How psychiatrists think - On Heidegger’s phenomenological approach and the scientific method

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How psychiatrists think

On Heidegger’s phenomenological app roach and the scientific method

S.A. Velleman, 1 Ph. Wuyts 2

ABSTRACT

Psychiatrists nowadays are often torn between two distinctive ideologies. With the field of

neuroscience rapidly growing, the understanding of the basic principle mechanisms of the

functioning of the human brain in general and in the event of pathological processes is

steadily increasing. For more and more complex questions that are dealt with in clinical

psychiatry, scientific explanations can be delivered. However, it appears that with this strong

emergence of a natural scientific way that is used to formulate and resolve mental illness, the

narrative approach slowly loses ground. The anti-reductionist movement argues that the

human mind is autonomous and that its fundamental characteristics cannot just be determined

within a framework that was developed to explain the laws that constitute the natural world,

opposing against a strict operationalistic approach of mental illness and defending a more

‘human’ alternative .

1 University of Antwerp, Belgium2 Division of Psychosis, Institute of Psychiatry, Ki ng’s College University London, UK



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How can psychiatrists confidently unite a narrative approach and first person perspective with

lower-level explanations of the natural sciences that constitute its physical core? We argue

that this question and its practical implications has become more tangible than ever before.

In this article we try to look beyond the current dichotomy and attempt to advocate for

Psychiatry as a unitas multiplex . We proclaim that both the scientific method and the

phenomenological approach contribute essentially to the practice of Psychiatry. Heidegger’s

Zollikon Seminars will serve to develop this methodological consciousness.

KEY WORDS Zollikon Seminars, methodological consciousness, phenomenology,

philosophy of psychiatry.



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INTRODUCTION

‘First, our thoughtful attention is directed toward the unique and distinctive character of

modern science. Second, it is directed toward the way of questioning, seeing, and saying of

phenomenology in the broadest sense. Third, it is directed toward the relationship between

science and phenomenology.’ (Heidegger 2001, 96)

Psychiatrists are experiencing an identity crisis. In medical school, they are predominantly

teached to approach illness from a natural scientific point of view, based on knowledge that

has been obtained through empirical research in several fields of science, e.g. anatomy,

physiology, pharmacology, epidemiology, etc. In clinical practice however, focus lies not just

on ‘the disease’ carried by the individual as the individual himself, his ‘suffering ’ and his

considerations of ‘being ill’ come into balance. These aspects fail to be addressed when using

a strictly natural scientific explanatory model.

The subjective interpretation and meaning of the suffering caused by the disorder to the

patient as a person force doctors to address illness not just as the dysfunction of a bodily

organ or system, but as a matter of consideration from an embodied self perspective,

demanding a holistic approach and intervention that can only be meaningful in the setting of a

therapeutic relationship between doctor and patient.



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Two Psychiatries?

Even though the interface problem is clearly not limited to clinical practice in Psychiatry,

we proclaim that it is especially relevant in this domain. This is probably due to the less

satisfactory natural scientific explanatory models of mental disorders and to the abundant

historical attempts to explain mental illness from human scientific perspective (that also

contributed to its moral connotations and stigma). The parallel background of modern

psychiatry – her affiliation with both the natural and the human sciences - has currently led to

the creation of two ‘Psychiatries’: a biological Psychiatry, mainly based on empirically

gathered evidence from neurobiological research, and a more philosophical Psychiatry

(psychodynamic, phenomenological ,…) with its fundaments in the continental European

philosophical tradition of understanding and conceptualizing mental illness, predominantly

focussing on the narrative character of the individual ‘ being ill ’ (Luhrman 2000). The entire

history of psychiatry is characterised by the alternating dominance of either one of these two

approaches. According to the National Institutes of Health we find ourselves nowadays in an

extremely biological phase, baptized as ‘the decade of the brain’ and characterized by a n

increased interest in the neurosciences (Fulford e.a. 2006). This general trend has been

interpreted as a reaction against the predominant position of the psycho-analytical theory in

psychiatry during the second half of the twentieth century (Kendler 2005).



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Is this identity crisis of a permanent nature? Will psychiatrists be forced to commute

between a Psychiatry based on the neurosciences , were the prominent role of the human being

as a person is threatened (Gadamer 1996) , and a narrative Psychiatry based on the story of the

patient, proclaimed ‘unscientific’ ?

The Methodenstreit between natural and human scientists (Fulford e.a. 2006) has led to the

clarification of their respective conceptual foundations. We consider it time however to

investigate whether and how it would be possible to think of psychiatry as a discipline based

on both perspectives. In this article we explore the possibility of conceptualising psychiatry as

a unitas multiplex , where the difference between the two perspectives is not resolved , but

accepted as her conceptual foundations .

GENERAL OVERVI EW

Before focussing on the actual methods of current psychiatric practice, the general question of

‘method’ will be examined and placed within the broader context of the philosophy of

science. The concept of ‘science’ is investigated and the distinction between the natural and

the human sciences explored.

The scientific method is firstly discussed. Her exact nature is explored and the parallel is

drawn with clinical practice.

This is followed by a critique on science. ‘Critique […] means “to distinguish”, “to set off”.

Genuine critique is something other than criticizing in the sense of fault folding, blaming and



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complaining. Critique, as “to distinguish”, means to allow the different as such to be seen in

its difference” (ZS 76 -77). The distinction will be made between the psychiatrist as a person

and his or her use of the scientific method in clinical practice . Psychiatrists are more than

scientists alone and base themselves on more than just evidence in their clinical work.

The concept of ‘phenomenology’ will be clarified along the way and Heidegger’s Zollikon

Seminars will guide the discussion. Important themes within the context of this article are the

ontological difference between ‘being’ and ‘beings’, the distinction between ‘thoughtful

thinking’ and ‘calculative thinking’ and the relationship between both.

ON TH E METHODOLOGY OF PSYCHIATRY AND THE ORIGIN OF ‘SCIENCE’

The question concerning the conceptual foundations of Psychiatry comes down to the

question concerning her methodology. In order to evaluate the significance of empirical data

obtained through neuros cientific research in groups of ‘similar patients’ or of the first person

narrative of specific life events of the individual in need when treating a patient, it is

important to think about the more fundamental difference on how this information is obtained.

Inspired by the methodological dualism of Jaspers (Jaspers 1997), a distinction can be made

between the ‘scientific method ’ on the one hand – which aims at ’erklären ’ or the causal

explanation of empirical facts, and the ‘ phenomenological method ’ on the other hand – which

leads to ‘verstehen ’ or the meaningful understanding of the patient’s story.



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It is not evident to make this distinction in every day clinical practice. Medical practice with

its disease-focused approach is largely based on operationalistic criteria, firmly based on the

ruling methodology of the natural sciences. This puts the physician and especially the

psychiatrist in a paradox: How can he or she use a methodology deducted from the realm of

physics –the study of ‘inanimate nature’ (ZS 135) – when studying the human being as a

person? An alternative and complementary phenomenological perspective is posited to

provide the necessary alternative approach to the patient as an ‘existing human being’, which

is the core concern in Psychiatry.

Within continental philosophy, a consensus on the relationship between ‘verstehen ’ and

‘erklären ’ appears to be obtained: scientific explanation is – as are art and literature – one way

of interpreting oneself and the world. Every explanation is a form of understanding, while

there are other forms of understanding than causal explanation alone. Verstehen is a more

general concept than erklären, therefore we can speak of a foundational relationship between

both (Gadamer 1975).

The scientific method

“What is distinctive of our 19 th century is not the victory of science, but the victory of the

scientific method over science’ (ZS 128).



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The hypothetical-deductive model of science was first developed in physics but over time it

has established itself as the current standard model in other sciences as well, e.g. the

biological sciences. It can be summarized as followed (Popper 1960):

First, empirical data is observed and described . Subsequently, a hypothesis is formulated

from within a specific theoretical framework that explains the observed facts in order to

control a given situation . Based on this hypothesis, predictions are deduced and subsequently

tested on their tenability using quantifiable experiments . Finally, the validity of the hypothesis

is assessed by the amount of useful applications it creates.

However, it is generally acknowledged that information gathering never happens in a naïve

way, without the use of certain theoretical presuppositions. ‘Goethe stated that “The greatest

would be: to comprehend that all facts are already theory”’ (ZS 247). Furthermore does

Heidegger postulate that the search for a causal explanation and the subsequent ability to

create a controlled situation in the future lie at the heart of the scientific method. Everything

that can be investigated using this method will in principle be causally explainable and

controllable (ZS 104-105, 128, 134). ‘Only what is measurable is real’ : a scientific dogma

according to Heidegger (ZS 80). ‘Everything not exhibiting the characteristics of

mathematically determinable objectivity is eliminated as being uncertain, that is, untrue and

therefore unreal’ (ZS 107) and further in relation to the final statement of the model of

science: ‘Natural science’s entire truth consists in its effects’ (Z S 27)



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The scientific method in clinical practice

Similar to the logic of science (Popper 1960), the most common form of medical decision-

making is the hypothetical-deductive model (Sacket 1991). In current clinical psychiatric

practice, the psychiatrist will try to obtain information on three distinct categories on his

patient: biological, psychological and sociological. This biopsychosocial model was

developed at the end of the seventies to counterweight the at that time prevailing practice in

which mental problems were only described and explained from a biomedical scientific

perspective (Engel 1977). Subsequently, psychiatrists will describe their findings using the

terminology of a predetermined theoretical framework. Based on what they have learned

during their training, they look for a possible diagnosis that can serve as a hypothesis, which

explains the current state of affairs. Explanations are sought for in the above-mentioned fields

of research: biology, psychology and sociology. The present mental illness of the individual

will then be analysed and interpreted as a dynamic interplay of factors of physical,

psychological and social nature. In other words, the psychiatrist will try to translate the story

of the patient, told from a first person perspective, in terms of symptoms of a possible disease

defined in a biopsychosocial framework.

However, the search for causal explanations (by the use of science) and coming to a

meaningful understanding of the patient’s story (phenomenologically) belong to v astly



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different methodologies. The question now arises how this distinction can be defined and how

these two methodologies can be related to each other in a meaningful way?

According to Jaspers, the distinction can be made from the point of view of reason. (1986).

Jaspers – following Kant – distinguishes between rationality , the use of the scientific method,

and reason , putting factual information within a broader perspective. As such, a non-scientific

approach can still be reasonable. Phenomenology seems to be a good example of this.

An initial diagnosis is always a conjecture that has to be confirmed by further

investigations. Based on documented diseases, certain predictions are made and tested by

means of quantifiable experiments. In Psychiatry, brain scans and neuropsychology e.g. are

used to achieve this goal.

In accordance with the preferred diagnosis a treatment is started which has proven to be

effective for the given disorder. Arguments in favour of a specific treatment come mainly

from scientific research, preferably under the guise of placebo-controlled trials (Everitt &

Wessely 2004). This form of practice is called evidence-based . This is the current dominant

model in medicine and Psychiatry. The use of the scientific method in psychiatry has led to a

re-evaluation of this discipline within the field of medicine (Bracken & Thomas 2004).

Nowadays, psychiatrists use a variety of psychopharmacological and psychotherapeutical

means to fight illness and disease. Even though many advantages come with this approach, it

is important to show the limits of its application. ‘The more the current effect and usefulness

of science spread, the more the capacity and readiness for a reflection upon what occurs in

science disappears’ (ZS 94).



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The will to explain is characteristic for the scientific approach and is concerned with the

relationship between man (in this case the doctor) and things (in this case psychiatric

disorders). However, when using this strict scientific approach the ‘intermediary medium’ of

the patient, that is he/she that undergoes the disorder and symptoms, is absent in the

quotation. That is, the physician/psychiatrist treats the patient, not just the disorder. This

encounter, between a physician and his or her patient, concerns an entirely different

dimension: the communication between people in a situation that is meaningful to them. It is

generally acknowledged that this encounter has a powerful effect and brings a crucial element

to treatment (its effect on outcome often called placebo).

HEIDEGGER’S PHENOMENOLOGICAL APPROACH

The term ‘phenomenology’ is used in a variety of ways within psychiatric discourse.

Grosso modo, three different ways can be discerned. Phenomenology can be interpreted as the

objective description of signs and symptoms of psychiatric disorders by a neutral observer.

This notion of phenomenology is dominant in the Anglo-American literature. Phenomenology

can also be regarded as the description of subjective experience. Jaspers developed, in this

sense, a way to improve his understanding by collecting autobiographical data of his patients.

Finally, phenomenology refers to a school of thought within the field of philosophy that

emerged at the beginning of the twentieth century (Husserl). It is mainly in this last sense that

the term will be used here. We will focus on Heidegger’s understanding of phenomenology



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and its importance for clinical practice (Binswanger 1963; Boss 1979; Sass 1992; Bracken

1999; Meynen and Verburgt 2008).

Between 1959 and 1969 Heidegger gave a seminar to a group of residents in psychiatry.

The notes of these seminars, by Heidegger himself, appeared for the first time in print in 1987

under the name Zollikoner Seminare and were translated fourteen years later in English

(Heidegger 2001). He gave these seminars together with Boss, a renowned Swiss

psychoanalyst who had been an analysant of Freud’s over dozens of sessions in 1925 (ZS

308). The first session was given at the Burghölzli , the famous psychiatric clinic of the

University of Zürich. Because of the ‘technical’, cold atmosphere of the then recently

renovated auditorium, the seminar was moved to Zollikon, at Boss’s home (ZS xvii -xviii).

Heidegger gives an exceptionally clear overview of his ideas in these Zollikon Seminars and

they can therefore be read as an introduction to his work.

The ontological difference

‘The difference between being and beings’ – the ontological difference – ‘is the most

fundamental and difficult problem’ (ZS 17). It is fundamental because it works as a landmark

in H eidegger’s theory. It is a difficult distinction because it doesn’t rely on logic as a result of

which it remained hidden to rational thinking for a long time.

What is being – and why is the question of being so important? The answer to this question

cover s Heidegger’s collected works ( Gesamtausgabe ).



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Firstly, being is not ‘ a being ’ . A being is something that can be described, explained and

controlled by employing certain theoretical models. Based on the discussion of the scientific

method, one can argue that scientists occupy themselves mainly with the study of beings.

They can for instance measure the amount of dopamine in certain regions of the brain in a

patient with schizophrenia. Scientific research has shown that in patient with schizophrenia,

the amount of dopamine in the striatum is increased compared with healthy individuals. This

has causal consequences on the behaviour of the patient. However, this apparently causal

relationship can also manifest itself in the opposite direction: behaviour can have an influence

on the architecture of the brain (Baxter et.al. 1992). This is important because based on this

information, solutions can be sought for to correct abnormalities. The brain of man is ‘a

being ’ and beings can be the object of scientific resea rch. The ‘being’ of one particular person

however, is not ‘a being’; as such it requires a very different sort of approach. Here we

encounter the crux of contemporary psychiatry, namely the exact nature of the relationship

between the individual experience of the inner world and the brain.

Secondly, being must be understood in a verbal sense. ‘Being’ is a dynamic concept and

has a thoroughly pervasive quality, i.e. it is already pre-ontologically given. E.g. it has been

determined by scientific research that the brains of patients with schizophrenia demonstrate

abnormalities, however, the being-a-person of someone with schizophrenia cannot be

measured, cannot be determined on brain scans but can only be experienced (Gadamer 1996).

Scientific research and phenomenological investigations cover different dimensions,

respectively man seen as an object and as a person.





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must disregard all science’ (ZS 8). This is what Heidegger calls thoughtful thinking or

phenomenology .

‘What the phenomena, th at is, that which shows itself, require from us is only to see and

accept them as they show themselves’ (ZS 62). The doctor has to have an openness for the

patient as that what he or she is, namely a person . ‘Being -open to what is present is the

fundamenta l characteristic of being human’ (ZS 73).

Heidegger’s contribution to Psychiatry

Psychiatry is a medical discipline and the purpose of medicine is the alleviation of the

suffering of the human being in need, not the accumulation of knowledge on disorders of the

human body as a goal on its own. Calculative thinking is necessary and justified to improve

our knowledge of the human being as a physical being, which can be understood and

explained using the scientific method. However as human beings are not just physical beings,

we must remain careful, that the calculative way of thinking does not become the only

legitimate way of thinking . This does not mean a dismissal of scientific discourse.

‘By no means should our discussions be understood as hostile towa rd science. In no way is

science as such rejected. Merely its claim to absoluteness – that is, as the standard measure

for all true propositions – is warded of as an arrogant assumption’ (ZS 110). ‘There is no



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abandonment of science, but on the contrary, it means arriving at a thoughtful, knowing

relationship to science and truly think through its limitations’ (ZS 18).

Both the phenomenological approach and the scientific method are part of the identity of

the psychiatrist. As mental illness often affects thinking (including judgment), feeling and

experiencing of one’s self and the world and often goes accompanied with a diminished sense

of self and a change of the personality, a strictly technical scientific approach might induce

the impression to the patie nt that he/she is ‘ his/her mental disorder’ and seriously endanger

the doctor-patient relationship and compromise the outcome of treatment. As such, a

phenomenological approach is an indispensible part of being a psychiatrist. A

phenomenological attitude will guarantee a necessary awareness for and open-mindedness

towards the other as a person in need, undergoing a mental disorder, not being (reducible to) a

mental disorder.

As such and with regard to Heidegger’s critique, we proclaim to think of psychiatry as a

unitas multiplex. We suggest that it is reasonable to make the distinction between the

scientific method and the phenomenological approach. A human being can be approached

technically as a being, but this always needs to happen as just a part of the more general

stance of the being-a-person of the psychiatrist as well as of the patient. Thoughtful thinking

means that one is conscious of this.



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CONCLUSION

In this article we posit that over the last decades, with the emergence of neuroscience and

evidence based psychiatry, young psychiatrist feel often torn in between two distinct

ideologies: the one relying on knowledge obtained through the scientific method and the one,

focusing on the narrative character of the patient, with a more genuine interest and openness

for the individual story of the patient as a human-being, undergoing mental illness.

We defend a view where the discipline and practice of Psychiatry should be based on both

methodologies at the same time, i.e. Psychiatry as a unitas multiplex . The use of a scientific

discourse can be justified as a ‘medium’ to investigate and treat the illness of our patients, but

it should certainly not attempt to replace the essential holistic and human approach that

discriminates medicine and Psychiatry from the positive sciences and that make our

treatments so much more successful than one would otherwise expect. As such, the identity of

the psychiatrist is determined by knowledge and attention for both distinct methodologies.

Both serve a greater purpose, i.e. the alleviation of the suffering of the other.

By exploring Heidegger’s Zollikon Seminars, we have demonstrated the relevance of this

methodological consciousness in current practice in psychiatry. Heidegger liberates us from

an unnecessary dilemma of ideologies: Psychiatrists ought to employ the scientific method in

order to improve the lives of their patients; however, they will always have to be on their

guard to prevent their technical way of thinking of becoming a technical way of being .



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We proclaim that supporting any attempt to reduce the existential encounter between two

human beings into strict operationalistic criteria would be a disastrous mistake and that an

approach on all aspects of the encounter between two human beings should be the cornerstone

of clinical practice in Psychiatry, not just a narrow focus on the study of the brain or genes of

the Homo sapiens .



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How psychiatrists think - On Heidegger’s phenomenological approach and the scientific method