In order to comment on the brilliant and erudite book by Giovanni Stanghellini, Lost in Dialogue,1 I must necessarily address some of the key variables in the debates regarding the relationship of phenomenology and mental health of the last hundred years. The complexity and pluralities of perspectives which are enabled by Stanghellini's work require this methodological approach, albeit in an abridged manner.

Phenomenological psychopathology is delimited, in many dimensions, by a web of ambiguities. Exploring these ambiguities characterizes the spirit of this book. As curious as it may be, originating in the academic discipline of the humanities, phenomenological psychopathology nonetheless has a double birth register, as it is equally positioned as a descriptive science and a hermeneutical one. Looking back to the first mention of this concept, namely in Jaspers' essay, "The Phenomenological Approach in Psychopathology," one might consider that it was created in 1912.2 However, if one carefully follows the same Jaspers regarding the status he ascribed to his very creation, one could get surprised. In the Introduction to his book General Psychopathology, Jaspers writes:

It is wrong to call this book "the principal text of phenomenology." The phenomenological attitude is one point of view...But the whole book is directed to showing that it is only one point of view among many and holds a subordinate position at that.3

Clearly, building phenomenological psychopathology as a new scientific field does not seem to be the original intention of the author. So, it might look awkward that this discipline had developed so successfully and autonomously throughout the twentieth and twenty-first centuries, as one can realize by studying the 2019 publication of the comprehensive Oxford Handbook of Phenomenological Psychopathology that brings together leading research regarding this topic from around the world.4 Are all these authors indebted to the original phenomenological intention of Jaspers? I should say, "yes and no."

"Yes," if one considers phenomenological psychopathology in its original Jaspersian meaning as a discipline concerned with the description of first-person experiences regarding altered mental states. The followers of this discipline may understand 1912 as the primum movens of their field. However, there is an even larger community of researchers to which the birth certificate of the discipline points to 1922, in an event in which the founding fathers Ludwig Binswanger and Eugène Minkowski laid the foundations for the study of the pre-reflective, transcendental, conditions of possibility of the first-person experiences, and thereby constituting a second-person, hermeneutic discipline. This first ambiguity is currently reflected in the division between two groups interpreting the role of phenomenology in mental health; although they are not mutually exclusive, one group privileges the examination of the language of first-person description of subjective experiences, and by doing so, is directly affiliating itself with Jaspers' approach. The other group ventures into the comprehensive analysis of the fundamental structures that allow the revelation of these experiences. The search for these fundamental structures is dedicated to the identification of the unitary way a person experiences one's mental alterations, that is, its essence.5 Since Eugen Bleuler, mental illness, in this sense, must be sought in the whole of human existence. The intuition of the essence of the alteration of the whole is thus the object of this science called phenomenological psychopathology.

However, Jaspers himself, reflecting upon the beginnings of this distinction, drew a kind of dividing line that will be fundamental for the comments I will make regarding Stanghellini's work. For Jaspers, this whole of human existence can only be the object of philosophical reflection; it is, in principle, alien to scientific investigation, whatever it may be. The limits of scientific knowledge would be, for the purposes of these comments, restricted to the efforts of access to the subjectivity of the patient by means of intersubjective empathy. In Jaspers' words:

But the theory we have been discussing refers to human life as a whole. This however is the proper theme of philosophy whereas science is only concerned with particular aspects of the whole. [GP 543]

With this statement, Jaspers delimits the boundaries between a distinct world, the philosophical one, uncompromised, on principle, with mental health investigations, and the scientific one, contemporarily called phenomenological psychopathology, for whom philosophy is, so to speak, an inspiration for the construction of a psychopathology-made-science. Thus, for Jaspers, philosophy and psychopathology-as-science are not reconcilable. This Jaspersian fracture brings several problems for subsequent authors all of whom venture into phenomenological psychopathology, since, for Jaspers, philosophy and science have distinct objectives and, consequently, demand distinct functions from the psychiatrist. Reconciling both demands has been a difficult task. Oftentimes, authors in phenomenological psychopathology either largely draw upon philosophy, thereby risking writing arcane texts, that are almost useless for clinical needs; or they draw upon their own ideas regarding psychopathology, thereby risking jeopardizing the depth of their analysis. Stanghellini's work is brave enough to successfully balance on this tightrope between these two abysses.

This tense dialogue between an autonomous philosophical discourse that is linked to a tradition of existential thought and another discourse that is also derived from it but focuses on constructing a clinical attitude together with a form of psychopathology as a tool for diagnosis to the end of providing care, marks Stanghellini's Lost in Dialogue from end to end. Importantly, for an author as prolific and experienced as Stanghellini is, this dialectic does not describe the entirety of his work; my considerations here are limited to Lost in Dialogue, a book that seeks to coordinate an anthropology as being the foundation for a psychopathology. And this foundation, in turn, is serving as a guide to develop the strategies for the clinical aspect. Articulating these three parts is the great challenge of the intellectual enterprise portrayed in this book.

Stanghellini's philosophical perspective is distinguished by the synthesis of three declared fundamental elements. First, by the emphasis on the dialogic notion, with special emphasis on the I-Thou relationship, of Buberian inspiration. Second, the importance of narrativity in the composition of the self, as understood from Paul Ricouer's perspective. Third, in a more diffuse way throughout the work, several perspectives of the Jaspersian philosophy of existence can be noted, especially the notions of cipher and housing (Gehäuse). I would even say that the main atmospheric inspiration (to stay with a concept defended by the author) of the book are the categories of Jaspers' philosophy, which privilege the ambiguous inaccessibility of the other but, at the same time, there is the inevitability of having the other as an existential horizon recognizable. Whatever influence one takes as being central to the anthropology defended by Stanghellini in the first part of the book, in each one the privilege is given to experience as it is being narrated in the first person. Truth be told, the author does not fail to point out the limitations imposed on the understanding of identity as the fruit of narrativity (LD 27). However, as a general spirit, narration stands out as a central element in the dynamics of the constitution of identity out of the dialectic with otherness; in Stanghellini's words:

Language is the means through which we exist. [LD 9]

A narrativity marked by the longing for access to an Other that necessarily reveals itself only as a concealment, that can merely be perceived through ciphers, as the author is arguing it and thus, he is agreeing with Jaspers' conception. I am interested in examining how this anthropology of first-person narrative dictated by the dialectic of alterity articulates with its direct consequences on mental health, the notion of psychopathology and that of cure.

Psychopathology:
The Notion of Mental Pathology

Consistent with the perception of anthropology set forth in the first part of the book, Stanghellini develops the notion of mental pathology as follows:

what we call "mental pathology" can be seen as the effect of the intolerability of the awareness of the Other's radical alterity. [LD 56]

That is, mental illness is part of the insoluble fissure inscribed in the human condition of inaccessibility to this Other who is, at the same time, the basic object of existence. This insoluble ambiguity, that is in itself constitutive of humanity, as it is common to all, can alternatively

generate defensive existential movements, alternatives, compensations, escape routes, or shelters that later develop into fixed forms of miscarried existence. [LD 56]

Mental illness is therefore not embedded in the root common to all existences, but in the way in which the self seeks to balance itself in the face of this original rift:

Mental pathologies may be read as miscarried attempts to struggle for a sense of reconciliation, to heal the wounds of disunion. [LD 65]

In other words, a mental pathology is a secondary reaction, a significant symptom, to put it in the author's preferred wording during the beginning of the second part, intended "to give a meaning to distressing experiences, to explain and cope with them" (LD 66). This conception of mental illness as being a secondary phenomenon rests firmly on the Jaspersian notion of housing (Gehäuse), as Stanghellini explicates:

mental disorders offer...a vulnerable shelter...a defense from the missed encounter with the Other. [LD 95]

This interpretive decision about the notion of psychopathology places Lost in Dialogue in the Jaspersian tradition of situating mental disorder into the dimension of subjectivity, and it is being understood as a dialectic with otherness. It is within that narrative when the other is partially absent, that the symptom of mental illness is secondarily formed. This decision, in turn, renounces the classic psychopathological conceptions, phenomenological or not, in which, since Bleuler, the apprehension of mental disorders is made through a double ontological scheme. For this phenomenological apprehension, schizophrenia originates from a primary rupture, namely the one between the pathological experience itself and the secondary reactions to it. They are epiphenomena in the anthropological dimension, although they are relevant from the symptomatologic point of view. In this context it is helpful to remember that the most classical distinction for situating mental disorders places the fragmentation of existence as the pathological core and the delusions and hallucinations as secondary phenomena.

By giving priority to the descriptive meaning of phenomenological psychopathology, enriched by a Buberian-Ricoeurian philosophical appreciation, Stanghellini outlines descriptive definitions of schizophrenia, for example the one where schizophrenia is seen as having at its center "the withdrawal from the intolerable failure of the relationship with the Other" (LD 102), in which

disincarnation and dis-attunement can arise as secondary, defensive involuntary strategies in a kind of existence faced with the awareness that the Other can only be approximated, not appropriated. [LD 105]

Stanghellini effectively shows that this protective withdrawal can be traced back to its emotional dimension, as a "protection for their own hyperaesthesia" (LD 102).

This enriched Jaspersian understanding is consistent with the conception of care as being

a shared project of reciprocal understanding between patient and clinician. [LD 171]

An existential project, shared by patient and clinician, guided by a strong ethical influence, whose aim is "the restoration of a disrupted sense of personal being" by means of a concerted effort of dialogical nature (LD 186). Reconstructing the life of the text, as the author puts it, is to an extent, reconstructing life.

However, for the defenders of the above mentioned second conception of phenomenological psychopathology, namely the hermeneutical conception, there is more to be seen.

The P.H.D. Method and the
Transcendental Move

Some of the statements presented in Lost in Dialogue are evidently not coherent with the arguments I have so far put forward. Schizophrenia may be simultaneously understood as being a "primary phenomenon...non-secondary to traumatic life situations" (LD 105). This conception of a disease as something original and irreducible per se can be enlarged to the whole field of psychopathology, and, in the words of Stanghellini,

does not exclude seeing abnormal phenomena as symptoms caused by a disease to be cured. [LD 113]

In short, a disorder is at the same time a secondary symptom and an original fracture to be healed by means of a quasi-medical perspective. This situation begs the question as to whether it is possible to reconcile these two perspectives that arise from different interpretations and uses of phenomenology in psychopathology, or, by using different words, does it make sense to reconcile them, in the name of a cohesive vision of mental pathology and treatment?

In order to investigate this question, a brief incursion into a passage of the book that appears to me to be the most consistent and profound is necessary, in which the P.H.D. method, Stanghellini's original invention, is presented. Stanghellini views the practice of care in the context of three basic dimensions, namely, phenomenological unfolding, hermeneutic analysis, and dynamic analysis, in short, P.H.D. In chapter 3 of part 3, the author's Husserlian influence manifests itself fully and thereby apparently abandoning the hitherto mostly Jaspersian texture of the work. Stanghellini notes that by scrutinizing the primordial structures of existence by way of the P.H.D. method

the second stratum [of the structures of the self] made visible by this process consists of the invisible conditions of possibility of the world disclosed in the first level. [LD 119]

Already in tune with the second conception of phenomenological psychopathology, the author relates understanding of pathologies to their conditions of possibility, and thus is

connecting a given experience (abnormal or not) with its transcendental condition of possibility. [LD 120]

It is these central changes in interpretation that will allow the notion of schizophrenia to be reshaped in Lost in Dialogue. Besides being a secondary reaction to an inaccessibility to the other, Stanghellini suggests that schizophrenia will also consist of

a given set of abnormal experiences originating from structural changes of subjectivity [which are] the core Gestalt or psychopathological trait marker of schizophrenia. [LD 149]

This shows that two simultaneous conceptions of phenomenological psychopathology are at work here. For the first one, care means a reconstruction of the necessarily intersubjective narrative of a self, by means of a dialectical interchange with the clinician. Concerning the second one, there are no clear references, although there are slight indications that a quasi-medical model would not be unwelcome. In an attempt to understand this duplicity and to bringing together these unlikely reconcilable relationships between anthropology, psychopathology, and care, Stanghellini's work offers an inclusive interpretation of the phenomenological tradition.

How to read Lost in Dialogue?

My point is that Stanghellini's contribution in Lost in Dialogue is a historical outlining of the discipline to which it belongs, a hybrid between philosophy and the applied humanities, characterized by its refusal of the formation of a closed system, and thereby shaping a methodologically open perspectivism. Very much in the tradition of Jaspers, Stanghellini makes his thought revolve around the multiplicity of perspectives of phenomenological psychopathology, and thereby moving toward an originality of his contribution. By assimilating philosophical concepts directly, transmuting them to serve his clinical purposes, and assembling them under a particular synthetic notion, Stanghellini upholds Jaspers' position that continues to be an intellectual antidote against every yearning for absolutism, intellectual or otherwise. I see Lost in Dialogue as the literary materialization of a passage especially dear to me, that is situated at the beginning of Psychologie der Weltanschauungen where Jaspers names the task for psychology:

Thus, the task consists in being systematic and yet attempting to not let any system enable to rule, so that as many systematic thoughts, possibly all of them, come into effect.6

Taking the message presented in Lost in Dialogue by its word, namely conveying the intention of unclosing reality in an effort of moving it toward a world of globally minded citizens, one can say that Stanghellini successfully encourages his readers to keep their eyes open by not adhering to any one closed system, but, instead, being able to take an active part in advancing distinct systems. This, to me, is the most democratic expression of a humaneness I can imagine of.

Some Psychopathological-Clinical Issues

In the composition of Lost in Dialogue the rare mention of works expressly dedicated to phenomenological psychopathology is striking. Most of the references with which the author dialogues come from what one could loosely call existential philosophies. This decision indicates Stanghellini's alignment with an anthropology that is unaccustomed to fixating on a single psychopathological form and, in a way, also to the way Jaspers approached the major existential themes of psychopathology. Thus, there is a vague character to the work, which invites the reader—almost forces one—to try to address some specific aspects of it, in the form of rhetorically asked questions to the author. Open perspectivism defends one from many forms of authoritarianism and intellectual absolutism and it thus may also leave room for some forms of incompleteness of the arguments, which are worth pointing out, particularly in a work dedicated to the dialogue between the two realms of philosophy and psychopathology. The pragmatical consequences for psychopathology and clinical care of these incompleteness are the main reason for the possibility of being able to raise these questions. I highlight three of them.

First, considering that the author builds his arguments, as mentioned above, on two perspectives, and that there are correspondingly two concurring definitions of the core alteration of schizophrenia, one can ask: from the psychopathological point of view, when should preference be given to an investigation of the language contained in the patient's narrative and when is the best way forward conducting an investigation of the conditions of possibility of it, guided by the P.H.D. method? Neglecting this question could be problematic.

Let me take as an example the delusional experience. If narrativity is the gold standard of any access to existential reality, it would be virtually impossible to affirm the occurrence of a delusional experience, unless the patient describes this experience as such. It is known how rarely delusional people, mostly at the beginning of their suffering, are aware of the essence of their altered experiences. If taken to its ultimate consequences, this emphasis on narrativity would make psychopathology disappear as a science of investigating conditions of possibility.

Moving methodologically from narrativity to the structure of the conditions of possibility and vice versa appear to be specific cases of the art of clinical care, upon which depends a successful outcome. Addressing this topic is crucial for each endeavor trying to advance any type of psychopathology based on an open perspectivism. For these reasons it would be valuable if Stanghellini were to further explore this relevant issue.

Second, when a symptom, say, schizophrenic, has as its foundation exactly the incapacity of having the Other constituted as an integral person (that is, when an understanding between patient and clinician is not established), what approach should the clinician take to overcome this impossibility of manifesting oneself as being an integral person for the patient? Likewise, when the rupture of structural intersubjectivity makes a schizophrenic patient unmotivated to elaborate upon themes regarding the patient's existence, that is, to transform them into a shared narrative text, how can the clinician proceed in the reconstruction of the patient's life?

These are arguably some core challenges for a mental health clinician. I would argue that successfully addressing this situation is crucial for the relevance of phenomenological psychopathology in current times. There is a trend in contemporary phenomenological psychopathology to understand the reconstruction of one's life as being primarily a narrative endeavor. However, as I have just pointed out, building clinical care exclusively on narratives may have as its consequence that the psychiatrist is simply unable to access and help to transform at the core the altered experiences of a person. In short, it remains unanswered what to do when language cannot be the guiding line of a recovery experience. The richness of the use of phenomenology in clinical care depends upon some answers to this problem.

Finally, I suggest that a more philosophical and yet equally unresolved question in the practice of psychopathology comes to the fore when reading Lost in Dialogue. It has to do with the nature of existing and, as such, of being mentally ill, and recovering from it. As the structure of existence presents as conditions of possibility temporality, spatiality, embodiment, and so on, it is reasonable to affirm that in certain conditions the relevance of the search for the Other as the origin of symptoms can be of lesser value. In other words, it remains to be an open question as to whether being mentally ill is always synonymous with losing the fundamental attunement to the Other, or whether it can also mean that at times one is unable to structure oneself as a coherent being in time. Perhaps both situations apply. This remains an unresolved issue with far-reaching clinical consequences. For example, if it is reasonable to sustain that in some cases the core of a mental disorder is temporal rather than intersubjective, recovering would mean to address temporality instead of otherness, which would putatively entail distinct, if not contradictory, strategies.

These three questions affirm, in a way, the great seminal potentiality that a work of impact such as this one has by contributing to the continuity and enrichment of central themes that define the bedrock of psychopathology. May Lost in Dialogue continue to inspire clinicians for many decades to come.