The Enigma “Ellen West”

The Enigma “Ellen West”

Ludwig Binswanger’s foundation case of existential analysis

The Enigma “Ellen West”

Ludwig Binswanger’s foundation case of existential analysis

“A mirror of twentieth-century psychiatry”

Vincenzo Di Nicola

Doctoral candidate Europäische Universität für Interdisziplinäre Studien

(European University for Interdisciplinary Studies)Saas-Fee, Wallis, Schweiz

Europe –Switzerland

Die Schweiz – Switzerland

Kanton Wallis – Canton du Valais

Les langues de la Confédération suisse

Swiss Philosophers

Jean-Jacques Rousseau

Richard Avenarius

Jean Piaget

Ludwig Binswanger

Swiss Scientists

Paracelsus

Albert Einstein

Wolfgang Pauli

Paul Dirac

Albert Hofmann

Psychiatres, psychologues et

psychanalystes suisses Auguste Forel

Hermann Rorschach

Carl Gustav Jung

Oskar Pfister

Eugen Bleuler

Ludwig Binswanger

Henri Ellenberger

Jean Piaget

Bärbel Inhelder

Elisabeth Kübler-Ross

Alice Miller

Carlo Strenger

The Case “Ellen West”

Ludwig Binswanger’s foundation case of existential analysis

“Ellen West”

(1888-1921)

Ludwig Binswanger

(1881-1966)

Der Fall Ellen Westby Ludwig Binswanger

1944-45: Der Fall Ellen West. Schweizer Archiv für Neurologie und Psychologie, 1944, 53: 255-277, 54: 69-117; 1945, 55: 16-40.

1957: Schizophrenie. Pfullingen: Neske.

1958: The Case of Ellen West: An Anthropological-Clinical Study  (trans. by Werner M. Mendel & Joseph Lyons, pp. 237-364), in Existence: A New Dimension in Psychiatry and Psychology (ed. Rollo May, Ernest Angel & Henri F. Ellenberger). New York: Basic Books.

Der Fall Ellen West résumé en français

Storch, Alfred (1958). « À propos de Schizophrénie de Ludwig Binswanger. » L’Évolution Psychiatrique, 3 : 577-602.

Ellenberger, Henri F. (1974/2001). À la découverte de l'inconscient, Paris : SIMEP. Réédité sous le titre Histoire de l'inconscient, Paris : Fayard.

Postel, Jacques (1993/2003). Dictionnaire de psychiatrie et de psychopathologie clinique. Paris : Larousse.

Ellen West: childhood, youth

Born in 1888 into a Jewish family, Ellen arrives in Europe at the age of 10

As a child, she expresses her character early: stubborn, mischievous, disobedient

Also: a good student, lively, ambitious, she applies herself intensely into everything she undertakes

Intelligent and sensitive, she takes the matura and then passes the exams to become a teacher which allows her to enter university

Ellen reads a great deal – notably R.M. Rilke and J.W. von Goethe

After these readings, she becomes an atheist and adopts a rebellious attitude towards bourgeois life

Ellen West: attachments

Ellen falls in love numerous times

Forbidden each time by her parents who oblige her to break up her engagements

At the age of 28, with her parents’ permission at last, she marries a cousin

Ellen West: embodiment

Around the age of 20 Ellen begins to be afraid to gain weight

She experiences strong cravings for food, accompanied by the fear of getting fat

All of which brings her to feel depressed

Ellen’s solution: taking laxatives to stay thin, up to 60 packets a day

Ellen West: embodiment (ii)

She has a miscarriage following a vigorous hike during which she has a haemorrhage

She suspends taking laxatives as she wants a baby

Her intense desire to lose weight returns: Ellen refuses to eat normally and starts taking laxatives again

Her menstrual periods disappear, yet she is motivated to stay thin which attenuates her sadness/depression

At the age of 30, she becomes a vegetarian

Ellen West: psychiatric career

At 31, after 3 years of marriage, now amenorrheic, having ended sexual relations for 2 years, Ellen decides to share her suffering with her husband

In this period, she makes 8 suicidal “gestures”

Ellen encounters medical specialists, visits Sanatoria, begins psychoanalysis and meets the psychiatric elite of the time: Eugen Bleuler, Emil Kraepelin and Ludwig Binswanger …

The psychiatrists are not in agreement about the diagnosis

Ellen West: subjective experiences

Ellen almost constantly experiences a pervasive dread which is at once generalized and connected to weight gain

She exhibits an obsession with thinness and a fear of gaining weight

She feels an “emptiness,” an “existential anxiety”

Ellen West: subjective experiences (ii)

Ellen lives a dichotomy: a split between the ethereal world and the tomb-world (according to Binswanger)

The spiritual versus the physical translated/experienced by Ellen as the ideal of the soul (pure and empty) versus the fear of her own embodiment (the heaviness/gravity of feeling full, pregnant, a bourgeoise)

Ellen West: explication philosophique

« Tout le mouvement de son existence s’épuise dans la peur phobique d’une chute dans la tombe, et dans le désir délirant qui planerait dans l’éther et cueillerait sa jouissance dans l’immobilité du mouvement pur. Mais ce que désignent cette orientation et la polarité affective qu’elle implique, c’est la forme même selon laquelle se temporalise l’existence. L’avenir n’est pas assumé par la malade comme dévoilement de sa plénitude et anticipation de la mort. La mort, elle l’éprouve déjà là, inscrite dans ce corps qui vieillit et que chaque jour alourdit d’un poids nouveau ; la mort n’est pour elle que le pesanteur actuelle de la chair, elle ne fait qu’une seule et même chose avec la présence de son corps. »

—Michel Foucault (1954). « Introduction ». Le rève et l’existence, L. Binswanger

Ellen West: philosophical explication

« Tout le mouvement de son existence s’épuise dans la peur phobique d’une chute dans la tombe, et dans le désir délirant qui planerait dans l’éther et cueillerait sa jouissance dans l’immobilité du mouvement pur. Mais ce que désignent cette orientation et la polarité affective qu’elle implique, c’est la forme même selon laquelle se temporalise l’existence. L’avenir n’est pas assumé par la malade comme dévoilement de sa plénitude et anticipation de la mort. La mort, elle l’éprouve déjà là, inscrite dans ce corps qui vieillit et que chaque jour alourdit d’un poids nouveau ; la mort n’est pour elle que le pesanteur actuelle de la chair, elle ne fait qu’une seule et même chose avec la présence de son corps. »

—Michel Foucault (1954). « Introduction ». Le rève et l’existence, L. Binswanger

Michel Foucault

(1926-1984)

Ellen West: philosophical explication (ii)

«  La mort, elle l’éprouve déjà là, inscrite dans ce corps qui vieillit et que chaque jour alourdit d’un poids nouveau ; la mort n’est pour elle que le pesanteur actuelle de la chair, elle ne fait qu’une seule et même chose avec la présence de son corps. » —Michel Foucault (1954)

See: Simone Weil (1947), La Pesanteur et la grâce/Gravity and Grace

Was she anorexic? Simone Weil is considered anorexic in the eating disorders and feminist literature

Simone Weil

(1909-1943)

Ellen West: “enforced separations”

Ellen experienced a quite impressive list of “enforced separations” (RD Laing):

Her father ordered her to break her first engagement.

Her second engagement was “temporarily discontinued” at the instigation of her father and mother.

Her first analysis is terminated for “external reasons.”

Her second analyst ordered her husband to leave her.

A psychiatrist ordered her to end her second analysis.

“Ellen West”

“Ellen West”

Kreuzlingen – Canton du Thurgovie

Das Sanatorium Bellevue 1857-1980 - Kreuzlingen

Famous Patients ofThe Bellevue Sanatorium

“Anna O” Bertha Pappenheim (1859-1936): July-October1882

Aby Warburg (1866-1929): 1921-24

“Ellen West” (1888-1921): January-March1921

Anno O Bertha Pappenheim (1859-

1936)

Anna O’s Physicians

Dr Josef Breuer Dr Sigmund Freud

Aby Warburg

(1866-1929)

The Constructions “ Ellen West”

“A Mirror of Twentieth-Century Psychiatry”

Edmund Husserl

(1859-1938)

Martin Heidedgger

(1889-1976)

Être et Temps/ Being and Time

(1927)

Emmanuel Lévinas :

« Heidegger est pour moi le plus grand philosophe du siècle, peut-être

l’un des très grands du millénaire ; mais je suis très peiné de cela, parce que je ne peux jamais oublier ce qu’il était en 1933, même s’il ne l’était que pendant une courte période. Ce que j’admire dans son œuvre c’est Sein

und Zeit. C’est un sommet de la phénoménologie. Les analyses sont

géniales …. Rassurez-vous : je ne suis pas ridicule, je ne saurais

méconnaître la grandeur spéculative de Heidegger. »

Emmanuel Lévinas

(1906-1995)

Hannah Arendt

(1906-1975)

Giorgio Agamben

(Born 1943)

Emil Kraepelin

(1856-1926)

Eugen Bleuler

(1857-1939)

Viktor Emil von Gebsattel

(1883-1976)

• Theodor Lipps (Munich)

• Max Scheler (Munich)

•Wilhelm Dilthey (Berlin)

• Emil Kraepelin (Munich)

1st Psychoanalysis of Ellen West:

February – August 1920

Hans von Hattingberg

(1879-1944 )

Vienna

Munich

2nd Psychoanalysis of Ellen West:

1920 - January 1921

R.D. Laing

(1927–1989)

Jean-Paul Sartre

(1905-1980)

Salvador Minuchin

(Born 1921)

Mara Selvini Palazzoli

(1916-1999)

Karl Jaspers

(1883-1969)

Bühler, Karl-Ernst (2004). Existential analysis and psychoanalysis: Specific differences and personal relationship between Ludwig Binswanger and Sigmund Freud. American Journal of Psychotherapy, 58 (1): 34–50.

Freud

Psychoanalysis

Biology/clinical psychiatry

“Body”

Binswanger

Existential analysis

Phenomenology/clinical psychiatry

“Existence”

Psychotherapy

Existential Psychiatry

Eugène Minkowski (1885-1972)

« Je donne une œuvre subjective ici, œuvre cependant qui tend de toutes ses forces vers l'objectivité. »

I am offering a subjective work here, which aims nevertheless toward objectivity with all its force.

Founded L’Évolution psychiatrique

Existential Psychiatry

Binswanger

Binswanger’s account is not about the person of Ellen but rather “of the existential Gestalt to which we have given the name of Ellen West” based on documents written by Ellen and her husband

His method is to lay out before him all of the life-history of Ellen in as much detail as possible, leaving out as far as possible all moral, aesthetic, social, medical or any kind of judgements, free of all pre-judgements.

He will direct his gaze at the finished form of her existence in the world, dissecting a dead butterfly of his fancy, not depicting the pathetic life of a defeated person.

RD Laing

… exactly “because he did not know her personally” the “conditions were particularly favourable to an existential analysis”

“No need to pass time in the presence of a person whose presence in the world is so totally unfortunate and miserable.

“The existential Gestalt that is Ellen West is unable to ‘relate.’ His study exemplifies exactly what he attacks.”

Evolution of Psychiatry

Clinical Psychiatry – Mental illness + biology

Dynamic Psychiatry – Psychoanalysis + clinical psychiatry

Existential Psychiatry – Psychoanalysis + phenomenology + clinical psychiatry

Critical Psychiatry – Psychiatry + or psychiatry –

Evolution of Critical Psychiatry

Systems

Gregory Bateson

RD Laing

Whitaker/Andolfi

Minuchin

Selvini Palazzoli

Culture

Frantz Fanon

Wittkower, Murphy, Prince

Arthur Kleinman

Georges Devereux/Tobie Nathan

Evolution of Critical Psychiatry

Feminism

Mara Selvini Palazzoli

Susie Orbach

Kim Chernin

Julie Kristeva

Luce Irigary

Politics

Frantz Fanon

Gilles Deleuze/Félix Guattari

Franco Basaglia

RD Laing/David Cooper

Thomas Szasz

Ellen West: interventions

Internal medicine

Psychiatrists – “psychoanalysts” 

Psychiatric consultations

Hospitalization

Interventions

Medical care, management

von Gebsattel, von Hattingberg

Kraepelin, Hoche, Bleuler, Binswanger

Bellevue Sanatorium

Closed unit vs discharge, assisted suicide, existential analysis post hoc

Ellen West: diagnoses

During her treatment

Melancholia (Kraepelin)

Hysteria (von Gebsattel)

Obsessional neurosis with manic-depressive oscillations (von Hattingberg)

Psychasthenia (Hoche)

Schizophrenia Simplex (Bleuler, Binswanger)

Readings of the case

Anorexie hystérique (Charles Lasègue)

Anoressia mentale (Mara Selvini Palazzoli)

Folie hystérique (Jean- Claude Maleval)

Anorectic (Salvador Minuchin)

Bulimia with obsessive-compulsive phenomenology, dysphoria associated with borderline personality disorder (Nassir Ghaemi)

Anorexia, melancolia, neurose narcísica (Manoel Berlinck & Ana Cecília Magtaz)

Insécurité ontologique, honte du corps (Jean-Claude Marceau)

Ellen West: diagnoses

During her treatment

Melancholia (Kraepelin)

Hysteria (von Gebsattel)

Obsessional neurosis with manic-depressive oscillations (von Hattingberg)

Psychasthenia (Hoche)

Schizophrenia Simplex (Bleuler, Binswanger)

Readings of the case

The sole psychiatrist who resisted to diagnosis her?

R.D. Laing, The Voice of Experience (1982)

He concentrates his critique rather on Binswanger’s method

His study of Ellen West contributed to distancing himself from traditional psychiatry, from the diagnostic perspective and from the concept of simple schizophrenia

The Gestalt “Ellen West”

Psychiatric phenomenology

Existential

Relational

Sociocultural

Phobia/obsession/delusion?

Emptiness, ontological insecurity

All relationships/Rx interrupted

A woman in a traditional/patriarchal family/society

A Jewish patient in an antisemitic society

Pierre Janet

(1859-1947)

Janet’s Case of Nadia

Chapter: « L’obsession de la honte du corps » The obsession with bodily shame

Young woman of 27 years who adopted a bizarre eating pattern for fear of gaining weight (two soups, an egg yolk, a spoon of vinager and a cup of strong tea with lemon juice)

She alternated between bulimic crises and hours of rumination on food and eating as torture

Dx: “anorexie hystérique” – hysterical anorexia

Janet, Pierre (1903). Les obsessions et la psychasthénie. Paris : Alcan.

“Ellen West”

Binswanger discusses the question of embodiment in psychosis

Dressed exclusively in pants until the age of 16 years

Death is for her is just the heaviness of her flesh, Ellen speaks of the ethereal world

“Nadia”

Cited by Binswanger

Seeks to hide her sex/gender by dressing like a man; she would really like to be without any sex, without any body

Beyond being thin, Nadia wishes to no longer be in her body and speaks of the existence of an angel

The Schizophrenias

Kraepelin

Klinische Psychiatrie (1899)

Clinial Psychiatry

Kraepelin proposes the dichotomy between dementia praecox et manic-depressive illness

Bleuler

Dementia praecox oder Gruppe der Schizophrenien (1911)

Dementia Praecox or The Group of Schizophrenias

Bleuler introduces the new term schizophrenias for dementia praecox

Who Killed “Ellen West”?

A Philosophical-Psychiatric Investigation

The Death of “Ellen West”

I became fascinated by the question of responsability.

Who caused her death, directly or indirectly?—Salvador Minuchin (1984)

After two suicide attempts by Ellen West, begins a series of consultations with the founders of modern psychiatry: Emil Kraepelin (1856-1926), architect of today’s psychiatric nosology, diagnoses melancholia finds a simple psychasthenia.

Alone in perceiving what the Gestalt reveals is Binswanger, confirmed by the authority of Eugen Bleuler (1857-1939) who named the emblematic condition of psychiatry: Schizophrenia Simplex (simple schizophrenia), a progressive schizophrenic psychosis

Their opinions notwithstanding, Ellen’s melancholy and her suicide attempts persist, accompanied by serious eating problems.

Convinced of the grave and incurable diagnosis, without hope, all therapies interrupted, suspended or withdrawn, Binswanger accedes to the patient’s request: Ellen is discharged from the Sanatorium.

After 3 days with her family, Ellen appears transformed: she has breakfast, at noon she eats well for the first time in 13 years, during the afternoon she goes for a walk with her husband, reads poems and writes letters.

All the heaviness is lifted from her being.

That night, she takes poison.

The next day, at the age of 33 years, Ellen West is dead.

Binswanger reassures the reader not less than 17 times that her suicide is “authentic.”

Laing concludes his reading with bitter irony: Poor little rich girl.

The Death of “Ellen West”

A suicide? - authentic?An assisted suicide?

A psychic-ontological homicide?

The Death of “Ellen West”

« An authentic suicide »

according to Binswanger (1944-45)

Binswanger, Ludwig (1944-45). « Der Fall Ellen West. » Schweizer Archiv für Neurologie und Psychologie, 1944, 53 : 255-277, 54 : 69-117; 1945, 55 : 16-40.

The Death of “Ellen West”

« An assisted suicide »

according to Akavia (2008)

Akavia, Naamah (2008). « Writing “The Case of Ellen West” : Clinical Knowledge and Historical Representation. » Science in Context, 21 : 119-144.

The Death of “Ellen West”

« A psychic homicide »

according to Lester (1971)

Lester, David (1971). « Ellen West’s suicide as a case of psychic homicide. » Psychoanalytic Review, 58 : 251-263.

The Death of “Ellen West”

An assisted suicide

The authenticity of which is precisely question

A psychic homicide in which suicide as a solution was induced from the outside

An ontological annihilation by the family, her husband et her physicians suppported by the psychiatrist Alfred Hoche and his justfication to “annihilate life unworthy of life”

The Death of “Ellen West”

A psychic homicide, an ontological annihilation

Binswanger errs with the diagnosis of schizophrenia, he consults Alfred Hoche, a psychiatrist known for his text with the jurist Karl Binding justifying suicide and euthanasie for “life unworthy of life”

He takes away her hope for living and collaborates with her husband to induce her suicide

After—more than 20 years later, he reconstructs The Case Ellen West to justify himself: he tries to convince us that his distance helps him to understand and insists 17 times in the text that the suicide was authentic

The Doctor-Patient Relationship

Von Gebsattel

Little known in the English or French literature

He speaks to the doctor-patient relationship

He insists on the presence of the person in both the patient and the doctor to resist the dehumanization of medicine (what Foucault will call desubjectivation)

Welie, Jos VM (1995). Viktor Emil von Gebsattel on the Doctor-Patient Relationship. Theoretical Medicine, 16: 41-72.

Alfred Erich Hoche

(1865-1943)

Karl Binding

(1841-1920)

« Vernichtung lebensunwerten

Lebens »

The Permission to Annihilate

Life Unworthy of Life:

Its Measure and Its Form

By Professors

Karl Binding, JD, PhD et Alfred Hoche, MD

(1920)

Medscape 2010 Physician Ethics

Survey

“Palliative care is one thing, but suicide is not within the scope of acceptable physician behavior.”

“I do not believe in assisted suicide, but I do believe in withdrawal of support. If the patient is terminally ill and suffering and there is absolutely no hope to survive, then I withdraw the support (eg, antibiotic treatment,

blood testing, or transfusions).”

“Assisted suicide is murder.”

Medicine and the German Jews

There are very deep historical and sociocultural ties between Germans, Jews, and medicine since the Middle Ages

In the evolution of German medicine, a language of the degenerating body and the metaphor of regeneration was elaborated and inscribed into theories and practices, to which Jewish physicians themselves adhered and with which they described themselves

The Jewish body was perceived as sick and diseased, the sign of a national disease due to their powerlessness as a people with a country (adopted by the early Zionists)

This perception—let’s call it an episteme or discourse following Foucault—becomes distorted and abused by the Nazis who speak incessantly of racial purity and the degenerate Jews

John M. Efron (2001). Medicine and the German Jews: A History. New Haven : Yale University Press.

Ellen West : victim of herself, of life, of assisted

suicide?

How could a sophisticated and brilliant man like Binswanger, coming from a medical tradition of great distinction (practically noble) on several levels—nationally (Switzerland), culturally (German) and in his family, and having Jewish friends, mentors and interlocutors (notably Freud) bring himself to consult a man like Hoche as a consultant for a patient who was Jewish, suicidal and in despair due to the diagnosis of an incurable illness?

We now know that Ellen West and her husband contested this choice of consultant and did not find him acceptable knowing very well his reputation based on his ideas about euthanasia and assisted suicide, which accelerated her departture from Bellevue Sanatorium

Hoche’s and Binding’s text will become the inspiration and justification for the final solution of the Jewish question, that is to say, the extermination of the Jews of Europe, declared by the Nazis at the Wannsee Conference near Berlin in 1942

Reflections

In spite of the efforts of many great thinkers of the 20th century – from Kraepelin, Bleuler and Binswanger to Selvini Palazzoli, Laing and Minuchin in psychiatry and Foucault en philosophy – « Ellen West » remains an enigma for us.

What remains possible for us is to undertake a philosophical archaeology to create new constructions of this case in order to integrate the phenomenological, systemic, sociocultural and ethical dimensions of her life.

Reflections

« Ellen West » is a mirror of 20th century psychiatry but the issues and the risks we find there are still present and salient

What is the central task of psychiatry: to comprehend, to classify or to

cure?

Is it possible to accomplish it (or them) objectively and at what price?

Whither then subjectivity?

Reflections

Is contemporary psychiatry more in the spirit of Kraepelin who inspires the thinking behind the DSM and evidence-based medicine or rather that of Bleuler, disciple of Freud, who inspired dynamic psychiatry?

Is it the critical and humanistic spirit of Laing who inspired the family and community psychiatry movement in Britain and beyond or that of Minuchin who declared that family therapy would take over psychiatry in the US?

Reflections

So that our human encounters in the clinical do not become or stay enigmatic (see von Gebsattel, Sartre, Foucault), we have the choice to practice our profession – this impossible profession according to Freud – in a way that is always more human and empathic.

Réflexions

« On ne peut comprendre les troubles psychiques du dehors » mais par « un effort constant pour saisir la situation de base et pour la revivre », ce qui nous rapprochera au « temps où la psychiatrie sera, enfin, humaine.» —Jean-Paul Sartre à l’avant-propos de Raison et violence (Laing et Cooper, 1964)

Reflections

“One cannot understand psychological distubances from the outside, on the basis of a positivistic determinism, or reconstruct them with a combination of concepts that remain outside the illness as lived and experienced … without a constant effort to grasp the basic situation and to relive it, without an attempt to rediscover the response of the person to that situation …which will bring closer the day that psychiatry will, at last, become a truly human psychiatry.”

—Jean-Paul Sartre, Foreword, Reason and Violence (Laing & Cooper, 1964)

Alain Badiou

(né 1937)

Pour guérir quelle blessure, pour ôter quelle écharde dans la chair de l’existence suis-je devenu ce qu’on appelle un philosophe? – Alain Badiou

Préface, Après la finitude de Quentin Meillassoux (Paris, Éditions du Seuil, 2006)

Alain Badiou

“What wound was I seeking to heal, what thorn was I seeking to draw from the flesh of existence when I became what is called ‘a philosopher’?”

“It may be that, as Bergson maintained, a philosopher only ever develops one idea. In any case, there is no doubt that the philosopher is born of a single question, the question which arises at the intersection of thought and life at a given moment in the philosopher's youth; the question which one must at all costs find a way to answer.”

Preface, After Finitude, Quentin Meillassoux (Continuum, 2008)

Ludwig Wittgenstein

(1889-1951)

The philosopher’s treatment of a question is like the treatment of an illness.– §255

Ludwig Wittgenstein, Philosophical Investigations (1953)

Bibliography

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Akavia, Naamah (2008). « Writing “The Case of Ellen West” : Clinical Knowledge and Historical Representation. » Science in Context, 21 : 119-144.  

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Marceau, Jean-Claude (2002). « La question de la corporéité dans le cas Ellen West de L. Binswanger. » L’Évolution Psychiatrique, 67(2) : 367-378.

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Selvini Palazzoli, Mara (1982). L’anoressia mentale : Dalla terapia individuale alla terapia familiare. Nuova edizione interamenta riveduta. Milano : Feltrinelli Editore.