Karl Jaspers' General Psychopathology was first published in 1913. One hundred years later, in the face of radical transformations of our world, not least in the domain of neuroscience, we have reason to assess in retrospect: Has Jaspers' understanding of psychopathology been overcome? What is the status of Jaspers' project within psychiatry today? This essay will address these questions.
It would be difficult to overlook the similarities of mood, debates, and main trends in psychiatric research between our time and Jaspers' time. Beginning with the 1850s a period of rapid enthusiastic advances in the natural sciences was followed by a period of skepticism and disappointment toward the end of the century. Jaspers remarks on the mood of stagnation and "therapeutic resignation" at the Heidelberg clinic where he worked in the years 1908–1915 and embarks on the task of reviving psychiatry by rediscovering its object, the pathos of psyche (mind or soul).
Similarly, in the second half of the twentieth century we witnessed large strides in causal explanation fostered by technological progress in all domains, psychiatry included, and as a result a deep crisis of psychopathology, which was deemed irrelevant or reduced to a subordinate role in psychiatry—as merely a list of symptoms. Contemporary presuppositions continue to reveal general adherence to the same biological reductionist dogma first articulated by German neurologist and psychiatrist William Griesinger in his 1861 claim that "psychic disorder is cerebral disorder," and reiterated today by neuroscientists and reductive and eliminative materialist philosophers. For example, Thomas Fuchs quotes the contemporary German psychiatrist Wolfgang Maier for affirming psychic disorders to be brain disorders, and mental states to be representable with medical imaging as states or processes of the brain. Going a step further, Paul Churchland urges us to abandon folk psychology as unscientific obscurantism, a completely misguided superstition, similar to erroneous causal concepts of the past such as phlogiston and witches, which evidently should not be simply renamed but must be radically eliminated and replaced by real science. The Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association 1980; 4th and 5th eds.), though anti-theoretical, is marked by unquestioned empirical reductionism (the Hempel-Oppenheim model of logical empiricism leading to objectify psychic phenomena).
The Paradigm Shift
In the last decade, however, there has been a shift away from pioneering self-assurance to more mature skeptical attitudes, hence Jaspers' questions and positions are timely again. Christoph Mundt explains that the extreme paucity and impotence of DSM categories—for example, their incapacity to validate separate clinical syndromes and their radical objectivism, which eliminates "the view from inside the patient based on empathy" (IKJ 42)—has provoked dissatisfaction with the present reductionism and reconsideration of theories promoting a more nuanced, comprehensive interpretation of mental pathologies. We are witnessing a reformulation of the debate about the epistemological, therapeutic, and ethical value of extreme reductionism, and an increasing skepticism about it.
This context explains the renewal of interest in the role of Jaspers' psychopathology in today's psychiatry. According to Stanghellini and Fuchs, after being neglected and dismissed as unscientific, a stop gap devoid of epistemic value, psychopathology is returning. Jaspers' investigations are giving rise to new debates both in methodological research, concerning, for example, understanding and the nonunderstandable, and also in clinical matters, such as defining delusion and self-awareness (EI xx-xxi). There emerges an awareness that psychopathology may be a sine qua non discipline for psychiatry and clinical psychology: thus descriptive psychopathology provides a common language and ground for psychiatry, a heterogeneous discipline whose adepts approach it from different angles—neuroscience, depth psychology, sociology, philosophy—each with its own language, method, and practice. While descriptive psychopathology is able to bridge the gap between understanding and caring, that is, between epistemological and ethical paradigms, as well as between human and clinical sciences, and to define what is abnormal and what is human in the irrational and incomprehensible, clinical psychopathology provides the data for diagnoses and classifications, and structural psychopathology, based on the meanings of personal experience, contributes to the understanding of intelligibility and its limits.
Jaspers founded psychopathology as "a science with its own object of research, own methodology, and own critical consciousness of method." His aim was high: that of founding a new psychiatric discipline by bringing "order into the chaos of abnormal psychic phenomena by rigorous description, definition, and classification and [to] empower[ing] psychiatry with a valid and reliable method to assess and make sense of abnormal human subjectivity" (EI xiii). The method of rigorous descriptions, definitions, and classifications that Jaspers introduces in psychopathology is phenomenological. With Jaspers, psychopathology, the domain to be mapped, and descriptive phenomenology, the method appropriate for the task, emerge together.
Jaspers' Descriptive Phenomenology
Karl Jaspers adopted Wilhelm Dilthey's hermeneutic with early Edmund Husserl's concepts of intuition, description, and presuppositionless methodology, and adapted them to psychopathology (EI xiii). Descriptive phenomenology will be consistently applied throughout the GP in confrontation with reductionism in its two forms of somatic and psychic approaches. Jaspers opposed the psychic model, which reduced mental disease to a moral or religious defect proper to the psyche and was especially critical of Freudian psychoanalysis, which interpreted conscious mental states as forms of self-deception. His main target, however, was the somatic model, which he called the "somatic prejudice."
Jaspers' dualist methodology of understanding (verstehen) and explaining (erklären) is grounded in Cartesianism and neo-Kantianism, a form of apophatic anthropology. From the beginning he declares his theoretical and methodological positions: he counsels existentialist respect for the mysterious and incomprehensible whole of the object of research that is the psyche, as well as for the uniqueness of the individual case, neither of which can be the object of scientific approach in themselves but only in their manifestations. Morbid psychic phenomena, Jaspers believes, are ultimately rooted in the "phenomenon Man" as "unconfined freedom which lies beyond the reach of empirical inquiry"; man is "the great question that stands at the margins of all our knowledge" (GP 30-1). Accordingly, he believes that psychopathology must be grounded in empathetic understanding of the patient experience in an intimate view from the inside. For therapy to take place, a profound relationship must be established between patient and psychopathologist, one in which authentic communication occurs.
Jaspers' emphasis on understanding and meaning points to a strong Weberian influence; however, there is a moment especially in schizophrenic delusion when the nonunderstandable is reached. The abnormal psychic states differ from the normal states by arising endogenously as a psychological irreducible. Since, faced with the un-understandable or the incomprehensible, rational understanding logically fails, empathic understanding must take over in a communication that necessarily transcends reason. Jaspers warns that resorting to causal, biological explanation departs from the inner subjective experience. He seems to view biological explanation as a deus ex machina, a prop, incapable of authentically solving the cipher of delusional pathetic psychic states. It represents a leap into a parallel world, a different paradigm and language, one that is irrelevant to individual subjectivity. The somatic perspective treats man as a creature of nature, but man, he insists, is a creature of culture.
Thus Jaspers' psychopathology underscores human duality, and brings together—in a tense relationship—natural science and human science. There is neither a one-to-one nor an integral correlation between psyche and brain, however. Jaspers is clear about his position regarding localization of the mental. As with Cartesian dualism, the temporal reality of the mental and the spatiality of the brain are heterogeneous orders and cannot correspond one to one as identity theory claims. According to Jaspers, the somatic assumption of correlation is not verifiable, but only a source of metaphorical interpretation. In relation to the methodological shift from empathetic understanding of individual existence to causal explanation, Jaspers discusses theory formation in psychopathology: Carl Wernicke, Sigmund Freud, Viktor Emil Von Gebsattel, and Erwin Straus (GP 534–46). Under the somatic prejudice, at the moment when the "alien," the nonunderstandable is encountered, Occam's razor is applied and the drive for causal explanation takes over: opaque sources beyond consciousness, such as physical events, phases, periods; that is, brain malfunction, disturbance in basal events, vital inhibition, repressive unconscious, noontime demons.
In this causal paradigm, the biological comes to replace existence itself. While both existence and the biological are impenetrable and incomprehensible, Jaspers avers that only existence is capable of infinite illumination. He is critical of the shift from meaningful understanding illumined by existence to explanation of biological causes that leads to a therapeutic indicated by somatic fact. Jaspers does not deny validity to the latter, but criticizes the confusion of the two that fosters a nonphilosophical philosophizing (the psychic reduction) and a pseudo-knowledge of the body (the somatic reduction)—two versions of reductionism that are equally dogmatic and unscientific, both biased and false. From a scientific perspective, the theology of the eclipse or loss of God is as empty a hypothesis as is "a disturbance in vitality." Knowledge of life should not attempt to simulate scientific knowledge. Jaspers explains that the totality of human life and its ultimate origin cannot be the object of any scientific research, "thus Gebsattel's theory [refers to] human life as a whole, which is the proper theme of philosophy, whereas science is only concerned with particular aspects of the whole" (GP 543). Morbid states cannot be contained in a scientific theory. Instead, a philosophical-existential interpretation is required. "Psychic life," he writes, is "an infinite whole, a totality that resists any consistent attempt to systematise it," and if we were to reduce it "to a few universal principles and seek comprehensive laws, we beg a question that cannot be answered" (GP 17).
This form of Cartesian dualism of understanding and explaining also indicates a Kantian apophaticism; Jaspers maintained that "man is only comprehensible when he is understood in somatic terms" (GP 18), thus only as a phenomenon, not as a numenon. Scientific causality accounts for extraconscious foundations of psychic life, the domain of the unconscious and the organic. It cannot encompass or comprehend conscious subjectivity. This is Jaspers' response to psychic reductionism, such as Freudian prioritizing the unconscious, as well as to somatic explanation (BM 76). According to Freud, subjective consciousness alone is the domain of meaning and understanding (BM 76-7). Jaspers observes, however, that meaning and understanding must be extended empathetically to the incomprehensible of individual inner experience toward a philosophy of existence.
It is for this reason that Jaspers appeals to phenomenological description, that is, the pure appreciation of facts, patient experience, without prejudice but with detachment and sympathy (GP 17, 20–2). In other words, Jaspers' call "to fully present reality," as Fuchs notes, is a Husserlian call "to the things themselves," which results in a sui generis epoche and precludes any attempt at definition or generalization of morbid conditions (BM 77). That is the reason why the major psychoses—melancholy, manic-depression, schizophrenia, and epilepsy—appear as particular constellations of symptoms rather than as fully defined and classified morbid entities.
Alternative Phenomenologies of Ludwig Binswanger and Michel Henry
For Jaspers, employment of phenomenology in psychopathology involves the description of experiences presented by the patient. He modeled his descriptive phenomenology after Husserl, and did not follow the evolution of phenomenology toward the eidetic approach explored by Ludwig Binswanger (1881–1966), the Swiss psychiatrist and pioneer in the field of existential psychology, influenced in particular by Husserl and Martin Buber, nor the phenomenology of the bodily subject of Michel Henry (1922–2002), the French philosopher and novelist. Binswanger developed a transcendental phenomenology of intentional consciousness, thereby complementing Jaspers' descriptive naturalist study that limits itself to the content of lived experience. For Binswanger, phenomenology does not mean the descriptive phenomenology of subjective manifestations of psychic life, as it does for Jaspers, but is rather to be understood in terms of pure transcendental Husserlian phenomenology. Binswanger insists that his method belongs to the science of transcendental phenomenology, which is neither "a psychology of inner experience," nor one of lived experience (Erlebnispsychologie), nor a phenomenology of lived time or space. Like Jaspers he distances himself from reductive explanations based on biological derivation, yet he also departs from the psychopathological attitude in order to discover the a priori structure of temporal intentionality.
Thus Binswanger adopts a pure transcendental phenomenological position in opposition to any psychological, natural, naïve attitude. The originality of his approach consists in the observation of the specific transcendental modification in melancholy and mania, that is, the dissolution of the constitutive connections inside the transcendental structural order. In his phenomenological analysis, melancholic disorder emerges as the outcome of the malfunctioning of the three egos—empirical, transcendental, and pure—in relation to intentionality and time. The pure ego is the key to his analysis because it is charged with the constitution of ego totality. Binswanger made visible both the empirical "I" through case observation and the transcendental "I" in the turn toward the structural elements constitutive of consciousness; the element missing is "the pure ego, [which] constitutes the unity of the mundane-empirical 'I' and the transcendental 'I,' as constituted experience is the unity of mundane-empirical experience and transcendental experience" (MM 117–8).
In nonmelancholic experience, the pure ego performs its constitutive and unifying function with ease. In melancholy, by contrast, the pure ego is distressed and constrained; its constitutive function is hindered and questioned. Melancholy indicates an alteration in the constitution of the pure ego, its perplexity and despair as a result of failing to fulfill its task. This negative moment actualizes itself as dysthymie, that is, as "melancholic depression, anxiety, and torment, or manic withdrawal from the task of total control over self and world" (MM 119). If in melancholy the pure ego's operation is impaired, however, it is never completely annulled as in the case of schizophrenia. That is because only its regulatory function suffers, not "the function of constituting the belonging-to-me of the I am" (MM 120–1). This belonging-to-me constitutes the critical aspect of melancholic distress, since the self in pain is mine: it is "I" myself (MM 121). The possibility of healing resides in the preservation of the belonging-to-me assured by the distressed yet functioning pure ego. The melancholic delirium of loss is the expression of the pure ego's despair when confronted with its failure in the task of constituting the totality of experience. The empirical ego suffers from the pure ego's withdrawal, and this suffering is a call back to the totality of experience under the guidance of the pure ego.
According to Binswanger, psychoses are nature's experiments, and as such are phenomenologically significant since they make visible the otherwise inaccessible transcendental operations. This implies a return from the constituted world back to its constitutive structural moments. Melancholy is not historically or biographically conditioned, in other words, it is not an existential condition; it is rather an ontological creation of Dasein: "Schizophrenia is an existential mode, and everybody has a private form of schizophrenia coming out of personal history whereas melancholy, despite the variety of themes of loss, undergoes a generic form of menace against human Dasein grounded in its being forsaken" (MM 134–5).
Michel Henry's phenomenology of the subjective body situates itself in between Jaspers' descriptive phenomenology of lived inner experience and Binswanger's transcendental phenomenology. Henry opposes the Gnostic-Cartesian dualism in which the body is a transcendent object confronting consciousness as its other. The being of the body is not a "being there," an objective determination whose finitude, contingency, and absurdity are revealed to man qua metaphysical being. Naturalism, idealism, and empiricism are all distortions of human nature, separating the spirit from what is regarded as an impersonal natural body. They misunderstand the essence of the human body as a first-person subjective body. Henry insists, by contrast, that the self and the body can never be separated: "the bodies will be judged." He elaborates his ontology of immanent pathetic subjective body as a more primordial beginning: as the original revelation of the absolute. Human reality is "I am my body" rather than "I have a body." Subjectivity comes embodied, is the life of the subjective body, life revealed in a sphere of absolute immanence. Henry maintains that subjectivity "has always already a primordial content, the content of the internal transcendental experience which gives life its irreducible primordial ontological density, a density that subsists even when life collapses in despair" (PP 269). This bodily self-knowing is a knowing of life and of subjectivity, a knowing that always involves the concrete individual, the "I," which cannot be given or received otherwise. Thus for Henry the subjective body is the ontological locus of primordial pathetic immanence where the absolute is revealed. All fundamental destinies of redemption and damnation constitute existential and ethical choices or modes of the totality of the "I," which can never be sublated.
Neuroscience and Phenomenology Today
Binswanger's transcendental analysis does not constitute a serious objection to Jaspers' project, nor does it resonate with contemporary sensibilities. In fact, from Jaspers' perspective, Binswanger's theory would be critiqued along with Gebsattel and Freud as a psychic approach leading to nonphilosophical philosophy. Henry's body subjective phenomenology, with its vigorous attack on dualism, puts in question Jaspers' asymptotic domains of psyche and body—an intuition that is being confirmed by neuroplasticity, as we shall touch on further in a moment. Indeed, Jaspers' trenchant dichotomy of psyche and body is perhaps the most vulnerable element in his psychopathology. As in the case of classical Cartesian dualism, the relation between the two orders of being becomes an insoluble mystery. Henry's subjective body seems a more adequate philosophical hypothesis than Jaspers' dichotomized being. Along this line, Fuchs notes that Jaspers' dualism isolates subjectivity and renders "corporeality foreign to understanding" (BM 82). Fuchs explains that science itself has been proven to be subordinated to cultural paradigms; the brain is now known as a "historically and socially constituted organ," translating biological process and subjective experience, while neuroplasticity has made evident that mind and body are engaged in "a circular interplay" (BM 82-3).
According to the neuropsychiatrist Eric Kandel we have been witnessing a movement from metapsychology and psychoanalysis to molecular biology and neurobiology in which functional imaging has played a major role. Prior to it, we had no immediate access to the brain except by dissecting it postmortem. Advances in technologies, especially brain imaging, are tools that confirm the intuitions of Freud, Wernicke, Alzheimer, namely that depression is a circuit disorder, a brain choreography involving not one area but multiple areas, a neural network. The network approach represents a paradigm shift in understanding mental conditions; phrenology is finally transcended. This confirms Jaspers intuition that no direct one-to-one correspondence can be made between mental state and brain area. The ringleader in this neurocircuit responsible for depression is Area 25 in the frontal lobe, the negative mood regulator. The other centers of this network: amygdala, stimulus-enforcement learning and stress regulator; hypothalamus, the regulator of drives, sleep, appetite, libido; hypocampus, memory regulator; insula, internal awareness; prefrontal cortex. A therapeutic of depression must restore the functional integrity of all the centers of this network. Now that the effects of treatment can be observed through imaging, treatment can be readjusted accordingly, however therapeutics is no longer subordinated to the somatic prejudice. On the contrary, it includes medication and deep brain stimulation of Area 25 (electrode activating Area 25 by pulse generator) side by side with psychotherapy, together or separately, as adapted to specific cases.
This integrative vision—which may confirm the validity of Jaspers' dualism as well as of Henry's subjective body—is also perhaps the result of growing skepticism about unilateral treatment, somatic and psychic. Kandel notes that for our first postgenomic generation, the "last great mystery that confronts biology is the nature of the human mind, the final step in the philosophical progression that began in 1859 with Darwin's insights into evolution of bodily form" where the result will be the "emergence of a new humanism, a humanism made more rational by a deeper respect for the genome and a greater understanding of the human mind" (PPB 383). Interestingly, the velocity of contemporary advances in technological assessment of the brain, especially brain imaging, imposes fast-paced readjustment not only in treatment but also in self-understanding. Science research suggests that brain imaging, pharmacology, and psychotherapy together provide the conditions for the possibility of understanding and living through and with depression. Peter Whybrow elaborates:
No single viewpoint can provide a sufficient explanation for depression or mania. These disorders must be understood in a multidimensional framework as illnesses representing the common dysfunctional pathway which results from the interaction of a diverse range of influences—genetic, familial, developmental, interpersonal, and neurobiological.
Subjectivity and philosophy cannot be eliminated from the equation of self-care by any technological advances. This view—at once generous and humanist—confirms both Jaspers' and Henry's intuitions. Would then a step further into Dasein analysis be warranted in today's psychiatry?
Psychic Pathos and the Task of Psychiatry
Jaspers extracts the existential meaning of clinical data and articulates a Dasein analysis (GP part 6). The existential evidence gathered in Heidelberg is put to use in his concluding philosophical reflections on the nature of being human and the value of liminal situations for authentic Existenz. The shattering in Angst is certainly such a limit and cipher. The reality of human incompleteness must be taken into account. For a being defined by incompleteness, sickness must be an ontological condition, and to provoke the psychological event that initiates a descent into the abyss of anxiety is a task of pedagogical love! Jaspers acknowledges that his philosophical stance is grounded in—but transgresses beyond—clinical psychiatry. He explains:
We cannot rid ourselves entirely of some basic philosophical viewpoint when formulating our psychotherapeutic goals...We cannot develop any psychotherapy that is purely medical, self-contained and appears to be its own justification…For instance, to dispel anxiety is generally thought to be a self-evident therapeutic aim...Large numbers, particularly of modern people, seem to live fearlessly because they lack imagination. There is as it were an impoverishment of the heart. This freedom from anxiety is but the other side of a deeper loss of freedom. Arousal of anxiety and with it of a more vital humanity might be just the task for someone possessed by Eros paidagogos (informing passion). [GP 803]
Existential anxiety is a condition for freedom and must be cultivated by the human individual whose horizon of being is the actualization of Existenz. For Jaspers, as for all philosophers of life, the beginning of authentic existence originates in Angst. It is only through confrontation with the limit situation of psychic pathos that the individual reaches deep hidden sources of Existenz, thus of creativity.
The answer proffered today—by sufferers and psychiatrists, the public and scientists—to Jaspers' claims that freedom and creativity are grounded in the abyss of anxiety; to Binswanger's argument that melancholy is a creative response of the three egos; to Michel Henry's philosophy of subjective pathetic immanentism—is that of an ultra positivist age verging on utopian denigration of the negative, mood or condition, and its denial of entry into the ideal citadel: the answer of a global late modernity and singularity.