International conference on Church Care for Mentally Ill People

Below are papers read at the International conference on Church Care for Mentally Ill People
November 13-14, 2018, Moscow (continuation)

The contribution of Phenomenology to a humane psychiatry with a human and Christian face

Dr. Maria Teresa Ferla

In every person, even when psychic disturbances become particularly intense and anguished, as in schizophrenia or melancholy (psychotic depression), areas of freedom remain.

"Every experience of psychic suffering is "an anthropological mystery". In psychic suffering, the anthropological texture of a person is even more transparent" (Kurt Schneider).

The fundamental structures of existence can be found in most exponents of phenomenological thought (Husserl and Heidegger), and have been codified in psychopathology by Karl Jaspers (Allgemeine Psychopatologie, 1913) and by Ludwig Binswanger (Zur phänomenologischen Anthropologie, 1947).

An important member of that school in Italy today is Eugenio Borgna (who I was lucky enough to have as my professor and guide from 1986 to 2000, while I worked at his side in the Psychiatry department of the Ospedale Maggiore in Novara).

Borgna's words document that even the most serious psychopathological disturbances are full of meaning, and witness that the fragility within which the ill person is immersed is not an absurd chasm but is instead a fully meaningful experience. The dimension of fragilita, indeed, is the existential dimension in which all humans live, whether in a ill or healthy state:

"Human fragility is a pillar of life: in the sign of the mystery surrounding us which makes us grasp only a part of what we glimpse within ourselves and others: mirrors that endlessly reflect dark images, which are not always decipherable, of the expressible and inexpressible, of anguish and hope, of the living and dying that is in each one of us" (Eugenio Borgna).

The heart and phenomenological psychopathology

The school of phenomenological psychopathology has opened up the narrow horizons of naturalistic or biological psychiatry, moving towards a conception of psychiatry as a human science which, within a global conception of man, finds within psychotic experience structures of sense and meaning which can ultimately be led back to human fundamental needs, to the very heart of man. It is thus possible to analyse the features of psychotic existence in an anthropological light: psychotic experience gains its own Gestalt, a form of life full of unity and meaning. Intuition is fundamental if one is to know and enter that reality, and those forms of life (Erlebnisse). Intuition is the phenomenological means of entering deep into the wounds of psychopathological experience: it is knowledge which is born from the heart, in the Pascalian sense.

In this regard, Maria Zambrano wrote: in the permanent culture of the heart, it does not burn like a fire but like a flame, a flame that does not generate pain but happiness. It is the light which lights up the path leading out of impossible difficulties, sweet light that offers comfort. In this same culture, the heart has wounds, which heal slowly and sometimes not at all: it could be said that these wounds never close because in a certain sense they are active, live wounds like those which constantly drip blood, preventing them from healing.

The transcultural anthropological elements to be found behind and within all symptoms and which are the foundation of the psychic world of the person are:

• the affective life, and in this the relational dynamics of primary relations (those with the paternal or maternal figures)
• the experience of being rooted somewhere, of belonging and identity;
• the experience of the lived physical body;
• the experience of time and space;
• language and communication (language as the house of being);
• the experience of memory and remembering;
• the experience of death and dying;
• the experience of blame;
• the experience of hope.

To get to know the person who is suffering and is entrusted to our care, it is fundamental to discover these dimensions of his life. The trust that is born within a therapeutic relationship, while accompanying the person along the treatment path, opens the way to this cognitive experience, which interprets symptom-signs: in some way, this is already a way to heal the anguish and fear of madness as phenomena of non-sense, of the absurd. It is precisely this absurdity which is frightening, and unsettles not only us, the so-called healthy ones, or the relatives or people who live close to those who are immersed in this suffering, but above all to the person suffering.

Empathy is the other cognitive and therapeutic instrument which enables one to create a relationship of sharing which is rehabilitative as regards the healthy part which survives even in the most serious forms of psychosis. The relationship becomes a type of involvement which happens through the body but beyond the body; through but beyond the face; through silenсe, beyond silence, through lived time and space, and the discovery of the meaning of illness.

If one remains at a distance, merely observing, then one cannot even scratch the surface of the psychotic experience. In so far as we try to grasp not only what separates us but also what we have in common with the psychotic person, then it is possible to enter the realm of human nearness, and of the reciprocit? of the dialogic encounter with a "you" as Romano Guardini said and wrote.

The rationalistic reduction in psychiatry

Rationalistic reduction is seen as the biologicalistic and socio-genetic-sociological concept of psychic disturbances: both these reductions deny the persistence of this elementary experience, this nucleus within the person making the person unique and is the very foundation of personal freedom.

The biologicalistic or sociologistic reduction of human beings deny the persistence of this elementary experience, this nucleus within the person which cannot be separated from will and freedom. The most noble and complex human expressions, such as feelings, intelligence, will, conscience (defined by psychopathology as the human functions through which man expresses his freedom as a desire for infinity and the experience of the satisfaction of that desire) are, within the sociological paradigm, the unchangeable result of conditionings and conflicts which the person has undergone; according to the biologistic paradigm, on the other hand, they are the result of biochemical reactions within the brain, and cerebral synaptic interactions and mediations.

Within the organistic-biologistic model, under the umbrella of Kraepelin's Praecox Dementia, which was identified at the end of the 1800s, but which lives on in the widespread conception today of chronic Psychosis, the patient is also denied the dimension of possible change (being cured). Therapy is denied the possibility of making an encounter with another happen in any moment of one's life, which will give the patient the chance - the hope - of an authentic relationship, which can allow for the sharing of suffering and its lessening within the path of a healing relationship.

The psychic world of the person therefore represents a much vaster world, and in order to understand and describe it, one has to broaden the paradigms of knowledge and leave rationalism behind.

The biological-naturalistic model partially explains the physiological bases of psychic processes; on the other hand, the social model partially explains the influences, adaptive and defensive capacities that humans develop in relations. However, it is only with the anthropological-existential model that we can understand (in the sense of verstehen to understand, not erklären - to explain, as Jaspers puts it) the meaning and sense of the lived events and agitations of someone in a psychotic condition: the expressive and communicative modalities change, but the constitutive nucleus even of someone who is suffering is that of the research for meaning, happiness, freedom, justice.

Symptoms or signs?

There have been schools of thought, first of all the German one which tends towards the clinical, psychopathological-phenomenonlogical, which have tried to find and bring out a human reading of psychopathological phenomena which are considered by naturalistic, behaviouristic and cognitivistic psychiatry as being absurd or simple symptoms indicating an illness "of the brain".

Illnesses of the mind are not illnesses of the brain (the phenomenological thesis which overturns Wernick's thesis, which affirmed the exact opposite).

The corner-stone which makes human beings human is the conscience (as Brentano and Dilthey have defined it, and above all Kurt Schneider, who brought it to light in psychopathology).

Of course, what is meant here is not the state of conscience (which would move us into neurology or neuropathology), but the I's conscience in the complex structure which Kurt Schneider discerned, and which has founded all psychopathology of psychotic experiences since.

When, as in psychotic experiences, the state of conscience is shown to be intact (in other words, there are no compromises at a neurological or biological level), psychopathological phenomena gain a dignity and significance which find their (psycho) origin in the unfolding of life, its primary relations, and the building up of the fundamental dynamics of relational and communicative life between the self and the world. They are therefore signs which need to be read and interpreted within the global context of an existence.

These patients' freedom can be seen within their own histories (anamnesis), examining them like a canvas against the light, rereading desires and acts and decisions in which it is possible to discern will and freedom. Certainly, one often sees the fear to desire, fear of one's own will, omissions and suspension of actions because of blocks and affective cohartations which depend on a state of anguish, the splitting of the I, deep depression or experiences of depersonalization or extraneousness to the point of delirium.

The experience of delirium needs to be seen as a radical set-back in communication in which the meanings of things, situations, events are radically "other" than what is commonly shared.

In delirium the capacity to trust caves in: everything is read within the figure of self-referentiality, in which the I is dominated by the extraneousness and hostility that the other represents with regard to oneself, one's goods and own life.

Reconstructing delirium from a psychogenetic point of view enables one to rediscover within the person's life moments and experiences which have generated such diffidence and such a closed attitude to the world: first of all, stories of betrayal, abandonment can be found within primary (parent) relations which determine the crisis of trust to the point of hostility (paranoia) towards everything and everyone. In delirium, there is a defensive and compensatory attempt to fill an emptiness which has been left by radical loneliness, and to reconstruct meanings which can piece back together the fragmentation into which the I has plunged.

In the same way one can understand hallucinations, in which listening (to voices), touching and seeing are different ways of communicating in which, since there is no-one other from the self with whom one can set up a relationship, an alternative relationship, a hallucinatory one, is built up.

Hallucinations can represent the last, distorted and desperate attempt to communicate through the perceptive organs (sight, hearing, touch) when all other communicative experiences have been destroyed. The hallucinatory world (that of voices) thus becomes the only space of relational exchange of which the I may become a victim, or else carry out in a passive way. More often hallucinations are interwoven with the world of delirium, colouring its contents with elements of ruin, persecution, guilt, greatness. Moreover, delirium can express the unsuccessful processing of the experience of guilt which is an anthropological characteristic that each person has to face and live. Projecting guilt outside oneself, on others who are close (family members or flatmates) or far (extraterrestrial beings or secret police) represents the most simplistic way of throwing outside oneself the weight and anguish which the guilt, if it is not worked out (or rather, forgiven) can generate: it is not necessary for particular events or situations to have taken place as regards guiltiness. It can be enough just to have the feeling that one has not been able to transmit and communicate affection, thanking: an act that did not succeed, an omission to the point of a thought believed to be have deleterious and devastating effects because of its harmful content. What has not come about is the experience of guilt within an affective relationship that forgives and relaunches.

"It is a sort of delirium of man's will… to find oneself guilty and reprovable to the point of the impossibility of expiation" (Nietzsche)

The experiences of the alteration of the I's conscience, which are the most serious conditions, can be read as the failure to reach the definition of one's self, of one's history, one's origins and identity (which may lead to the atrocious doubt or conviction that one is not what one thinks one has always been) or the failed definition of relations between oneself and the outside world, which remain marked by pathological links such as symbiosis in which the expressiveness of the I never manages to emerge as distinct and autonomous. The extent to which affective dynamics within the family act on this alteration has been well demonstrated by many psychologists of the family with regard to the pathological role played by symbiotic relations in the genesis of schizophrenic psychosis.

Freedom and responsibility

If this is the way psychopathological phenomena are conceived, then, clearly, also the desires and acts performed by those who live psychopathological experiences (even the most serious) must be analysed as an expression of people who can and want to answer for their own will and their acts like any other person; only exceptionally are they devastated and changed beyond recognition in these capacities.

It is not by chance that it is not so much the clinical but the legal expert who evaluates such capacities: they must be described with an extra specificity, i.e. with a special reading that also analyses the patient's judicial law awareness as well as their awareness of the illness in a broad sense.

There are particular psychotic conditions which, because of the total loss of contact with the world (schizophrenic autism) or because of the pervasiveness of persecutory delirious experience (which invades every area of one's experience) or because of the devastating experience of guilt become evidently dangerous or at least extremely aggressive.

This type of psychotic experience compromises "intention" and "will", alienating the ill person, towards whom it is necessary to set up "protection" of the patient's and others' rights, starting from the right to exist and let others exist.

These serious psychopathological experiences therefore require "assertive" methods, in which the loss of the patient's freedom is juxtaposed with the carer's taking on of the responsibility, even making use of ways of containing possible repeated dangerous acts.

That said, and recognizing that there are specific, partial or total compromising conditions of the ability to understand and will, and therefore of the liability of the patient, the principle of liability, responsibility and accountability of the psychic patient as regards illegal acts remains intact.

The need to be guilty (according to the book by Stangerup) is a need common to everyone, even to people who are ill: in it one can recognize the ultimate need to expiate guilt, to be redeemed, forgiven, saved at the start, once and for all, but also each time, in our specific and repeated faults and errors.

Conclusion

It is the reasons of the Pascalian, Schelerian heart which allow us to know in psychiatry too, the interior life, interiority without which the various expressions of psychic suffering are banalized and emptied of meaning.

Psychopathological experiences are manifestations of communication disturbances (in the heart-rending nostalgia for this dialogue which is our destiny).

Only if we approach a person affected slightly or drastically by psychic suffering, with an immediate openness to dialogue, and with the love of which we are capable (in the sense of modus amoris of Binswanger), can there be the hope that the other person reveals to us what is in their heart and memory, allowing us to glimpse the secret correlations of his or her suffering, pain, desperation and interior wounds.

The boundless regions of the heart and soul lie in the depths of every life: psychotic or non-psychotic.

This psychiatry is like a raft sailing against the current created by to the luxury cruise ship on which the dominant psychiatry of today travels: that of drugs and indifference to dialogue.

Our raft travels towards the mysterious path of suffering, listening to it and interpreting its secret resonances, which are invisibile to the cartesian eyes of reason, but recognizable by the reasons of the heart.

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