In 5 minutes, so much can be accomplished.
Let’s imagine that you, Dr Jones, are sitting in your office on a warm day in June, waiting for your next patient, and staring out the window that overlooks the street, one story below. Suddenly, a woman strolling on the sidewalk catches your attention. She has long, blonde hair; a look of keen intelligence, and a smile on her face. All at once, you feel overwhelmed with emotion. Your eyes brim with unexpected tears; your heart flutters; your face flushes, then quickly blanches.
How would we explain your psychophysiological reaction in response to seeing this woman? How would we understand it? These 2 terms--explanation and understanding--turn out to be conceptual windows into 2 different yet complementary approaches to human psychology. Thus, a neurophysiologist might offer (very roughly) the following explanation of your reaction:
Dr Jones’ retinal photoreceptors registered the image of the woman and sent electrical impulses to the optic nerve. The impulses passed through the optic chiasm to the lateral geniculate bodies of the thalamus, and eventually to Dr Jones’ occipital lobe. At the same time, a second visual pathway allowed nerve impulses to activate primitive limbic system structures, including the amygdala. Activation of the amygdala resulted in Dr Jones’ strong emotional reaction to the woman.
Now, allowing for considerable oversimplification, this is a perfectly reasonable causal explanation for your emotional reaction. But few of us would argue that it provides us with much understanding of why this particular woman seemed to have such a dramatic effect on you. Enter our friend, the phenomenologist, who--for purposes of our discussion--has a detailed understanding of your mental state, personal history, and relationships. She gives the following account:
Dr Jones did not actually know the particular woman who passed by on the sidewalk. The 2 had never met. But the woman reminded Dr Jones of a dear friend from college, who had died over 20 years ago. Dr Jones had long harbored guilt feelings about failing to stay in touch with this friend, and felt particular regret over not having visited this friend when the woman was gravely ill. When Dr Jones saw the woman outside, he initially experienced a mixture of joy and sorrow, followed almost instantaneously by deep remorse and anxiety.
Ah--a much more satisfying narrative, but no more correct than our neurophysiologist’s explanation. The 2 narratives are complementary, and represent 2 different modes of knowledge. The philosopher of history, Wilhelm Dilthey--and later, the psychiatrist Karl Jaspers-- used the terms erklaren (causal explanation) and verstehen (meaning-based understanding) to describe these 2 modes of knowing.2
In all the sciences-but particularly in the human science of psychiatry3--we often experience a dialectical tension between erklaren and verstehen. For example, the psychiatrist who is seeing a severely depressed patient may view the patient’s condition using 2 basic schemas, sometimes oscillating from one frame of reference to the other: (1) This individual’s brain function--her serotonergic system, neurocircuits, nerve growth factors, etc--may be aberrant in some way that is causally contributing to her depression (erklaren); (2) In addition, and equally important, this person’s recent job loss has led to a profound loss of meaning and self-esteem in her life, which is clearly relevant to her current depression (verstehen). We can analogize this dialectic to viewing that famous “perceptual ambiguity” picture, which may be seen either as a young or an old woman, depending on what elements of the picture you are attending to--there is only 1 picture, but 2 ways of perceiving it.
Phenomenology may be understood as a subtype of meaning-based understanding: it is concerned with the meaning a particular perception has for a subject. For the phenomenologist, a perception is not merely the passive reception of data. Rather, perception is always about something--it is intentional. Perception is always accompanied by interpretation, and has a particular intrapsychic structure. For example, Dr Jones’s perception of the woman strolling on the sidewalk was structured by Dr Jones’s chronological recollection of events and their associated feelings. Phenomenology thus aims at a structural understanding of the person’s felt experience.4
It should be evident that this approach is quite different from that of either the neuroscientist or of the external observer using a largely descriptive method, such as we find in the DSM. Phenomenology is not hostile to neurobiological or descriptive approaches; nor does it take sides in the perennial controversies over mind versus brain, psychological versus neurological causation, and so forth. Phenomenology simply brackets, ie, suspends judgment on, these issues; instead, it goes back to the things themselves, to use philosopher Edmund Husserl’s famous saying.4 That is, phenomenology is concerned with how the person actually experiences the world, not with theories that try to account for that experience.
By now, the busy psychiatrist-reader is entitled to ask, “OK, so how does all this phenomenology help me in my day-to-day work with patients?” Or, in the pragmatic terms of philosopher William James, what is the “cash value” of phenomenology as it relates to clinical practice? Well, to begin with, phenomenology has a clear connection to the foundation of nearly all successful therapy; namely, empathy. After all, if the psychiatrist hasn’t a clue regarding the contents and structure of the patient’s felt experience-the way the patient interacts with and interprets her world-how can the psychiatrist possibly have empathy for the patient?
Furthermore, by understanding the contents and structure of the patient’s felt experience, the psychiatrist may also be guided toward one or another diagnostic conclusions. The distinction between ordinary grief and clinical depression provides a case in point. To be sure, there is no bright line between intense, prolonged grief and clinical depression, and the 2 states have several features in common. As Dr Sidney Zisook and I5 pointed out recently, both grief and major depression often involve intense sadness, problems sleeping, concentrating, eating, and interacting with others. But the underlying experiential structure of normal, productive, or uncomplicated grief differs in important ways from the psychic structure of major depression. For example, in the grief that follows the loss of a loved one, the bereaved person often experiences pleasant memories of the deceased; believes that the grief will eventually pass; and has a sense that better times are ahead.
These positive features are rarely present in a bout of severe, major depression. Moreover, unlike the person with major depression, the person with ordinary grief does not typically have the sense of being a worthless or unlovable person, nor is he usually suicidal. These and other distinguishing phenomenological features are summarized in the Table. Notice that none of the features in this Table could be gleaned simply by observing the patient, or by obtaining DSM-type data (eg, by noting the patient’s affect, psychomotor activity, checking her weight, sleep pattern). Rather, these phenomenological features are part of the patient’s experience; it often requires persistent and empathic exploration to elicit these contents of consciousness.
Even psychotic conditions lend themselves to a phenomenological analysis. For example, the psychiatrist Silvano Arieti,6 in his classic work, Interpretation of Schizophrenia, provides a meticulous analysis of the phenomenology of schizophrenia-in effect, deconstructing the world-view of many individuals suffering with schizophrenia. Consider Arieti’s description of the patient in the advanced stages of schizophrenia:
A certain equilibrium seems to have been reached; the patient seems to have accepted, at least to some extent, his illness; and anxiety seems decreased or even absent . . . typical of this stage, however, is the effort to stop the decline, to retain whatever grasp is possible on the escaping reality . . . in some patients the delusions and the hallucinations have lost a great many of their unpleasant qualities . . . some [patients] hear voices that bring them comfort. In some of these cases, the delusions of persecution have been replaced by delusions of grandeur.
How much richer these phenomenological descriptions are than the symptom checklists of the DSM framework!7 Moreover, an understanding of the inner world of our patients may have important implications for the therapeutic alliance; after all, if you do not understand that your patient finds comfort in his auditory hallucinations,8 how will you understand his deep-seated reluctance to take antipsychotic medication?
Psychiatry nowadays is often tarred with the label of being overly biological or reductionistic. To be sure, psychiatrists struggling to understand their patients during 15 or 20-minute “med checks” are well aware of the limitations under which they work. In-depth understanding and phenomenological analysis take time. Nonetheless, many of us remain interested in the contents and structure of our patients’ inner world9--and if we ask the right kinds of questions, more can be accomplished in 5 minutes than you might think.
Table --Phenomenology of uncomplicated grief vs major depression10-14
|Productive/uncomplicated grief||Major depression/melancholia|
|Emotional connection with significant others preserved (“I-thou” state)||Self-focused; depressed person feels outcast, alienated, alone|
|Grieving person feels that grief will end some day; life will be better||Feels depression will never end; hopelessness; feels time itself is slowed or stopped|
|Self-esteem, personal potency generally well-preserved||Self-loathing, guilt, low self-esteem, sense of personal impotence|
|Rarely suicidal||Often suicidal|
|Grief is mixed with positive feelings, such as pleasant memories of a lost loved one||Lacks positive feelings, memories; often feels ambivalent, conflicted over loss|
|Grieving person can be consoled (by friends, literature, and so forth)||Person often inconsolable; mood often autonomous, impervious to others|
DR SCHWARTZ COMMENTS
Ron Pies is right to stress the first five minutes of the psychiatric interview. And yes, Rabbi Schneerson, in the first five minutes, so much can be accomplished! This is especially made clear to me nowadays in my current work in the psychiatric admitting service of a large, active public mental hospital. Here, just about ALL the “action” is typically in those first five minutes – for that’s where I so often make my initial diagnostic impression, which guides so much of the rest of my treatment,1 and even more importantly (because I could be wrong about this diagnosis), that’s where I develop an alliance, or fail to develop an alliance, with my newly arrived patient. And what guides me – is phenomenology. My patient and I share a world, as improbable as that may initially seem to both of us. But we have to find it… find a “connection.” How? Well that’s the task of phenomenology!
So this guy comes in, and he tells me he is God. (the following case is fabricated but it all could have happened…) “What brings you here today?” Well, I am God! I am YOUR God! Judgment is here!.” Me? I react startled – I look down, cover my face, and withdraw into myself, and then, peeking, look him right in the eyes…. “Wow!” “That’s a lot.” “Hmm….Let me understand what you are telling me…” “Let me see…Are you telling me… Perhaps you are telling me… that you are God over THERE? And I am God over HERE? …… Is THAT what you are telling me?”
Now I am looking right at my patient…. Perhaps that’s what he is telling me… Perhaps this - We are all God and he is God over there and I am God over here….Well, I can deal with that! Unlikely, but possible. But….
“NO!! He tells me… (But with a degree of empathy now…We are, after all, talking to each other! I didn’t talk at him – didn’t let him talk at me……. Unlikely, but one never knows) “NO!,” he booms back to me. Not that! I AM YOUR GOD! GOD ALMIGHTY! THERE IS NO GOD BUT ME! He is staring at me now – giving me the full force of his being…… But more than that – he is pleased – he is TALKING TO ME! (Sort of, anyway…) He is conversing with another human being who is perhaps taking him seriously – and yet not giving an inch – but conversing, neither judging nor patronizing nor surrendering.…. People laugh at him, they get angry with him, the shun him, they tell him that he is crazy… Well perhaps here – finally? – unexpectedly? -- is something perhaps different …..Some consensually validated intersubjective co-constituted reality...
…… But what comes next…. Well I shrink back, look down a bit, hold my hand in front of my face, and peek through….And I come back again to the conversation……For round two…
”Wow!” “Well,” “That’s a lot…..” Hmmm… Well” “Now from what I’ve read,” I tell him, “I might be in a lot of trouble.” “I’ve read that if you see God – pointing in his direction, and it really is God… well you are in trouble…You could go… go blind! You could die!” Now I am quiet….
”NO SILLY.” He tells me…. Noooo…. Not with me …… I’m Jesus……. You know, Jesus! You can touch me… (He grins) You can look at me…. We can talk….”
“Oh!” I respond… “Like Jesus…” “Oh!” “Well I can understand that…” “I can deal with that!” “Well great! I can talk to you, fantastic, good, so let’s talk….”
And we do… we talk…
Now THAT’s a phenomenological first 5 minutes…. A relationship has developed between two people - one of whom is a doctor and one of whom is a patient - and furthermore, a relationship that is neutral and even perhaps mutually respectful. (And yes, one CAN play roles in existentially honest relationships…) We can talk to each other. Neither party has surrendered to the other…Neither party has dominated…. Dignity is maintained, talk time can happen – an entire psychiatric examination can happen (and did, and does..). We can get to the amygdala if we need to, or to power and aloneness and pride and humiliation, and to sleep and appetite and diurnal variation in mood, or to anywhere we need to go. To the diagnosis, to the treatment, to the psychological and social factors, to wherever my craft and our shared reality and co-constituted world takes us…
So THAT’S phenomenology. Phenomenology makes psychiatry work… phenomenology makes psychiatry fun…..Give it a try…. Put down your checklists for a few minutes and let phenomenology shine through!2-7
Thanks, Ron, for a great column.
Michael Schwartz, MD
Austin State Hospital
References for Dr Schwartz' comments
1. Schwartz MA, Wiggins OP. Typifications: The first step for clinical diagnosis in psychiatry. J Nerv Ment Dis. 1987;175:65-77. [Abstract in Psychiatric Digest. 1987;7:6-8.]
2. Wiggins OP, Schwartz MA, Northoff G. Toward a Husserlian phenomenology of the initial stages of schizophrenia. In: Spitzer M, Maher BA, eds. Philosophy and Psychopathology. Berlin and New York: Springer Verlag; 1990: 19-34.
3. Wiggins OP, Schwartz MA, Spitzer M. Phenomenological/descriptive psychiatry: The methods of Edmund Husserl and Karl Jaspers. In: Spitzer M, Uehlein F, Schwartz MA, Mundt C, eds. Phenomenology, Language, and Schizophrenia. New York and Heidelberg: Springer Verlag; 1992: 46-69.
4. Schwartz MA, Wiggins OP: The phenomenology of schizophrenic delusions. In: Spitzer M, Uehlein F, Schwartz MA, Mundt C, eds. Phenomenology, Language, and Schizophrenia. New York and Heidelberg: Springer Verlag; 1992: 305-318.
5. Naudin J, Gros-Azorin C, Mishara A, et al. The use of Husserlian reduction as a method of investigation in psychiatry. J Consc Stud. 1999;6:155-171,
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7. Schwartz MA, Wiggins OP. Schizophrenia. Diagnostic and Anthropological Perspectives. In: Chung MC, Fulford KWM, Graham G, eds. Reconceiving Schizophrenia. Oxford: Oxford University Press; 2007.
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