On Existential Analysis

By ROLAND KUIIN, M.D.

MERICAN psychiatrists have frequently insisted that: "To be able to understand the theory of existential analysis we first will have to be

shown how such theory applies in actual therapy." This seems much tile same as if someone says: "Only after I have learned to make myself understood in a certain foreign language will I start studying its words and grammar." After all, it is not possible to build a bridge first and then do tile calculations to guarantee its firmness. These two comparisons have not been chosen at ran- dom. They are intended to convey an impression of the amount of effort needed on the part of anyone who would wish to come closer to an under- standing of Existential Analysis.

Ludwig Binswanger, the originator of the Existential Analytic Mode of Research and Work in Psychiatry, started out by working for nearly twenty years on the foundations necessary to carry out his intentions. The Existential Analytic Mode of Research is not an arbitrary system based upon one of many possible assumptions, whirls, with equal jnstification, could have been exchanged against one altogether different. It is a mode of research which in every science, by inner necessity, will have to be undertaken sooner or later. In our case, the investigations presently discussed originated within the concrete sciences of clinical psychiatry and Freud's psychoanalysis.

Sciences are, of course, not definite or final creations, immovable and established once and for all, but are constantly developing and changing. There are, however, two fundamentally different ways in which this may happen. One is the increasing illumination of a particular field of a science. Thus, as investigative results and their specific implications steadily grow in number, a greater number of scientific papers are written, and the books containing our knowledge grow more voluminous and the students must learn more. But there is a fundamentally different way in which movement in a given science may take place. During recent decades this latter way was found extremely fruitful especially in the field of physics. We refer to the investigative method of returning to the very foundations of a given science. In this way these foundations themselves again become unstable. This is achieved by focusing upon the almost invariably overlooked presup- positions of a science and by critically examining them as to their origin and meaning. Or to express it differently, we now reinvestigate the fundamental concepts upon which the science is built. Such is the meaning of existential analysis for both clinical psychiatry and psychoanalysis. In other words, ex- istential analysis is not a new branch of these established sciences nor is it an addition to their scientific methodology, developed to further the progress

Read at the Special Scientific Meeting "'Symp.osium on Psychiatric Therapies ir~ Europe'" of the Philadelphia Psychiatric Society on March 23, 1959.

Translated by Kurt Anstreicher.

62

ON EXISTENTIAL ANALYSIS 63

of these sciences and to broaden their results. The central problem of existential analysis is not a psychiatric or psychoanalytic theme, but the question what is psychiatry and what is psychoanalysis?

It is not an easy undertaking--we are only at the starting point and it is obvious that much work is still to be clone until a stage comparable with that of present-day physics can be reached. Of certain facts, however, we are sure: that we are not dealing with any adventure, with a hobby, with the useless complication of simple facts, or with arbitrary constructions, but on the contrary, that we are dealing with an absolutely necessary step forward, which psychiatry and psychoanalysis can avoid as little as modern physics has been able to ignore tile radical changes in its foundation. Although gener- ations may pass until we shall know what psychiatry and psychoanalysis as we know them today really are and mean, although it may not yet be possible to fully comprehend the meaning of existential analysis, the time will come when existential analysis will have been recognized as the first and most essential step within these sciences towards a critical study of their founda- tions.

Such reflective study requires not only careful selection of a principle and methods, but must obtain its direction from those sciences whose foundations are to be investigated. Edmund Husserls' "Phenomcnology" in particular provides existential analysis with a method. What does that mean? Psychiatry and psychoanalysis developed as medical sciences, which means that they operate with concepts like illness, symptoms, etiology, and therapy. Science then interconnects these concepts into a system. When a human being hears "voices," the psychiatrist recognizes the "symptom" of an "illness," which he calls "Schizophrenia." Phenomenology on the other hand is the method of "letting the things themselves speak." Its motto is "towards the things them- selves." Hallucinations then are not conceptualized as the symptom of an illness, but the question is asked what hallucinations as such mean, and what they indicate, "they" as such and not "scientifically" connected with the psychiatrist's system of concepts. Both psychiatrists and phenomenologists proceed from the same starting point, which is their sick fellow man. How- ever, while the phenomenologist and existential analyst remain with the fellow man, the psychiatrist will go on to the system, to disease, etiology and therapy. In the psychiatrists' case record the patient as a fellow man disappears behind case histories and progress reports, the description of symptoms, and other details of interest to the clinician. I must even state that the patient as a fellow man completely disappears behind single facts. Only facts are mentioned and discussed, not the sick human being. With these remarks I do not wish to criticize the method of the psychiatrist; since, in both psychiatry and psychoanalysis, such procedure may be necessary to achieve their common a im~tha t is, the recovery of the patient. The only purpose of the above statements is our intention to demonstrate that and how phenomenology is altogether different from clinical psychiatry and psycho- analysis. Through the careful study of Husserls' Logische Untersuchungen one may acquire the ability to examine phenomenologically. Without such

~4 ROLAND KUtlN

studies and such basic understanding it is impossible to understand pheno- menology and existential analysis. An introduction to the field is offered by Binswanger in the first of his collected Vortraege und Attfsaetze ("Lectures and Essays").

We have just distinguished between phenomenology and existential analy- sis. Such differentiation is necessary, and is based upon tile fact that existential analysis is built not only upon Husserls' Phenomenology, but also upon Martin Heidegger's Daseins Analytik. The scope of this paper does not permit a full discussion of all the problems involved; we only want to men- tion that the physician who wishes to practice existential analysis must also be entirely familiar with Martin Heidegger's book Sein ttnd Zeit.

As it is not possible in a few words to explain fully the orientation and approach to problems in existential analysis, you probably will want to learn at least something about the results of its careful and prolonged investigations. Though the findings are fundamentally the same for all forms of mental ill- ness, these can he demonstrated more readily with regard to schizophrenia than with neuroses and similar disorders. We start out with the meeting of the physician and one certain schizophrenic fellow man, and from what has been said so far it is obvious what we now will have to investigate. As exist- ential analysts, we ask for the presuppositions which the psychiatrist silently implies when he goes about to examine the patient psychiatrically in order to reach his goal, that is, to arrive at a diagnosis, and to start some therapy which he hopes will improve, if not cure, the patient.

What the psychiatrist takes for granted is that he and his patient will understand each other. He assumes that words will have tile same meaning whether used by the patient or by him and that tile patient will be willing and able to explain to him his normal and abnormal experiences.

For further illustration we shall choose an example: a middle-aged schizo- phrenic lady states she bears voices out of a teapot; the psychiatrist listens to this report and decides that she suffers from hallucinations. The patient re- fuses to accept this and gives various illustrations in support of her conclusion that her statements an d experiences were factual. The physician makes a diag- nosis of mental illness, of schizophrenia. If the patient comes to know this she will be angry and will decide that the physician lacks understanding of her. Quite logically the physician prescribes medication and the patient, just as logically from her point of view, does not take it. The physician has the patient committed to a hospital, medication is given by injection, tile pa- tient, who of course has other symptoms besides, improves and the physician therefore concludes that he has been right. The patient on the other hand, is still not grateful and feels just as misunderstood now as she did prior to treatment. From this, the physician concludes that she has not yet fully recovered.

How would the existential analyst, in this case, handle things differently from the psychiatrist? \Ve have learned that he searches for the silently over- looked presuppos!tions from which the psychiatrist proceeds as from some- thing self-evident. In our example such a presupposition is the assumption

ON EXISTENTIAL ANALYSIS ~5

that "'teapot" lneans tile same to patient and physician. This, however, is not correct.

The procedure of the existential analyst is the asking of questions; first of all, lie asks for the meaning of things, in our case, of the teapot and again firstly, for the meaning tile teapot has for all of us. We all know that a teapot is a household tool which is used for preparing and pouring tea. Moreover, the teapot may be meaningfid in various other connections. Thus, the teapot would have very definite meaning for all the laborers involved in making teapots, another meaning for the manufacturer who produces them anti still another one for the businessman who sells tllem. To the collector of antique china the teapot may mean esthetic pleasure or investment, but no longer represents an article to use, as it does to tlle housewife. But even for the housewife the teapot may prove meaningful in different ways, according to whether she uses it during a tea party, lmndles it doing her dishes, or uses it, not to prepare tea, but to water her flowers. All of the above describes the po.tentialities of a teapot. When asking for the potentialities of objects the existential analyst als0 finds that the potentialities of objects have limitations. For example, a teapot cannot be used for driving like an automobile, and similarly we do not hear voices come out of a teapot.

The next step for the existential analyst would now be to very carefidly question the patient as to what this hearing of voices out of the teapot is all about. What do the voices say and under what circumstances do they appeal'? Are they loud or soft, do they speak fast or slowly? Is it possible or not to recognize them as the voice of a certain person? How does the patient react to them? Do we deal with an acute or chronic state? Along these lines we ask questions anti first of all clarify phenomenologically the hearing of voices, as has been done very thoroughly by certain schools of psychopathology. "~Ve cannot discuss all this in detail, lint must be satisfied to learn that the patient hears voices out of the teapot net as we might hear voices simply from an adjoining room, but tlmt the teapot talks to her jnst as a hnman being and only a human being will talk to us.

Here the existential analyst continues his questioning and asks how it is possible that a teapot could talk. We have seen that the teapot receives its meaning from the role it plays for those who deal x~qth it. An article like a teapot is not a lifeless, dead obiect; on the contrary, all things interconnect according to their meaning for the lmman being and for the inter-relationship of human beings. If we all agree that the teapot is not something like a neighboring room, or an open door, or an open window from where or through which voices could be heard, then tiffs also is again due to the fact that for us the other human being's meaning is definite and his potentiali- ties lmve limitations. Hence it follows that the human voice (to refrain from considering certain teclmical measures which are of no meaning for our patient and which we therefore at this point can ignore) is bound to the presence of a Imman being and cannot, by itself, move into a teapot.

We therefore conclude that for our patient, who hears voices out of the teapot, teapot and fellow man are not the same as they are for the rest of

66 ROLAND K U t t N

us, and that other potentialities and limits of potentialities of objects and human beings have emerged. Here, the existential analyst goes on to ask whence these new potentialities have come and how it happens that apparent- ly natural limitations of tlle potentialities of objects and human beings are not longer seen and considered. Now it is apparent that it is tile constant contact with obiects and human beings which teaches us which potentialities we must or may expect and what their limitations are. To make it possible for the lad),, mentioned above, to hear voices out of tim teapot, a change or modification of her contact with objects and of her relationship with human beings must have occurred. While the psychiatrist will state that tile woman is schizophrenic because she hears voices, the existential analyst concludes that she hears voices because her relationship to her fellow men and to obiects has changed. The sum total of all relationships, which a lmman being has, and within which other human beings and objects appear to him, is called his world. It is from this world that human beings and obiects receive not only their significance for us, but also their potentialities and limitations. We all agree on the nature of a teapot because it receives its meaning from a world common to all of us. In this world the schizophrenic does not partici- pate in the same way we do and the existential analyst examines the modifications in the structure of the world in which the schizophrenic lives. As an example we might mention Binswanger's case study of Ellen West and also his book on schizophrenia containing five snch studies.

To enable the physician to understand the psychotic patient is the principal aim involved. This requires that things--in our example of the teapot, the human being in general and the certain sick person in particular~must be experienced and understood in a very special and individual way. Only when this Imppens can the physician contact the patient in the patient's own world, speak out of the patient's world, and use words with the meaning they have in the world of tlle patient. Once this happens the patient will feel under- stood, and then only will there develop a true relationship between patient and physician, a relationship between two human beings.

Clinical psychiatry overlooks this, not recognizing the fact that certain problems are created by its silent presupposition that a teapot is the same for the patient and for us. Our questioning, however, is not yet finished. Existential analysis certainly does not claim that its influence upon the schizophrenic is identical with that of modern psychopharmacology, and yet existential analysis is extremely interested in the results of psychopharma- cology insofar as it examines, not only how the disease process changes the patient's world, but also whether and to what extent such changes can be reversed by means of drug therapy, and how this affects tlle clinical picture. For this reason it is not at all difficult to understand that the existential analyst works also in the field of psychophannacology.

Furthermore, existential analysis is concerned with the attempts of modern psychiatry and psychoanalysis to do psychotherapy with schizophrenic pa- tients, provided such therapy centers in the hnman being. As Binswanger himself has emphasized on a number of occasions, existential analysis de-

O N E X I S T E N T I A L A N A L Y S I S 67

veloped mainly as a reaction to recognized shortcomings of psychiatry and psychoanalysis and not out of a search for new therapeutic possibilities. The considerable practical-therapentic significance of existential analysis neverthe- less becomes increasingly apparent. One must admit that this aspect of our method is yet relatively undeveloped and here again we are, at this time, forced to confine ourselves to a few sketchy remarks, without in the least being able to develop the problem in all its dimensions.

We saw that tile lad), who hears voices out of the teapot lives in a world different from ours, in a world of changed relationships to human beings and to objects and, also to her own self, another issue which at this time cannot be gone into any further. Her experiences in contacts with human beings and with objects differ from ours. One may ask oneself whether this insight could not be used therapeutically. This is now actually the case. Treatment tries to improve the patient's ability to find her way in tile world w e h a v e in common and to make it possible for her to accept the potentialities and limitations of objects and human beings, on tile basis of the common experi- ences of other human beings in tlle world we share. This, however, means that she must learn to relate differently to objects and human beings, to gain other experiences in her dealings with them and to explore new, previ- ously inaccessible, experimental possibilities.

This can be accomplished by the actual contact with objects. Towards such contact the patient is led in occupational therapy. Existential analysis allows us to understand why and how occupational therapy with schizo- phrenic patients can produce rcsults, how much can be achieved and what tile limitations of its clficacy are. Similar statements could be made regarding the effect of games and their significance for the relationship to other human beings. Above all, however, it is the ability of the physician to verbally com- municate with the patient which not only enables him to understand the patient in the patient's own modified world, but also permits him to demon- strate to the patient the fracture lines where the patient's deviation from the common world can be noticed. Finally, an entirely different possibility may now appear. It may be possible to gain influence over the manner in which the patient, in his specific way, designs his world. To this end the physician will talk about the nature of certain objects. With the lady mentioned many times now, he will talk at first, not about the teapot, but possibly about a neighboring romn whence he and she together can hear the sound of voices; he may t~llk about doors and windows through which voices are carried in and out and the like. All of a sudden then the patient will feel understood and a relationsbip will develop between tlle patient and the physician not unlike tile relationship of psychoanalytic "transference." This relationship also can be cultivated and improved therapeutically, and be made use of. The reason for this is the fact that ever), contact with objects and ever), discussion about ob- jects already implies and involves the relationship to other human beings, and that tile relationship to other human beings will change whenever object relationships undergo modifications.

What, in the case of the schizophrenic patient, has to be worked out in

~ IIOLAND KUIIN

tile most tedious way, under difficulties which my presentation call hardly attempt to depict fully, will simply happen, largely by itself, in the case of the neurotic patient. For this reason one may be able to treat and recover such patients without even the slightest notion of the aforementioned complex relationships. In the last analysis, however, identical problems, only more hidden, are present in the neurotic patient, and a clearly understandable, steady conduct of therapy, without all theory strange to the patient, is possible only when the therapist succeeds in finding the fracture areas where the patient's own world is separated from tlm one common to us and when re- construction of the mode of experience proceeds from there.

While it has not been possible to answer your initial question fully, in the short time available, I may still lmve been able to transmit to you perhaps some small amount of insight into tim problems of existential analysis, as such problems arise, whether in practice or research, in clinical psychiatry and psychoalmlysis. V~re hope that you may now be better able to appreciate the meaning and significance of two sentences written by Binswanger concerning the relationship of existential analysis and psychotherapy:

"'\Ve were surprised to see bow readily some of our not always very bright or educated pa- tients were able to respond to the existential-analytic techniqt,c of exploration as tlmy felt themselves understood. Indeed in this restoration of natural comnmnication lies, here as everywhere, the conditio sine qua non for any psychotherapeutie success."

Roland Kuhn, M.D., Assistant Professor, University of Zurich; Mental State Hospital, Miinsterlingen, Thurgau, Switzerland.