylum in the city of Gorizia, which is situated on the Italian border with Slovenia, contained cages for unruly patients, barred windows, high walls and fences, and the primary “therapy” on offer was electroconvulsive therapy and insulin shock therapy. Many of the patients had been there for years with no prospect of release.
In many ways, the asylum that Basaglia took control over exemplified a nightmarish version of the kind of total institution that Goffman had described; it confirmed his claim concerning its destructive power, and Basaglia was shocked to witness the inhuman treatment and social degradation that the patients were routinely subjected to.
One of Basaglia’s first decisions as new director was to limit the use of straitjackets and shock therapy. He also gradually removed fences, gates, and locks. Next, he set about to change the organizational dynamics of the asylum. He introduced a bar, a football pitch, televisions, radios, a hairdresser’s salon, and a library, and soon the patients also started to edit and produce their own magazine. In order to address the power relationship between the doctors and patients, Basaglia forbade the doctors to wear their anonymizing white coats, and most importantly, he introduced hospital-wide community meetings chaired by the patients, where they together with the social workers, nurses and doctors could decide on matters related to the daily life of the hospital.Footnote 41
Basaglia was fighting against the segregation and social exclusion of the mentally ill. He was well aware of the fact that phenomenological psychiatry had only changed institutional practices marginally, but phenomenological theorizing had a profound impact on Basaglia’s own practice.Footnote 42 In line with Minkowski, Basaglia was of the belief that it was possible to understand the patient’s experiential and existential situation, and he specifically referred to Husserl’s epoché when describing how one should engage with the patients.Footnote 43 Rather than seeing them through diagnostic categories, as schizophrenic or depressive, the psychiatrists should try to relate to and attend to the patients as unique individuals. To be able to do so, it was necessary with a bracketing of the diagnostic labels, with a suspension of the theoretical framework of psychiatry.Footnote 44 Only by performing a kind of epoché on the very notion of mental illness, only by suspending all the preconceived and stereotypical conceptions and expectations that one might have regarding the mentally ill, would it be possible to obtain some kind of comprehension of the patient’s being-in-the-world. Importantly, Basaglia was not out to deny the reality and existence of mental illness—as he remarked in a lecture given in Brazil in 1979, “Those who say that mental illness does not exist … are imbeciles”—but he argued that the violence of the asylum system was ultimately more dehumanizing and more destructive of the personal dignity of the patient than the illness itself.Footnote 45 In addition, he urged the psychiatrist to question his own role and the status of the science he represented, and he insisted that a proper assessment of the nature and cause of mental illness would have to include a critical look at the social, institutional, and political parameters.Footnote 46
Basaglia’s model of a care community, marked by principles of ethics and democracy, that was first attempted in Gorizia became an inspiration for change in many other psychiatric hospitals in Italy. It had a huge impact on public opinion and eventually also started influencing national law and policy. After Gorizia, Basaglia continued his efforts at the San Giovanni psychiatric hospital in Trieste. When he arrived in 1971, the hospital contained 1200 patients, 800 of which had been committed involuntarily. During the following years, massive changes were effectuated, the hospital grounds were opened to the surrounding city, new community mental health clinics were opened, the patients were permitted entry to the labor market, and, by 1977, only 130 patients continued to live on the premises.Footnote 47
In 1978, the Italian Parliament then passed Law 180, also known as the Basaglia Law. The law restored the constitutional rights to the mentally ill. Psychiatric patients were from now on to be considered patients like other patients. It contained directives for the abolishment of the entire Italian asylum system and demanded that all current and chronic patients should gradually be discharged and reintegrated into a whole range of community-based services. Acutely psychotic patients could still be hospitalized, but at small psychiatric wards in general hospitals and not in psychiatric hospitals.Footnote 48