What Is the Role of Philosophy in Psychiatry, Thomas Fuchs?

The University Clinic of Heidelberg has a long tradition of philosophers working in psychiatry. Professor Thomas Fuchs, the head of the research unit Phenomenological Psychiatry and Psychotherapy, explains how phenomenological research is carried out in a psychiatric hospital and how his philosophical commitments are present in his interaction with patients. The interview illuminates some main features of his thought concerning embodiment, affectivity and the unconscious. Fuchs understands emotions as relational, bodily and spatial phenomena, and he argues that the unconscious is not some hidden chamber in the depth of our psyche but experienced by our bodies.

Thomas Fuchs, your research unit at the University Clinic of Heidelberg, Phänomenologische Psychopathologie und Psychotherapie (Phenomenological Psychiatry and Psychotherapy), investigates the philosophical foundations of psychiatry and psychotherapy from a phenomenological point of view. How would you describe the objectives of phenomenological research in psychiatry?

The major goal of this research unit is to investigate the subjective and intersubjective experience of mental disorders by phenomenological means. The usual objective of psychiatry is to look for the underlying causes of mental disorders in order to treat them. Phenomenological investigation, however, brackets this common approach and abstains from the quick look at the underlying causes and what lies “behind” certain symptoms. Instead, phenomenology tries to understand, grasp and describe, not just specific symptoms, but the whole of a patient’s experience of his being-in-the-world.

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The aim is to grasp that experience in interaction with the patient and to describe its major dimensions such as embodiment, temporality, intentionality, intersubjectivity and experiences of space, atmospheres, feelings, and connection with others. We are also interested in the existential dimensions of disorders, such as how they change your way of life, the concept of yourself and how you deal with the major break they have brought into your life. These are the major existential questions that mental illness poses to patients.

What are the research interests of the phenomenological research unit in Heidelberg, and how do you understand their significance in terms of therapeutic practices?

This unit is particularly specialized in embodiment, that means, all issues of the lived body, including the body memory and changes of one’s relationship with the body in mental disorders. As we are interested in the lived, embodied, and holistic experience, the approach is very compatible with experience-centered therapies, such as creative therapies, body-oriented therapies, music therapy and art therapy, which address the self-experience and the self-experiencing of the patient. These therapeutic practices do not often have an explicit theoretical and conceptual background, but phenomenology provides them with a clearly formulated theoretical framework. These therapy forms are also used in this hospital. Art therapy was something I introduced to this clinic, and music therapy has been known and applied for a much longer time. Body-oriented therapies, such as dancing and dance-movement therapy, have been introduced more recently, but they are not yet very well established.

In empirical research the word “phenomenology” can be used in various ways. Sometimes it can mean interviews or autobiographical descriptions, in other occasions the field of neurophenomenology. The research environment in the Heidelberg University Clinic is multidisciplinary. What types of methods, besides classical philosophical phenomenology, are used by the researchers to investigate patients’ experiences?

Phenomenological interviews and descriptions of patients’ experiences form the main basis for a phenomenological analysis. These can be done in different ways, for example by semi-structured interviews or self-descriptions of the patient. Patients’ self-reports and literary descriptions are very valuable sources. From time to time we also have research projects that use structured interviews or self-rating questionnaires, formulated by psychiatrists. One of our doctoral researchers applies movement analyses carried out in a movement lab, where patients are investigated during certain movement procedures. We can then compare these objectified features of movement in space with the subjective bodily experience of the patient. Another project investigates the interaction of patients with delusions by structured or semi-structured interviews to figure out how they explain why their views are not compatible with those of others.

Developing a certain interview procedure may also be part of a specific project. When Louis A. Sass and Josef Parnas were leading the development of the semi-structured interview-techniques based on phenomenology (EASE, EAWE)¹, they found it astonishing how they could follow these sets of questions with patients and become aware of the layers of experience that previously were difficult to make any sense of. The patients felt somehow strange in their bodies and with themselves, unfamiliar and different from others without really knowing why or how to describe it. The phenomenological interview helps them to express and understand these basic experiences better. At the moment we are developing a new, phenomenological interview for depressed patients. With the help of the patients’ feedback we are able to see how the questions work and how they should be modified and refined. This development process takes a lot of time.

Understanding the coexistence of philosophy and psychiatry in Heidelberg requires understanding its historical background. The University Clinic has a long tradition of philosophers working in psychiatry. For example, your professorship is named after Karl Jaspers. In the article “Existential Vulnerability: Toward a Psychopathology of Limit Situations” you use Jasper’s phenomenology to discuss certain cases of mental disorders.² What in your view is the most important legacy of Jaspers?

The research unit Phenomenological Psychiatry and Psychotherapy was founded in 2000, but, as you said, it has a long tradition before that with some major figures of phenomenological psychopathology in Heidelberg and in Germany, such as Hubert Tellenbach and others. It’s quite difficult to summarize the importance of Karl Jaspers’ work, because he is still so significant to psychiatry and to our understanding of psychopathology as a whole. General Psychopathology is still a groundbreaking work for psychopathology, and it has been written about extensively during the last ten or twenty years.³ The 100th anniversary of its publication in 2013 led to a series of books, papers and journal editions on Jaspers. There are several aspects of his work that can inform the phenomenological approach to psychopathology even today: his ideas of empathy and existential communication and his insistence on the autonomy of psychopathology with regard to neuroscience are still valuable. Jaspers didn’t deny that certain major mental disorders may have biological origins, but he insisted that they have an irreducible dimension of subjectivity that can only be approached by phenomenological means.

In my own work with patients, I find his conception of limit situations particularly useful. Jaspers does not actually discuss limit situations in General Psychopathology; the analysis has been drawn from his other works, but I have tried to make it fruitful for understanding the existential dimensions of mental disorders. On the one hand mental disorders are limit situations themselves, as they put our everyday lives and views of ourselves into question, but on the other hand they can also be the result of a limit situation, where a patient experiences a breakdown of their former, commonsensical assumptions about the world, how life should be and how it should proceed. The concept of limit situation can be helpful in both cases, also in order to understand, together with the patient, what exactly triggered the illness.

However, I won’t deny that I also have problems with Jaspers’ hesitation towards deeper phenomenological analyses of mental disorders. I wouldn’t say his works were superficial, but he always stayed on the level of description and never followed the phenomenological movement or its development neither to transcendental phenomenology nor to phenomenology of the body. He largely ignored all these major developments of phenomenology. In fact, he warned against going too deep into existential and anthropological questions, because he thought that the human being cannot be grasped and represented completely by holistic approaches. He also had a severe reservation towards psychoanalysis and towards the idea that the unconscious conflicts, strivings and drives could play a major role in mental illness, its explanation and treatment.

One of the themes of this issue is the unconscious. In your article “Body Memory and the Unconscious,” you introduce a concept of the unconscious that challenges the traditional psychoanalytical views.⁴ How would you describe your relationship with psychoanalysis today?

My relationship with psychoanalysis is an ambiguous one. I’ve learned a lot from psychoanalysis, and I have found it a necessary perspective for my work. I started with cognitive-behavioral therapy when I did my psychotherapeutic training, but then I also went to family and psychodynamic therapy and thought that psychoanalysis is something I should learn. I think I know quite a bit about it and I’m applying the psychodynamic approach myself.

However, my major hesitation is a philosophical one. Freud’s whole metapsychology seems speculative and dualistic to a severe extent. I find problematic the ideas that there would be an inner psyche that is somewhere deep inside us and that the unconscious would be a kind of basement where all kinds of representations, images, wishes, and drives play their roles, and nobody can interpret and explain all that, unless you are a psychoanalyst. I’m skeptical of this type of expert knowledge. Moreover, we should ask what the psyche is in the first place. Is it supposed to be this specific realm apart from the body where all these ideas, values, the ego or the super-ego rule over the body and its drives?

Phenomenology would claim, instead, that everything that is unconscious could at least be experienced and understood by the patient. Everything which is unconscious is not somewhere in the brain or somewhere in the psyche, it is enmeshed in your way of being: behavior, attitudes, body, habits, ways of interacting with others and the whole way of living your life in a certain environment. The unconscious is embodied and enacted. Of course, I can have thoughts, images and ideas that others cannot see, but it does not turn my inner life to an “inside” from which I need to get out to reach others. I’m already in the world, I am this body, this living bodily being.

The phenomenological critique of psychoanalysis also has implications in terms of therapy. Being a patient, a therapeutic process as a form of interaction should lead me to see the different layers of experience, my own unconscious behavior and wishes that are already there. Otherwise it could never be my own mental life that becomes accessible in a therapeutic process but something that is only learned from another person and something which remains alien to me because it is not part of my experience.

Your work is known of its emphasis on the body, situatedness, and interaffectivity which refers to interactive formation of emotions.⁵ Could you explain what you mean by the concept of embodied interaffectivity?

The main idea leads to the direction that we already talked about, namely that emotional life is not something inside but something which is embodied and between ourselves and the world. It’s not just something inside your head or your brain where you would make evaluations of the incoming stimuli. In phenomenological terms, emotions are lived and spatial ways of relating to the situations and others in your life. “Lived and spatial” in this context means that the relation you have with a certain situation engages your body in a way that can only be described in spatial terms. For example, you are attracted by or feeling aversion towards something, you want to withdraw or approach something, to raise or jump or to hide – these movement tendencies that you feel in our body are inseparable from emotions.

Similarly, what is inseparable from emotion is bodily resonance, as I call it, which is not only movement but all kinds of sensations in your body: feelings of warmth, tickling, shivering, constriction or expansion, tension or relaxation, etc. The body is a constant resonance organ for emotions. This resonance is the way in which you are interacting with a certain situation with its affective qualities. The situation is what sets you into resonance, but only because you are resonating with the situation. Relations and interactions between the body, the situation or the other person create the emotion. In other words, emotion is something that you feel in relation with the world and with others and it bridges the distance between things and yourself. Embodied interaffectivity then means that two resonating, affective bodies are interacting and in relation to each other. You can use the metaphor of two tuners of a musical instrument: if you bounce one tuning fork, the other one will start resonating as well after a certain time, creating this joint movement. That is also what our bodies do in relation to another person, another object or a situation.

You are a psychiatrist and also a psychotherapist. In what ways are your philosophical views present in your clinical work with patients?

It is not easy to answer how the philosophical background is present in the clinical work, but it is something that informs your ways of interacting with a patient, your questions and interests. Phenomenological analysis does not form a regular framework for asking the patients certain questions or describing in detail certain dimensions of their experience. There is just not enough time for it. A thorough phenomenological investigation takes place in specific research conditions, in which we use phenomenological interviews, such as the EASE, in order to take more time with the patient and ask them about the basic, often pre-reflective, not quite conscious experiences in more detail. In research this approach can be developed in a deeper and more extended sense.

Usually psychiatrists ask for certain manualized list of symptoms, which are worked through, such as do you experience voices, do you have the experience that someone is behind you, are you able to do your daily work, do you have feelings of guilt, and so on. These symptoms are of course characteristic to mental illness, but they do not give a description of the holistic way of experiencing, for example how it is to be depressed or persecuted by unknown forces or anonymous enemies, or how your body changes in certain schizophrenic experiences. That requires very subtle verbal descriptions and the capacity of the psychiatrist to ask certain additional questions to describe and clarify these hardly describable experiences.

I think that my phenomenological background is most concretely present in my psychotherapeutic practice. As pointed out, the phenomenological approach tries primarily not to look for what lies deep inside the patient or underneath their experience but to elaborate on the preconscious bodily experience and ways of interacting and experiencing the world. I do not use any phenomenological jargon, of course, when I talk with patients. It’s more like a certain way of looking at the experience that informs my interaction, I would say. This way means following the moment-to-moment process, as near as possible to the here and now of our shared situation – and this is where the phenomenological attitude can be most helpful.