Toward a Phenomenologically Orientated Psychiatry

Introduction

Over the last two decades there has been a renewed interest in the relevance of phenomenology to psychiatry. This essay aims to outline three distinct (though nevertheless interrelated) ways in which contemporary phenomenology has influenced the field of psychiatry.

I begin by briefly discussing the historical context in which contemporary phenomenological approaches are grounded, highlighting the work of Karl Jaspers on psychopathology and subsequently, the unintended consequences of attempts to operationalise descriptive psychopathology through DSM-III. This will also allow us to clarify important differences in the way in which the term ‘phenomenology’ is utilised in the literature. I then outline three ways in which phenomenology has influenced psychiatry over the last two decades. The first is that phenomenology offers a largely novel explanandum for psychiatry, through its emphasis on anomalies in the structure or form of conscious experience, in contrast with psychiatry’s more traditional focus on anomalies of content. I will illustrate this by appealing to the example of disturbances in ipseity in schizophrenia, drawing on work by Louis Sass, Josef Parnas and Dan Zahavi. The second, is that far from being simply a descriptive practice, phenomenology can generate new explanatory theories for psychiatry. Here, I give the example of phenomenologically informed explanations of deficits in intersubjectivity in autism, drawing on work of Thomas Fuchs and Shaun Gallagher. The third is that the phenomenology can provide a means to better understand and empathise with patients’ experiences. Here, I draw on Dan Ratcliffe’s notion of ‘radical empathy’ in the context of depression. I conclude that central to all three examples is a (previously overlooked) emphasis on anomalies in the form of conscious experience in patients with mental illness - that is, in the ‘modal space’ in which self, other and world are disclosed - and that this remains a pertinent area for future research.

Background

Key to psychiatry as both a medical discipline and a science is a comprehensive knowledge of the signs and symptoms that constitute its various disorders. Traditionally this has been termed ‘descriptive psychopathology’ and forms the basis of psychiatric nosology. Correctly identifying features of psychiatric disorders has obvious implications for both psychiatric research and clinical practice. In order to study neural correlates of particular phenomena, for example, we must first have a valid and reliable conceptualisation of the phenomena in question. In clinical practice, correctly identifying pathological phenomena forms the basis of diagnosis and guides treatment and prognosis.

Of great significance is that psychiatry’s object of study consists of the conscious, experiencing mind. This subjective element is notably missing from the objects of study in the natural sciences. The question arises as to how subjective experience can be studied from within the empirical positivist framework that has formed the basis of the natural sciences – or indeed whether it can at all? This dilemma was well recognised by Karl Jaspers at the beginning of the 20^th century, who was influenced by recent debates at the time (the ‘methodenstreit’) regarding whether psychology as a human science should utilise the same methodologies as the natural sciences. Influenced by Weber’s view of sociology as a hybrid discipline, Jaspers argued that psychopathology too had ‘a foot in both camps’, both as a natural science concerned with explaining the brain, but also as a human science concerned with understanding the meaning and experiences of its subjects (Thornton 2007, p92). Disheartened by what he perceived as ‘brain mythologists’, Jaspers emphasised the importance of not only ‘causal explanation’ but also of what he termed ‘static’ and ‘genetic’ understanding. The former (which he also termed phenomenology) refers to an empathic understanding of an individual’s subjective experience. The latter pertains to how different states can be meaningfully connected (Thornton 2007, pg96). The result was Jaspers’ landmark book ‘General Psychopathology’ which sought to systematically describe pathological experience (Jaspers 1997).

Despite Jaspers’ insights into the importance of subjective experience in mental disorder and the translation of his book into English in 1963, there was a significant shift away from whatever influence his phenomenological approach had gained in Anglo-American psychiatry from the 1970s onwards. This was following the introduction of the DSM-III which sought to operationalise psychopathology and diagnostic practice, influenced by positivist philosophers such as Hempel and in response to a worrying lack of diagnostic reliability either side of the Atlantic (Parnas and Zhavai 2002).

Although the operational approach was intended as a diagnostic guide to index disorders, there were unforeseen consequences, including overemphasis and reification of diagnostic criteria which were erroneously taken as comprehensive descriptions and resulted in a subsequent de-emphasis in psychiatric phenomenology with “classics in psychopathology…largely ignored” (Andreasen 2007). More recently, concerns regarding the DSM’s overemphasis on reliability at the cost of validity, has led to recent alternative nosologies of psychopathology (Cuthbert & Insel 2013, Kotov et al 2017). In addition, there has also been a renewed interest in what phenomenology might offer psychiatry.

Before we consider three contemporary phenomenological approaches in psychiatry, it is necessary to distinguish between different uses of the term. In mainstream psychiatry, as in Andreasen (2007), ‘phenomenology’ is often used to denote any form of descriptive psychopathology in terms of signs and symptoms from a “behaviouristic or common-sense point of view of how things appear” (Parnas and Sass 2008). Although Andreasen critiques the operationalisation of psychiatric diagnosis, she shares a fundamental assumption, namely that psychiatric phenomena are open to empirical description (and reduction) in the same way that other features of natural world are. Parnas & Zahavi (2002) note “in this framework, consciousness and subjective experience are treated on par with spatio-temporal objects of the natural world…”. The result is that the nature of subjective experience is largely ignored. This is in contrast with Jasperian phenomenology which requires a pluralistic approach, taking seriously the metaphysical challenges of explaining and understanding subjective experience. Despite his insights, Jaspers has been criticised as failing to explicate what his “alternative mode of phenomenological analysis” actually entailed (Parnas & Sass 2008). Contemporary scholars have drawn on the principles of continental phenomenologists such as Husserl, Merleau-Ponty and Heidegger to offer new insights for psychiatry. Although there are notable differences in concepts and methodologies, there remains a shared focus on the exploration of the structure of consciousness as experienced from the first-person perspective (Smith 2018). It is this use of ‘phenomenology’ to which I will refer.

1) Anomalies in form (over content) of experience as a psychiatric explanandum

Phenomenology is concerned with the structure of conscious experience, that is, it seeks to make explicit the necessary and invariant features, rather than to simply describe its content (Zahavi 2018, p44). In doing so, it affords the opportunity to consider what happens when these most basic shared background features change or breakdown and their relevance in the context of mental illness. Though this emphasis in form over content of experience was recognised by Jaspers (Jaspers 1997, pg58), it has largely been overlooked by traditional Anglo-American psychiatry.

Parnas and Zahavi (2002) present five central features of the structure consciousness; self-awareness, temporality, intentionality, embodiment and intersubjectivity. Each of these represents a basic and generally shared aspect of the form of subjective experience and therefore, a potential aspect that may be radically altered in certain circumstances, such as in mental illness. By recognising the medium through which self, other and world are experienced, as a topic of investigation in its own right, we are provided a new explanandum for psychiatry. Rather than discuss each of these in turn, I shall instead consider just one feature of consciousness - self-awareness - and discuss this in the context of ipseity disturbance in schizophrenia (Sass and Parnas 2003).

Central to conscious experience is its subjective quality. There is something it is like to experience the colour red, to be in pain or to feel sad. This also extends beyond perceptual and emotional states. Take for example, the qualitative difference between imagining and remembering an object. This what-it-is-likeness is sometimes termed ‘qualia’ (Tye 2021). Furthermore, experiences consist of something it-is-like for me. There is a sense of subjective selfhood to whom these experiences are happening – a ‘first-person-givenness’ of my experience (Parnas and Zahavi 2002). This represents a fundamental and tacit feature of experience as belonging to me. When I experience pain for example, I recognise this as my pain, without the need for inference or reflection on its status in relation to myself. Rather, the ‘mine-ness’ of an experience is built into the experience itself. This most basic form of self-awareness is termed ‘ipseity’ and is neatly articulated by Parnas and Zahavi (2002) - “To be aware of oneself is not to apprehend a pure self apart from the experience, but to be acquainted with an experience in its first personal mode of  presentation, that is, “from within”…The subject or self referred to is not something standing opposed to, or apart from or beyond experience, but rather a feature or function of its givenness”.

Sass & Parnas (2003) propose that a core feature of schizophrenia is a breakdown in the first-person-givenness of experience via a disturbance in ipseity, consisting of ‘hyperrexflexivity’ and ‘diminished self-affection’. These aspects are complementary, with the former referring to a heightened awareness of, and attention toward, what are ordinarily tacitly or passively experienced features consciousness and the latter, a “weakened sense of existing as a vital and self-coinciding source of awareness and action”. This results in what were previously basic, implicit, background features of selfhood being drawn into the spotlight of awareness and perceived as ‘other’, unrelated to self, as one would an object. At the same time there is a breakdown in the sense of ‘minimal-self’ typically associated with the first-person-givenness of experience. Consider for example, the phenomena of thought insertion whereby there is simultaneously an experience of one’s own thoughts as foreign and object-like accompanied a lack of any sense of one’s thoughts as my own.

By providing the example of ipseity disturbance in schizophrenia, I have attempted to illustrate how phenomenological inquiry into anomalies in the form of subjective experience represents an explanandum for psychiatry in its own right. It is important to highlight that such approaches, including that of Sass & Parnas (2003), are explicitly more than a descriptive endeavour but rather seek also to offer explanatory insights, in this case by offering a unifying account of positive, negative and disorganisational symptoms in schizophrenia. In this next section I will discuss how insights from phenomenology can influence and generate explanatory theories in more detail, by considering the notions of embodiment and intersubjectivity in social cognitive deficits in autism.

2) Phenomenologically informed explanations

It is well recognised that there are deficits in intersubjectivity in autistic individuals (Baron-Cohen 2008). Intersubjectivity refers to the relation between subjects and has been traditionally conceptualised as ‘the problem of other minds’ with two prominent responses, ‘Theory-Theory’ and ‘Simulation-Theory’ (Carruthers & Smith 1996). The issue at hand is, if the only mind I have direct access to is my own, how can I understand the intentional experiential states of others?

Theory-Theory utilises the ‘argument from analogy’, proposing that through observation of the external bodily states and behaviours of others, we infer mental states via comparisons with our own behaviours associated with our subjective experience in similar situations. For example, when I observe someone grimace, cry out and rub their foot, having stubbed their toe, I can infer they are experiencing pain based on a stored body of knowledge about my own experiences and associated behaviours in comparable situations. This process requires taking a theoretical stance and relies on an ability to generate a representational theory of mind (Hutto & Ravenscroft 2021).

In contrast, Simulation-Theory, argues that we often do not need to represent the minds of others to infer their intentionality, but can rather make use of our own minds to simulate what another person might be thinking. In other words, our own mind acts as the model (Goldman 2013). This is grounded in part in the discovery of mirror neurons which are activated both during one’s own intentional actions but also during the observation of intentional actions of others (Gallese et al 1996).

Both theories have been utilised to explain deficits in intersubjectivity commonly seen in autism and are supported by at least some empirical evidence. Theory-Theory hypothesises a dysfunctional theory of mind module in the brain (Baron-Cohen 1997) and is supported by evidence that autistic children often fail in standard false belief experiments compared to their peers (Baron-Cohen & Frith 1985). Simulation-Theory proposes that deficits in the simulation process may account for differences in intersubjectivity seen in autistic individuals, with some studies demonstrating under-activation mirror neurons (Sato et al 2013).

From a phenomenological standpoint, both theories are conceptually problematic. Theory-Theory has been criticised for being cognitively over-demanding and impractical for common day-to-day interactions (Gallagher 2004), too ‘representationally heavy’ (Hutto 2011) and in engaging in a circular argument, presupposing knowledge of the minds of others in the first instance, the very thing it sets out to explain (Zahavi 2018 p89). Simulation-Theory does not seem to be able to account for the observation that when we experience the mental states of others, we do so as distinct from our own subjective experiences. This ability to differentiate empathic access to others’ experiences from our own experience is essential, as Zahavi (2018, p93) points out (citing Husserl) “had the consciousness of the other been given to me in the same way, the other would cease being an other and would instead become part of myself”. Common to both theories is the assumption that the mind is fundamentally enclosed and isolated from the experiences of others, making impossible to experience the minds of others directly. The framing of the problem in this way rests on a Cartesian split between ‘internal mind’ and ‘external body’. In contrast, phenomenological approaches emphasise “…we can experience the other directedly as a minded being, as a being whose bodily gestures and actions are expressive of his or her experiences or states of mind” (Zahavi 2018, p94).

Central to a phenomenological account of intersubjectivity is that the mind is embodied and also embedded in a shared context (Fuchs 2015, Gallagher & Varga 2015). Importantly, on this view, experiences are not simply private and enclosed but rather are expressed outwardly through our gestures, facial expressions and actions. Merleau-Ponty recognises this through his notion of ‘intercorporeality’ stating, “In perceiving the other, my body and his are coupled, resulting in a sort of action which pairs them. This conduct which I am able only to see, I live somehow from a distance. I make it mine; I recover it or comprehend it. Reciprocally I know that the gestures I make myself can be the objects of another’s intention” (Merleau-Ponty 1964). Direct access to the other’s lived-body allows for a feedback loop of bodily action and perception between two subjects, without requiring mindreading or mentalization and is supported by work in developmental psychology which emphasises the role of ‘primary intersubjectivity’ in social cognition at the early stages of development (Trevarthen 1979).

Both Fuchs (2015) and Gallagher & Varga (2015) draw upon these insights to offer an alternative explanation of social cognition and associated deficits in autism, in which abnormalities in primary intersubjectivity are fundamental, both developmentally and in adult life. At the heart of their argument is that children with autism display deficits in primary intersubjectivity in the form of motor-sensory integration impairments, in their first few years of life (before theory of mind impairments should appear around the age of 4). This includes “postural instabilities, atypical gait, mistiming of motor sequences, motor coordination problems” and so on (Gallagher & Varga 2015). It is argued that deficits in primary intersubjectivity as well as secondary and tertiary levels such as “imitation and affect attunement” and problems in “situational coherence” (Fuchs 2015) best account for social-cognitive impairments seen in autism, rather than deficits in theory of mind or simulation.

Whether or not such an approach is superior will largely be borne out empirically. The point is that phenomenological approaches can generate new hypothesises and testable theories.

3) Radical empathy in psychopathology

A third implication of phenomenology for psychiatry is its ability to help facilitate an empathic understanding toward patients. Despite his emphasis on the importance of understanding, Jaspers conceded that some aspects of mental disorder were beyond the reach of empathic understanding and ultimately un-understandable (Jaspers 1997 p96). Ratcliffe (2012) however offers a way in which we might expand our empathic abilities, at least in some circumstances.

At the outset, he distinguishes between what he terms ‘mundane empathy’ and ‘radical empathy’. Broadly speaking, mundane empathy refers to the kinds of empathy we utilise in day-to-day life. He discusses this in the context of both theory-theory and simulation-theory and arrives at a ‘hybrid-theory’ to account for mundane empathy, whereby we may use explicit or implicit simulation “but in the context of a distinctive kind of attitude towards the person” in order to gain an understanding of their subjective states. Whether or not mundane empathy would be better encapsulated by the more phenomenologically informed approaches of Gallagher and Fuchs outlined in the previous section is not something Ratcliffe addresses, however this does not detract from the main thrust of his argument, which is to use the limits of mundane empathy as a point of contrast with radical empathy, which undoubtedly would require the kinds of higher level cognitive capacities not envisioned by Gallagher and Fuchs (see below).

The important aspect of mundane empathy is that it falsely assumes a shared medium or ‘modal space’ through which the world discloses itself to us. In other words when empathising, we typically “interpret other people’s experiences against the backdrop of [an assumed] shared world” (Ratcliffe 2012). Mundane empathy can fail, when we fail to consider there may be a different kind of difference at play, that is a difference in the form in which worldly objects are given to us in the first instance, even if their content is broadly the same. By way of analogy, consider observing two equally matched athletes swimming 50 meters as fast as they can. The first swimmer, Bill, finishes in less than 30 seconds whereas the second swimmer, Tim, (who for our purposes is in a separate pool) takes a dismal 20 minutes. At first this appears difficult to comprehend – both athletes are of similar skill, both trying their best, neither was injured and so on. Why was there such a difference? We can only make sense of this situation if we investigate more thoroughly and discover that Tim in fact was swimming through a viscous jelly that merely appeared as water and hence slowed him down. This difference in medium was something we hadn’t even considered could have been different and hence why the situation remained incomprehensible.

The un-understandability of some experiences then, for Ratcliffe, can occur in mundane empathy because we fail to employ a more explicit, cognitively demanding, ‘radical empathy’ - the starting point of which is recognising that there may be differences in the most basic, taken-for-granted ways in which the world presents itself in the structure of subjective experience between individuals in the first place. This assumption of a shared modal space is what Husserl refers to as the ‘natural attitude’. But in what ways might these differences manifest and how can one engage in radical empathy to ‘get at’ them?

Building on Husserl’s phenomenology, Ratcliffe (2012) argues that “the experience of belonging to the world is not a matter of having a belief-like intentional state with the content ‘the world exists’, rather it involves having a sense of reality…a grasp of the distinction between ‘real’, ‘present’ and other possibilities, without which one could not encounter anything as ‘there’ or more generally, as ‘real’”. Here, he means taking something to be the case – the cup on my desk as real and present, for example, in contrast to as imagined or as remembered – entails specific features of the structure of the experience itself – what Husserl terms a ‘horizonal structure’. To appreciate what it means for something to be ‘there’, is to experience a ‘space of possibilities’ within the ‘structural horizon’ associated with that perception. The cup is disclosed to us as something that intrinsically possesses a variety of possibilities: that it can be viewed from another angle, that it can be grasped. That it can be moved or rotated. It appears as something that can be interacted and engaged with toward our own ends, for example drank from. It might appear as inducing ‘affective’ qualities, the desire for the taste of bitter coffee or in my case, repulsion at the sight of mould! It is this intrinsic ‘space of possibilities’ that is assumed to be unanimous in mundane empathy. To radically empathise we must actively take a ‘phenomenological stance’ whereby we attempt to ‘bracket’ or suspend this ‘natural attitude’ which erroneously takes the ‘structural horizon’ for granted and seek to consider the ways the space of possibilities can become distorted.

Ratcliffe considers how radical empathy can help understand experiences of depression. His quote of a patient’s experience illustrates the point nicely. “It became impossible to reach anything…if the essential thing that we mean by chair, something that lets us sit down…something that shares our life in that way, has lost the quality of being able to do that?”. Hopefully, here, the distinction between mundane and radical empathy becomes clear. The patient evidently understands what a chair is for, he perceives it as real, yet it is somehow ‘different’. On the surface it seems incomprehensible how this can be the case in a shared modal space. On the other hand, once we recognise it is the patient’s space of possibilities itself that has altered or transformed to the extent that everyday objects no longer afford the same actions or carry the same meaning, we are able to glean some understanding.

Such an approach has obvious clinical implications in enhancing the doctor’s understanding of the nature of her patient’s distress, developing the patient-doctor relationship and in approaches to treatment such as providing a focus for psychotherapy.

Conclusion

In this essay I have attempted to demonstrate three ways phenomenology has influenced psychiatry. The first is that by a more in-depth interrogation of subjective experience, it can offer a novel set of explananda for psychiatry in terms of anomalies in the structure or form of experience, an area which has largely been overlooked in Anglo-American psychiatry. The second is that far from simply a descriptive exercise, the phenomenological approach can generate new explanatory theories that can be empirically tested. Lastly, the phenomenological stance can provide a ‘way in’ to better understand and empathise with patients’ experiences that may have previously been considered un-understandable.

Central to all three is the phenomenologically informed insight that some mental disorders may be constituted, at least in part, not just by differences in the content of experience but by differences in the way in which that content is presented subjectively to that individual – that is, the very medium or form of their experiences – the ‘modal space’. The first example considers anomalies in the way the self is disclosed in form of ipseity disturbance in schizophrenia. The second presents anomalies in how others are disclosed through deficits in intersubjectivity in autism. The third addresses anomalies in the disclosure of world through a narrowing or transformation of the ‘space of possibilities’ in depression.

Each example, however, is not wedded to the section in which it was presented. Ratcliffe’s ‘horizon of possibilities’ also offers a rich description of the way in which experiences can break down and could provide the basis for novel theories or explanatory accounts. Similarly, Sass et al provide a means to employ Ratcliffe’s radical empathy to better understand schizophrenic experiences. As such, future phenomenological work could mutually benefit from investigating the various anomalies in the form of experience, that is, in the way self, other and world are disclosed subjectively across different disorders, generating new testable theories and utilising these insights to enhance the clinician’s empathic understanding of their patients’ illness.

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