Ludwig Binswanger and Martin Buber: Contributions to an Intersubjective Approach to Psychosis
Ludwig Binswanger was a pioneer in establishing a non-reductionistic approach to human suffering and distress.
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 Heidegger’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 Stanghellini 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).
Binswanger, a psychiatrist at the Burghölzli Psychiatric Clinic, was critical of Freud’s theories of psychopathology as well as Heidegger’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 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 life-long 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 integrated 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).
Now to the essential corrective of Martin Buber: Buber understood the human being in terms of dialogical relations-an antidote to the suffocating reductionistic objectification that has a stranglehold on much of psychiatric research as well as in the general culture (see Martti Siirala’s concepts of collective splitting). As pointed out by Mick Cooper (see his excellent Existential Therapies published in 2003 by Sage Publications), that of all the existential philosophers, it was Buber who examined concrete relationships between individuals. Cooper noted:
“Buber holds that the I is always in relation to an Other, but he makes a fundamental distinction between ‘I-It’ and ‘I-Thou’ attitudes to this Other. In the ‘I-It’ attitude, the other is experienced as thing-like, determined object[what comes to my minds are the television and journal ads reducing the questions of human problems to psychopharmacological ‘solutions’-Paxil is the answer to your ‘social phobia’]: an entity that can be systematised, analysed and broken down into universal parts... By contrast, in the ‘I-Thou’ attitude, we behold, accept and confirm the other as a unique, un-classifiable and un-analysable totality: as a freely-choosing flux of human experiencing [for an excellent discussion of the question of free-will vs. determinism from a neuroscience basis see Walter Feeman’s How Brains Make Up Their Minds published in 2000 by Columbia University Press]. For Buber, such an I-Thou attitude requires a meeting with the Other as they are in the present, rather than in terms of our past assumptions [Bion’s without memory and desire] or future needs.
It is an opening out to the Other in their actual otherness-and a loving confirmation of that otherness-rather than a self-reflexive encounter with our own stereotypes and desires. Buber also argues that such an I-Thou attitude requires the I to take the risk of entering itself fully in to the encounter: to leap into the unpredictability of a genuine dialogue with all of its being-including its vulnerabilities-and to be open to the possibility of being fundamentally transformed by the encounter. Buber is not talking here about a merging with the Other-we cannot encounter what we are...What he is suggesting...is that we have the potentiality of experiencing moments of deep I-Thou connection with Others” (p. 20).
The significance of the I-Thou relation was recognized by Ferdinand Ebner in his “Das Wort und die geistigen Realitäten.” Ebner thought that psychosis is the complete closedness of the I to the Thou. Neither love nor words are able to reach the person. The person who is psychotic talks past the other, is unable to speak to a concrete Thou. The world has become a projection of his I (similar to Louis Sass’ views on self as all and self as nothing). Buber thought that if a person does not represent the a priori of relation in her/his living with the world, it ‘strikes’ inwards. Consequently, confrontation of what is over against one takes place in oneself (Bleuler & Minkowski’s autism), and this means self-contradiction, ‘the horror of an inner double’ (I think of one of my patient’s autistic withdrawal from what he experiences as persecutory relations resulting in his being in continuous persecutory hallucinatory and delusional internal relations, significantly, he says with himself which feels like not-me). The person loses her/himself in a maze ever more profoundly.
Viktor von Weizsäcker (highly regarded by Martti Siirala), a physician and existential psychiatrist, made important contributions to the field of psychosomatic medicine and was very influenced by Buber. Von Weizsäcker emphasized the self isolation of the person with psychosis, there is little Thou for its I. The result of this absence is the installation of this double, for the state of this aloneness is unbearable (see the work of HS Sullivan & Frieda Fromm-Reichmann on loneliness). The split in the I reflects on the felt unattainable relation of I to Thou. Von Weizsäcker, in his medical anthropology, recognizes the difference between an objective understanding of something and the ‘transjective’ understanding of someone. The patient is a subject, like the physician, who cannot become an object without a loss of vital contact.The most important aspect of ‘inclusive’ therapy, according to von Weizsäcker, is that the physician allows her/himself to be changed by the patient (see Searles ‘patient as therapist’ as well as the work of Gaetano Benedetti), this contact brings the I and Thou closer together.
Hans Trüb, a psychotherapist influenced greatly by Buber, realized that the abyss in the patient calls to the abyss, the real, unprotected self, in the psychotherapist, and not to her/his confidently functioning security of action.
I would like to end this with the profound words of Martin Buber and Bakhtin:
"A soul is never sick alone, but always through a betweenness, a situation between it and another existing being. The psychotherapist who has passed through the crisis may now dare to touch on this” (Buber).
"I am conscious of myself and become myself only by revealing myself to another, through another and with the help of another...Every internal experience ends up on the boundary. The very being of [woman] man (both internal and external) is a profound communication. To be means to communicate...to be means to be for the other; and through him [her] for oneself. Man has no internal sovereign territory: he [she] is all and always on the boundary" (Bakhtin).
