Should neurology and psychiatry merge?

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4 ottobre, 2012 - 11:27

A specter is haunting continental psychiatry, especially in Italy: the fear that psychiatry may be "swallowed up" by neurology. This fear has historical roots, because for a long time Italian psychiatry has been, in terms of teaching and research, a slave to neurology, within the channel of an archaic and reductive type of positivism.

Naturally, the situation can be different if we acknowledge that neurology and psychiatry share neuroscience as their foundational science.

For those of us who see phenomenological psychopathology as one of the pillars of psychiatry, the question could be put in these terms: What relationship can be established between phenomenological-eidetic and empirical research?

Some might be tempted to assert that there is no relationship at all between phenomenological-eidetic research, which attempts to reach the constitutive essence of phenomena, and empirical research, which compares data that can be reached objectively, except for the fact that psychiatry often uses both methods, consciously resigning itself to having to do a sort of epistemic "somersault." I shall try, on the other hand, to say that such a radical dichotomy is no longer tenable today, either on the plane of praxis or on that of theoretical premises.

The recent reprinting in Italy of an extensive and rich article by D. Cargnello (1999) on "The Ambiguity of Psychiatry," spurs all psychiatrists who try to be aware of the epistemic foundation of their thought and action to think about the dilemma of psychiatry that, Cargnello writes, "compels those who practice it to waver between having-something-in-front-of-them and being-with-somebody." Confronted with the apparent aporia of these two positions, one wants to reply: neither one nor the other, but both. Of course, it has to be reiterated, with Cargnello, that we must never "go past the limit of the critical distance that makes a person not somebody, but merely something." I would add that the practice of psychiatry is based precisely on this: on a continuous, unnatural modulation of the distance between therapeutist and patient, and that only extremely radical positions--for example, either constant identification or constant objectification--lead to opposite, impossible kinds of psychiatry. By saying this, perhaps we do nothing more than repeat what K. Jaspers has written in another key (1913, 1959): "What essentially characterizes the psychopathologist derives from the fact that he is dealing with human beings... The psychopathologist is bound to his own ability to see and experience inside himself, and to the breadth of his own horizon... Remaining impassible and being touched move hand in hand and cannot be opposed to each other, whereas cold, detached observation, by itself, does not see anything essential."

Jaspers's vibrant, and for every psychiatrist fundamental, precepts lie on a different plane: that of "subjective" phenomenology, which posits the precondition for psychopathology in the priority given to inner experiences, to their formal aspects (but, looking more closely, also to their recurrence as themes in the patient's life story) and the observer's move to understand them by understanding himself: the limit of the "comprehensible" thus becomes not a limit to psychopathological research, but a regulating element of it. "Die Natur erklaeren wir, das Seelenleben verstehen wir," Dilthey teaches us, even if today countless divides have opened up between the "sciences of nature" and the "sciences of the spirit."

In the meantime, the very term "objectification" of persons, which sounds like a moral condemnation, can have different meanings, such as the difference between objectification on the ethical and political plane and objectification on the plane of knowledge. I do not betray a person's subjectivity by putting some of his/her blood in a test tube, for example, to determine his/her lithium level; nor, by making a statistical study, for instance on the frequency of objectifiable characteristics by using the rating scales of H. Tellenbach's pre-melancholic typus (1974), do I fail to consider that "Nihil est praeter individuum," as the philosopher Roscellino pointed out in 1087. Besides, going beyond Jasperian psychopathology, as in the anthropophenomenology of Binswanger, Cargnello, Blankenburg, and other great scholars, means setting oneself on a plane where the dichotomy of comprehensible vs. incomprehensible inner psychotic experiences is never encountered; it means going beyond the effort to understand by means of identification (Einfuhlung), which is practically impossible without emotional participation, and aiming instead at throwing light, in the psychotic, on "what the 'world' that is his world is in essence" (D. Cargnello, 1999). As everybody knows, precisely this project of knowledge of the totality and essence of a human presence was, for K. Japsers, outside the sphere of scientific psychopathology.

Whatever the case may be, the psychopathology of Jaspers, Schneider, Huber, and many others has been and is the surest foundation of clinical psychiatry, compared, for example, with methods used today that neglect or underestimate subjective experience and that fail to listen, in their effort to pursue criteria that are as "objective" as possible. We do not know, on the other hand, if the anthropophenomenological manner of throwing light on the human presence will be fundamental for all of psychiatry or will remain "une glorieuse inutilité." (A. Tatossian, 1979, 1997).

In the meantime, as we wait for a problematic merger, must we, as it appears, live with the polyparadigmatic nature of the practice of psychiatry and observe, as C.H. Rumke does in his words quoted by Cargnello as proof of the psychiatrist's openness, that "il prend son bien où' il le trouve"? This statement seems to me more an expression of resignation than of openness to a merger between different branches of knowledge.

Besides, for someone like me, immersed from the very beginning in clinical psychiatry, a not negligible problem is what model of psychopathology can act as a base for determining and prescribing therapy with the right medicines and for helping to make them work as effectively as possible.

With regard to the relationship between the phenomenological and biological approach in psychiatry, I shall attempt to outline my opinion on their integration, which I feel is not only possible and useful but even inevitable, both in practice and in research, without letting this force us psychiatrists into the role of mountebanks of epistemology. To this end, my base will be the theory of knowledge that grew out of the rigorous investigation made by E. Husserl (1913) of facts and phenomena that manifest themselves in the consciousness in the course of knowing, and in particular to the epistemic model for which we are indebted to the thought of H.G. Gadamer (1993).

I maintain:

1) that once it is evident that psychiatric nosography is an unreliable companion not only for therapy but also for neuroscientific research (H.M. v. Praag 1993), the plane of reference that holds true is that of psychopathology and its trans-nosographic vocation;

2) that, on a more theoretical level, the old Dilthean divarication-opposition between "sciences of nature" and "sciences of the spirit," like Jaspers' opposition between Erklaren and Verstehen, has continually shown gaps and passages between them, and a cut-and-dried dichotomy is no longer sustainable, not only in the concrete acceptance of a person as patient, but precisely from the viewpoint of research, when it is kept in mind that a useful "methodological" reductionism is one thing, and an impossible "ontological" reductionism is another, one that seems to me quite distant from today's biological horizon;

4) that the indispensable plurality of research methods in psychiatry and their reference to diverse branches of specialized knowledge concerns the techniques utilized, but at the same time involves a unitary framework common to every branch of knowledge, which precisely because it is shared enables and renders necessary their integration, in a virtuous complementarity between phenomenological and empirical research.

In other words, our way of advancing towards knowledge implies in any case a "hermeneutical circle" (H.G. Gadamer) in which--whether the researcher is aware of it or not–there is a constant move and reference back and forth between generalized precognitions, or to call them by their name, "eidetic intuitions of essence," and their verification or refutation using the data produced by empirical research.

Psychiatry has always--we know--had multidimensional horizons of knowledge, and in the history of ideas strongly opposing theses have coexisted, such as J. Heinroth's (1818) idea that mental disturbances always derive from sins or stormy passions, or W. Griesinger's (1845) that psychoses can be associated in a linear manner with illnesses of the brain. It is also evident that the great fundamental theses of psychiatry are widely related to the world views in vogue at the time, in a succession of philosophical perspectives. Nonetheless, psychopathology is, above all, a method; it has no preconceived theory of the mind, and its methodological premises are openly declared. This is one more reason why it has claimed and claims to be a sort of common language, a basic "koiné" of the various psychiatric dialects. There is no lack of good reasons to maintain this, even if we cannot ignore the persistent difference between causal connections and connections of meaning. At any rate, searching for a typological arrangement of the structures of meaning and tending to identify psychopathological regulators on a higher level than symptomological fragments, psychopathology has pursued the attempt to found an objective science--in terms of rigor and communicability--of subjective phenomena, delineating the cogent integration between the "impersonal-biological" and the "individual-historical" dimensions in the concrete manifestation of mental disturbances and the concrete therapeutic approach to them.

In therapeutic practice, we continue to need psychopathology, in the particular phenomenological sense that derives from Jaspers. Since, if we neglect or underestimate the background texture of the psychopathology that makes the patient's lived experience the essential way to approach the patient, we are on the border not only of making arbitrary-conventional reifications, but also of losing the only solid basis for our pharmacological prescriptions. It could happen, moreover, that even adopting a less categorial and more dimensional psychiatry, the paradigm of reference for the prescription of drugs might come from a simply symptomatic diagnosis (perhaps transnosographic, given that it has been demonstrated that individual symptoms do not have diagnostic specificity), but without any concern for what overall structure of the patient is being expressed by the symptom, nor any consideration of the truly fundamental relationship--very often fluid and modifiable by therapy--between experience and its possible or impossible elaboration by the patient.

An essential point that psychopathology, in its various phenomenological declinations, has put forward is the centrality of the relationship between the person as a whole--if one will, the "spiritual" person in Scheler's sense (1950)--and the abnormal experiencing that can pervade him. The choice of therapy, whatever it may be, must take this too into account: the comparison between the person and the abnormal experience, or rather, abnormal because disproportionately prevalent; in more pragmatic terms, the relationship between "primary illness" and "coping." Binswanger's relationship between the "height" of experience and the "width" of the personological base is, I believe, the specifically anthropological matrix of the pathology of the psyche. All psychiatric phenomena, as manifested clinically, could be traced back to the vicissitudes of this relationship, and I suspect that it is essentially on this equilibrium that it can be made more rigid, but also fluid and dynamic, on this proportion-disproportion between experiencing and elaborating, that we can have an effect with our drugs.

There is no psychiatry, nor could there be, that does not feel the influence of some philosophical system, but a scientific enterprise should be attentive to the utmost to its epistemic foundation above all, to its own premises. The less we are critically aware of this foundation, the greater is our risk of being swallowed up in one of the dominant ideologies. Another temptation is that each psychiatry may feel self-sufficient and exhaustive, in the sense that underestimates or ignores her basic assumptions and pre-cognitive premises that are inevitably her base.

If this is true for every scientific enterprise, it is even more so for psychiatry, a sphere in which we confront and work with basic functions of the human being, the phenomenological study of which remains fundamental. Naturally, by "phenomenological" study I do not mean--as unfortunately some do--a simple list of symptoms or of fragments of behavior, but a study of lived experience (in Jaspers's sense), and also research, through the variation in the "eidos" and the search for essence (in the Husserlian sense), into how the person sees himself as a whole and projects his world.

Thus, phenomenology furnishes a method for describing states of mind, the psychic facts that these are--phenomena as phenomena and not as they are theorized or reified. This descriptive method is a tool on one hand for delineating and ordering psychopathological phenomena, and on the other it furnishes us the phenomenological-empirical material and describes the path that leads us to the "eidos" of phenomena, the general core characteristics belonging to all the possible examples of the class of objects considered.

Without such a global, essential eidetic insight inevitably preceding the observation of the parts and the collection of data, no knowledge is possible, neither everyday nor diagnostic knowledge, nor that of a project for research. Scientificness is guaranteed not by an impossible absence of general preconceptions and precognitions, but by awareness of the eidetic paths that have led us to our precognitions and willingness to change them if they should clash with the empirical data.

Phenomenological psychopathology, especially in its post-Schneiderian developments, offers devices of knowledge that can be mutually integrated with empirical, and in particular biological, research, avoiding a sterile reductionism, but also avoiding constructing, in opposition to a "mindless" psychiatry, a psychopathology bound to be forever "brainless." Phenomenological psychopathology holds that the phenomena it observes and brings out, starting from the inner experience of the person, besides being translatable into "symptoms," are "signals" that refer back to essential aspects of particular ways of being, subtended by particular ways the mind functions, which is not immaterial to neurobiological research.

Let us keep in mind that a fulcrum of Husserlian phenomenology of knowledge is the problem of the formation of general concepts through "eidetic variation", concepts that touch the essence, the eidos, of an object. Eidetic variation is a way of reasoning that is constantly implied in every scientific labor (M. Spitzer and F.A. Uehlein, 1992), in which we do not merely add data to data, which could, in any event, be meaningless, like the data accumulated by a powerful computer operated by a monkey, but we formulate--explicitly or implicitly--general concepts concerning the whole even before knowing the parts, and without which we would not know which data to add and which to leave out.

In short, while epistemologists say that an innocent eye does not exist, Luigi Pirandello had already written that "a fact is like a sack: it won't stand up unless you put something in it." This is what makes the claim of an a-theoretical research, untouched by basic assumptions and mental precognitions, so marvelously absurd. "Without the eidetic property, the object [and thus, I add, also the object of research] loses its identity," notes J.Z. Sadler (1992).

Far from keeping us from knowing, the general, overall, eidetic premises make us capable of seeing things as they are. The absence of precognitions, even if it could be achieved, would blind us to what is there to be seen.

We interpret events only against the background of presuppositions and preconceptions that are inevitable and necessary to the activity itself of knowing. By doing this, we move inside a "hermeneutic circle" where a global precognition, the fruit of eidetic research on the unvarying core attributes that indicate the essence of an object, is compared with the research on partial data, which in turn can modify the earlier view of the essence. "The (hermeneutic) circle," writes H.G. Gadamer (1986, 1996) must not be degraded as a vicious circle, nor should it be considered an inconvenience that cannot be eliminated. In it lies a positive possibility of the most originary knowledge..." "A comprehension directed with methodical conscientiousness should not only exert itself to realize what it has anticipated, but also to make it aware of itself in order to evaluate it," so that "the scientific topic is ensured by the things themselves," Gadamer continues.

This is not a recipe of a school of thought, but an adherence to the "facts" of experience, reaffirming--against abstract theses--the simple observation that to know is to intuit. The Husserlian "eidetic vision of essence" and the "categorial insight" are not sophisticated philosophical theorems, but the ways by which the intention to know is actually fulfilled in the consciousness. The distinction between "essence" and "fact" (in other words, between intuition of the essence and collection of information), while it can define the terrain of phenomenological research with regard to particular sciences, opens up to the methodological awareness that the empirical given, the object of empirical research, is not something ultimate, already fatally determined by precomprehension of the essence, but also something primary and fundamental, which cannot be left out in knowing and "which supports in turn every evident comprehension of essence," Gadamer goes on to point out.

We must not think--and this is one of the great lessons of phenomenology--that precomprehension has the negative connotation of prejudice. It has the sense of an overall judgment inevitably and intuitively anticipated. Bringing it to light and using it critically, which means the possibility of modifying it, are the royal road to knowledge.

Besides, this epistemic path has been applied, as we know, to the complex and even awkward problem of how the psychiatrist concretely makes a diagnosis, above and beyond what he/she may consider to be his criteria for choice, underlining the fundamental role, in diagnostic-nosographic knowledge as well, of the mental process that can be called "typification" (M.A. Schwartz and O.P. Wiggins, 1987), as an essentially pre-conceptual manner, formed, in any case, in his/her contact with experience. Here too, the circuit between overall intuition and observation of the parts is at play. And possible preconceptual errors can be corrected only by means of the data found, data that would nonetheless have no import on knowledge, no identity of meaning, without the general intuitive eidetic background that enables them to be discovered. A scientific attitude seems to consist precisely in this: in being aware of one's own preconceptions that shape the research plan and in not considering them to be absolutes.

Thus we return to the essential value of the "hermeneutic circle" in the process of knowledge. Whatever our point of departure or our specific competence and method of research may be, we are in that circle and we must necessarily reach a preconception (and phenomenology shows how), a preconception that is in reality a vision of the essence, an intuitive hypothesis of the general and unvarying characteristics of the object being studied, a vision that orients our knowing and our projects for research. We then need a knowledge and an empirical verification of the data (and biological research can teach us how), which have meaning in terms of the eidos of the phenomenon and are capable of telling us what they have to say, acting (retroacting) on it and modifying it, in an endless circularity.

How could we, for example, plan and carry out a neuroscientific study of the phenomenon of "hallucination" without having beforehand a preconception of what we call hallucination? How could we approach the problem of an eventual neurobiological specificity of the schizophrenic process and the vulnerability to it without taking into consideration the phenomenological studies of base symptoms and "sequences of transition" (G. Gross and G. Huber 1995), or views of essence indicated as "autism" or as "loss of natural evidence" (W. Blankenburg 1971)? How could we conduct an empirical-statistical study of the pre-melancholic personality without comparing it with phenomenological visions such as of the Tellenbachian typus (G. Stanghellini, C. Mundt 1997), etc.?

The problem is thus not to eliminate the hermeneutic circle between phenomenology and empiricism, which would be impossible, but to fit into it properly.

To be sure, we come from the old parable of Karl Jaspers, who said that the research of phenomenological psychopathology and somatic research in psychiatry are like the exploration of an unknown continent conducted by research expeditions who landed on different beaches and are separated by a distance so great that they will never meet. Today, however, we can update Jaspers' simile not only by correlating with more general structures that psychopathology has brought to light at a presymptomatic level, but also in the awareness of one sole paradigm of knowledge, one sole circuit that links phenomenological psychopathological research and empirical research, as neurological research is predominantly, against the background of a shared neuroscience.


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