Ludwig Binswanger: Contributions to an Intersubjective Approach to Psychosis
December 25, 2004

Ludwig Binswanger was a pioneer in establishing a non-reductionistic approach to human suffering and distress, a psychiatrist and member of a family with a long tradition in psychiatry. His grandfather and father were medical directors of the Kreuzlingen Clinic in Switzerland (Anna O had been a patient there). Binswanger maintained a long-term friendship with Freud, despite their theoretical differences - which suggests that the deterioration of Freud’s relationship with Jung, and others in the psychoanalytic society, was not primarily a product of Freud’s purported inability to tolerate disagreement. (See his book, Sigmund Freud: Reminiscences of a Friendship, Grune & Stratton, New York, 1957.)

Emmy van Deurzen-Smith (see her Everyday Mysteries: Existential Dimensions of Psychotherapy, published in 1997 by Routledge), an existential psychotherapist at Regent’s College in London and someone who is responsible for the contemporary resurgence of this approach in the London school of existential analysis, noted:

“Binswanger considers mutuality, or being-with to be fundamental to human existence. Instead of having to choose between Heidigger’s inauthentic being with others or authentic being alone, we can redeem ourselves and others through true encounter in Buberian style. This encounter, which is a loving mode of being, is what the therapist should aim for with the patient.” (p.147)

Binswanger emphasized that therapists should observe and describe the world relations of the other with the greatest care. He disagreed with the reductionistic thinking in psychiatry as well as in some of Freudian psychoanalysis. He attempted to locate meaning within the person’s relations to self and others as represented even in the most unusual symptomatology thereby countering theoretical exclusion of psychotic patients from psychological understanding (a needed antidote to Jasperian incomprehensibility. (For a searing criticism of Jasper’s position of delusions as incomprehensible, see an excellent new volume on schizophrenia and bipolar disorder by Giovanni Stranghellini, Disembodied Spirits and Deanimated Bodies: The Psychopathology of Common Sense, published in 2004 by Oxford University Press. Stanghellini views Jasper’s incomprehensibility as the effect of de-personalized understanding). Van Deurzen-Smith concluded:

“Perhaps the most significant contribution of Binswanger was to systematically emphasize the importance of finding out what a patient means by a symptom, or any other aspect of their expression of themselves. The psychotherapist is never allowed to interpret anything in accordance with a pre-established system of meaning that is of the therapist’s invention. In good phenomenological tradition it is the underlying specific meaning that is explored and never guessed at or imposed. This aspect of Binswanger’s contribution remains most relevant today.” (p. 149)

Binswanger’s theory of intersubjectivity is an important alternative to the individualism of much of philosophical (e.g., Sartre), psychiatric (neo-Kraepelinian reductionism), and certain psychoanalytic ( some forms of Freudian and Lacanian psychoanalysis, etc.) thought. Binswanger emphasizes mutual recognition - the subject emerges from the relation (Hegel) - a refreshing antidote to counter-dependency (e.g., the theory of destructive narcissism brilliantly described by Herbert Rosenfeld), rugged individualism in personal relations as well as in political thought (reliance on omnipotent solutions) which eschews collective dialogue.

Binswanger, a psychiatrist at the Burghölzli Psychiatric Clinic, was critical of Freud’s theories of psychopathology as well as Heidigger’s neglect of the importance of interpersonal love in his theory of authenticity. Binswanger believed that self-realization can only be achieved through reciprocity in relation. He valued Martin Buber’s philosophy of dialogue. His phenomenology of love is heavily influenced by Buber’s I and Thou. I think that perhaps Gaetano Benedetti, who also worked at the Burghölzli Clinic, was influenced by Binswanger’s concepts of duality and intersubjectivity and applied these to his understanding of psychotherapy with persons with schizophrenia. For Binswanger, reciprocity was predicted on a dynamic balance between separateness and relatedness. Benedetti understands the psychotherapy of psychosis as an attempt to assist the patient to integrate the separate and symbiotic selves which are de-integrated in schizophrenic psychosis. In the latter, there are vacillations between a fusion transference with others and the world (e.g., hallucinations, referential paranoid experiences) and an autistic retreat from relation (negative symptomatology).

Binswanger follows Buber in arguing that human relations are by their essential nature dialogical (not simply referring to a linguistic mode, rather to a basic structure of human existence - currently, this is being mapped in infant research by such theorists as Colwyn Trevarthen in Scotland. See his “The self born in intersubjectivity: The psychology of an infant communicating” in The Perceived Self: Ecological and Interpersonal Sources of self-Knowledge, edited by Ulric Neisser for Cambridge University Press in 1993.

For Heidigger (Being and Time), human existence (Dasein) comprehends the authentic sense of its Being when it anticipates the inevitable possibility of its own nonrelational death. Death cannot be represented by the other, hence, authentically existing dasein for Heidigger, is essentially alone. Binswanger disagreed with Heidigger’s claim that authentic existence as being-towards-death is the condition for authentic being-with-others. Binswanger (Frie 1997) stated:

“Heidigger stresses again and again that existence, world, being-with, and dasein-with, are equiprimordial constituents of being-in-the-world. For him, however, the existential emphasis is throughout on being-self as one’s own most potentiality-for-Being-whole, out of which the authentic being-with-others first becomes possible” (p. 79)

For Binswanger, the human Dasein is an irreducible duality. Dasein in its original form is a “we-hood,” against which the expanse of existence, selfhood and individuality appear as secondary. Binswanger entered into a lifelong friendship with Martin Buber. For Buber, the subject of intersubjectivity is central to his entire philosophy. Frie (1997- Subjectivity and Intersubjectivity in Modern Philosophy and Psychoanalysis: A Study of Sartre, Binswanger, Lacan, and Habermas, published by Rowman & Littlefield) noted:

“According to Buber, the character of a relation is determined by which of the basic words is spoken: when I-Thou is said, the I is different from the I that speaks the primary word I-It.” (p.89)

Buber believed that I-Thou and I-It relations are dialectically related. The I-Thou word can only be spoken with one’s whole being. It is characterized by mutuality between two subjects, openness and directness. The I-It relation constitutes a bending back towards oneself, away from the other, who is considered instrumentally as an object for one’s own use. For Buber, persons are sick in the ‘between.’ The dialogical context cannot be understood as two individual existences, but only as that which has its being between them. Frie articulated:

“The between exists only in relation, and is not continuous, but is reconstituted with each new human encounter. The between essentially denotes the reality of relation.” (p.91)

For Binswanger, the mutual relationship of love, the dual mode of love, constitutes the most original and ‘highest’ form of human existence. Merleau-Ponty (Frie 1997) remarked:

“To love is inevitably to enter into an undivided situation with another. From the moment one is joined with someone else...One is not what he would be without that love; the perspectives remain separate-and yet they overlap.” (p.92)

Binswanger believed that in the dual mode of love, the I can only recognize a Thou through an encounter based on mutuality and reciprocity. I am reminded that in the Biblical tradition, loving and knowing co-constitute each other. One cannot really get to know and understand another person unless one is willing to establish a libidinal open link with her or him.

Binswanger noted: “...our conception of Daseinsanalysis is anthropological, erotic, or dual, and begins from Dasein as ours...From the perspective of this Dasein, existence (as mine, yours, his/hers) can only be understood anthropologically as a deficient mode.”

Binswanger thought that hate arises from the experience of estrangement and alienation within the love relation and is directed towards the other who is the cause of the feeling of instrumental objectification. In love, separateness and union must exist simultaneously (similar to Benedetti’s concept of pathology - a de-integration of separateness and symbiosis - and his correlative view of therapeutic action - fostering the capacity to avoid self-loss while experiencing states of autonomy or relatedness).

Binswanger predicated intersubjectivity upon the dialectical relationship between separateness and sameness. In this model of Binswanger’s, the theoretical perspective of Harold Searles in the psychotherapy of chronic schizophrenia would not be a linear (albeit alternating) movement from pathological to therapeutic symbiosis and finally to individuation, rather, in terms of therapeutic action, it would entail a dynamic relationship between a more therapeutic symbiosis (less threatening, and therefore less generative of hate and annihilation anxieties than a pathological symbiosis) and individuation - the two poles co-constitute each other (could not exist without the other). Benedetti and his colleague Maurizio Peciccia like to use the metaphor of light - in illuminating the self-it consists simultaneously of waves (symbiotic self) and particles (separate self).

Frie (1997) concluded:

“Binswanger insists that intersubjective reciprocity must always be predicated upon acknowledgment of the other’s alterity. Without affirmation of difference, the other will become dominated and dependent, or be reduced to a mere third person, one who stands over and against me. By elucidating the interrelation of separateness and togetherness, Binswanger provides a framework within which to understand the structure and importance of reciprocity in a love relation” (p.106).

As an “interpersonal psychobiologist” (a term given to me by Maurice Green, M.D.), I assume that the phenomenology of love and compassion registers neurobiologically and somatically. t is to this question that we now turn.

In a fascinating new volume of a scientific dialogue between the Dalai Lama and Western scientists (“Destructive Emotions: How Can We Overcome Them? : A Scientific Dialogue with the Dalai Lama” narrated by Daniel Goleman, 2003, Bantam Books), Tibetan monks have been subjected to various neuroimaging techniques (e.g., fMRI) in order to explore the effects of such processes as meditation, e.g., on compassion for all beings including enemies, on neural functioning. Richard Davidson, of the Keck Lab for Functional Brain Imaging and Behavior at the Madison campus of the University of Wisconsin , along with Paul Eckman at the University of California at San Francisco , were some of the investigators. In brief, what they found was quite astonishing. Some of the many findings were that the startle response (to a gunshot) was completely suppressed [with implications for therapy of persons with PTSD as well as other affective disorders - personally I thought of the P50 evoked potentials observed in schizophrenia research - according to a meta-analysis of the neurobiological & neuroscience literature by R. Walter Heinrichs in his In Search of Madness: Schizophrenia and Neuroscience, published in 2001 by Oxford University Press - showing this measure to be the most reliable in distinguishing persons with schizophrenia from controls, even more than any neurobiological finding such as ventriculomegaly].

The researchers also found that a compassionate state of mind shifts neural activation from the right middle frontal gyrus [associated with chronic states of dysphoria, e.g., depression and anxiety], to the left middle frontal gyrus [associated with states of pleasure, happiness, etc.]. Compassion, as the Dalai Lama pointed out is also good for the one who experiences and acts compassionately towards others. I believe this is what Harold Searles noted in his concept of patient as therapist and the need for the therapist to see and acknowledge the patient’s psychotherapeutic strivings, often underlying what seems to be destructive attacks on the analyst. His concept of the psychotherapeutic impulse (which we have adopted as our newsletter logo for ISPS-US) is quite in line with this new research.

The therapeutic symbiosis has a profound stabilizing effect on our neurofunctioning (see Research on Altruism & Love: An Annotated Bibliography of Major Studies in Psychology, Sociology, Evolutionary Biology, & Theology, edited by Stephen Post et al in 2003 for the Templeton Foundation Press for an in-depth review of these issues - one pointing to the altruistic trend as non-reducible to simple self-protection - I think of the courage so many individuals displayed on 9/11 staying within the towers in order to comfort and rescue the wounded knowing full well at the time of the gravity of the situation).

Brian Koehler PhD
New York University
80 East 11th Street #339
New York NY 10003

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