Go back to the things themselves.
Psychiatry involves an intensely vital contact with the most extraordinary states of mind. The contact is vicarious and has a huge emotional and imaginational impact on the clinician because of the way states of mind conjure up or express fragments of worlds and moods.
I recall this vividly as a medical student, and I see it in the medical students who come to psychiatry as part of their education in medicine and in the young doctors who have decided to specialise in the field. This experience of mental illness may – indeed, should – illicit interest of an intellectual or scientific kind, but at root it is experiential and emotional, and it begins not with the experience of oneself but with the experience of another person.
Let us start with some examples of the raw experience to try to convey that point of contact with extraordinary states of mind. They are met in the clinic, but they might also be met in literature, in memoir or in everyday life. The key feature is a subjective or first-personal structure: people are talking about their experience.
I was suddenly caught up in a peculiar state; my arms and legs seemed to swell. A frightful pain shot through my head and time stood still. At the same time it was forced on me in an almost superhuman way how vitally important this moment was. Then time resumed its previous course, but the time which stood still stayed there like a gate. Jaspers.
I did not wake up one day to find myself mad. Life should be so simple. Rather, I gradually become aware that my life and mind were going at an ever faster and faster clip until finally … they both had spun wildly and absolutely out of control. But the acceleration from quick thought to chaos was a slow and beautifully seductive one. Kay Redfield Jamison.
It started about two and a half months ago. I started to get a bit down, and then I suddenly went down. I went away somewhere with my church for a convention, and after that, when I came back I felt depressed then. I’ve got no thoughts, up there. I’ve got no thoughts and I can’t think. I was lying in bed some time ago, and there’s nothing. I was aware they were vanishing, my thoughts were going. I’ve got no thoughts, can’t think. Research interview (severe depression, from Owen).
I am a manic depressive. When I’m up, I have no judgement, but fantastic drive; when I’m down, I have judgement, but no drive at all. In between, I can pass for normal well enough. This book is the record of an up. It was written during the three weeks of a manic phase; it is therefore perhaps more informative about my state of mind in those weeks than about the events it describes. When I’m up, my values shift and my inhibitions drop away: there are many things here that I would not dream of saying in my present state – but, having written them, I have left them as they are. Robin Farquharson ([Reference Cassirer4], p. 7).
It’s only here for a little while [the hospital the person has been living in for six months]. They’re going to move it soon. Don’t you have a makeshift hospital, they put it up for a couple of months, till they’ve finished what they’re doing? A hospital could be anywhere. Research interview (Acquired Brain Injury, from Owen).Footnote 1
These passages will be familiar to practising psychiatrists, but that familiarity does not blunt the memory of first point of contact. There is an original richness of meaning, value and narrative structure to the individual accounts and a diversity across them. Human beings respond to that – it is not like responding to something neutral. And we respond by seeking to understand and interpret or we turn away from that first point of contact – either unintentionally or intentionally – to make it neutral.
First-personal human experience has a particularly important quality because it is in this zone that we find our concepts of the self or the ‘I’ or ‘myness’, and it is a short distance from this experience of myness to thinking that it is in first-personal experience that we find who we are – our personhood. So, psychiatrists find themselves close to moral or ethical matters with the experience of illness and, in psychiatry, where this experience is extraordinary, both psychiatrists and patients can find moral or ethical intuitions about selfhood and personhood very activated. In Chapters 2 and 3, we will focus on the phenomenology of mental illness rather than moral or ethical issues, but the connections between phenomenology and ethics are present and will be explored in later chapters.
Problems of Interpretation
Before we enter further into phenomenology, we need to consider a general problem of interpretation of first-person experience which becomes an important issue for psychiatry: that it is possible to have first-personal experiences that deceive us. The following are some everyday examples from my experience, and the reader can synchronise them with similar experiences of their own.
I have had a compelling experience consisting of recalling an image of my first school and walking toward it, only to subsequently realise, after someone showed me a photograph of the school building, that I was conflating a memory of seeing a photograph with a vaguer memory of walking to school. So, during that moment of recalling, as an adult, the image of my first school and walking towards it as a young boy, I was having an experience that was not true to itself – the experience took itself to be something that it wasn’t. That is an example of self-deception. It is one-off and easily adjusted to.
But now consider this one: I perceive the ground as thrusting me forward as I step off the London underground escalator onto a fixed floor. Because the thrust is so powerfully experiential, I have to tell myself that this is an illusion. The perceptual illusion persists despite the self-coaching, and it becomes a recurring experience whenever I step off an escalator. I have had to learn to discount this ‘thrust experience’ as an unreliable guide to stepping off escalators – to discount the experience, as it were.
Finally, consider a self-deception experience that is more holistic and less restricted to regions like memory and perception: on a few occasions I have woken from a dream, and then have woken from the waking from the dream. The dream was lucid and less easily discounted – until … well … I woke from it.
Experiences of the fallibility of my first-personal experience have an unsettling effect on my self-certainty: I become aware of my own unreliability as an experiencer, and also less sure that the question ‘who am I?’ can be answered solely within the first-personal zone.
Of course, these familiar experiences of the fallibility of experience are well known to psychology. Experimental psychologists have found plenty of evidence of mismatches between self-report and accuracy on specific mental processes measured in the laboratory.Footnote 2
Human psychology exists outside the laboratory too. Artists have unveiled types of self-deception which may elude the laboratory but are pervasive in human affairs nonetheless. Shakespeare, for example, in his tragedy of Hamlet uses the device of ‘a play within a play’ to unveil self-deception.
Hamlet’s beloved father, the King of Denmark, has unexpectedly died, leaving Hamlet in an altered mental state. His mother, Queen Gertrude, has hastily remarried, which wrong steps him emotionally and arouses suspicions in him as to her motives. Hamlet puts on a play called ‘The Mousetrap’ for his mother, about a queen who is wooed by her husband’s murderer. On her husband’s deathbed, this queen says:
Hamlet’s aim is to hold a mirror up to his mother, to challenge her sense of emotional fidelity to her dead husband and her feeling that she has been anything other than true. When Hamlet asks his mother if she likes the play, she remarks about the fictional queen:
And Hamlet thus achieves his aim of showing his mother’s self-deception about her own feelings for her dead husband. But Shakespeare also gives us a whole play (not just a play within a play) to show us a fuller picture of Hamlet’s first-personal experience: his grief about the loss of his father with its distorting paranoia as he struggles, and tragically fails, to adjust.
The psychology of everyday life gives plenty of instances of self-deceptions, as Freud and other dynamic psychologists draw attention to. They can reach extreme levels which can tip them over into being clinical phenomena. These are self-deceptions in the sense of taking own’s own experiences to be something which they are not. They are experiences which are not true to themselves and might be seen as instances of bad acting or false expression, as Queen Gertrude says about the fictional queen in ‘The Mousetrap’ and Hamlet says about Queen Gertrude.
But what about experiences, perhaps like Hamlet’s paranoia, which are true to themselves (i.e. not versions of bad expression) yet which nonetheless lie within the domain of psychopathology? We need to consider that there can be experiences about something, with self-reports that achieve some accuracy in describing what they are indeed about, which, nevertheless, are states of mental illness. They might be termed ‘authentic psychopathology’.
The experiences described in the excerpts at the start of the chapter are not obviously getting themselves wrong or failing to be true to themselves as expressions. When reference is made to ‘time standing still’ or that ‘my thoughts were going’ or that ‘my values shift’ or that ‘a hospital could be anywhere’, we have to consider that these are radically different kinds of experience which people are struggling to accurately describe – in a similar way to how describing a complex landscape may be difficult. Describing what it is like to be aware of time or values in ordinary experience may tax anyone’s powers of expression. In this context, one can be more or less accurate about describing experience that one has no grounds for doubting (or that others have no good grounds for thinking is inauthentic experience in the sense of self-deception).
These forms of psychopathology are different kinds of experiences, and they are not illusions or self-deceptions. What, therefore, is the structure of these experiences? What do they refer to if not ordinary objects of experience? And what is disordered, dysfunctional or disproportioning about them? These questions bring us into psychiatric phenomenology. But first, we need to ask ‘what is phenomenology?’
What Is Phenomenology?
We will approach this question in two ways, and I do not wish to claim that they are exhaustive. The first approach is to examine what the term ‘phenomenology’ means to philosophy. The second approach is to look at what ‘phenomenology’ means to psychiatrists.
The term ‘phenomenology’ was used by three philosophers who are widely regarded as first movers in an influential stream of twentieth-century thinking called the ‘phenomenological movement’: Edmund Husserl, Max Scheler and Martin Heidegger. Despite the fact that they all walked together in a movement – especially in its early phase – they did not fully agree with each other, and so in appraising what ‘phenomenology’ means philosophically we have similarities and differences rather than something entirely unitary. I will outline their views in this chapter, and look at the use some psychiatrists have made of them in Chapter 3.
My second approach is to look at what ‘phenomenology’ means to psychiatrists. Here, at the most basic level, ‘phenomenology’ means the symptoms and signs (the indicators) of pathology and the careful description of those symptoms and signs. An important use of the term in psychiatry was introduced by Karl Jaspers in 1913. Jaspers was influenced by Husserl’s early work, but developed a nuanced approach of his own which was closer to the basic descriptive meaning of phenomenology in psychiatry. I will discuss the basic meaning of descriptive psychopathology in this chapter before introducing Jaspers’ richer approach in Chapter 3. Let us now look in more detail at what phenomenology means in philosophy.
Phenomenology in Philosophy: Husserl, Scheler and Heidegger
The sequence of names – Edmund Husserl, Max Scheler, Martin Heidegger – is chronological and reflects these three philosophers’ respective ages and appearance on the intellectual scene. All of them were culturally German and familiar with the traditions of German idealism and romanticism, but they came from very different backgrounds. Husserl’s background was mathematics and logic; Scheler’s was sociology and ethics; Heidegger’s was theology and ancient philosophy. All three wanted to refresh philosophy by connecting it, fundamentally, with human experience after an influential period of scientific materialism in European culture, and they had varied phrases or mottos for this project. Husserl spoke of a ‘method’ to enable scientists to go ‘back to the things themselves’ (see epigraph at start of chapter). Scheler spoke of an ‘attitude’ that seeks the most intensely vital and most immediate contact with things which are ‘in themselves there’ in the act of experience ([Reference Atkins8], p. 138). Heidegger also spoke of an attitude – a sort of self-reflectiveness directed at dismantling concealments in experience. He defined phenomenology, via the ancient Greek root of the word, as the discourse (-logy) regarding that which shows itself (phenomenon-) ([Reference Schiller9], pp. 85–6). Emphatically, all three thinkers stressed that they were not interested in ‘mere appearances’ or in what was ‘behind’ the appearances, but rather in what was given in appearance in itself. Scheler even claimed that, in this sense, phenomenological philosophy was the most radical empiricism and positivism:
[Phenomenology] looks for a content of lived experience which ‘coincides’ with all propositions and formulas, even those of pure logic, for example the principle of identity. Any question of the truth and validity of these propositions is suspended as long as this requirement is not fulfilled.
An example will help to show what these philosophers were trying to do with this idea of lived experience.
Consider the experience of the colour red. There are two ways (or modes) of experiencing red which are different from what the phenomenologist’s primary interest in red is. The analysis of these two modes, and their differences, the phenomenologists regarded as important for showing, or un-concealing, a third way of experiencing red which, to paraphrase Husserl’s motto, ‘went back to red itself’. Scheler considered this in an essay called ‘The Theory of the Three Facts’ [Reference Byron10], wherein he thinks about ways in which the experience of red is conditioned by interests, both instinctual and intellectual. In the first mode, which he called the ‘natural attitude’, we experience red as linked to our environments and everyday concerns, interests and activities. An example of this is the lived experience of the red bus going by or the red ‘Stop’ sign. Scheler thought that this natural attitude is our default mode as humans and is ‘natural’ in that sense. Experiencing red in this mode is particular, contextual and conditioned by time and place – as in the red of the flag of a country or sports club, or the patch of flowers in a garden. It can be considered as the view of red from somewhere and sometime.
In the second mode, which Scheler called the ‘scientific attitude’, red is experienced in abstract, generalised terms which make no necessary use of the immediate experience itself. This way of experiencing red is harder to attain because it requires a kind of intellectual effort or attention that is not found in the natural attitude. In the scientific attitude, red is constructed. This, for example, is the sense of red in contemporary physics, for which red is electromagnetic radiation falling in the wavelength range of 625–700 nm and frequency range of 400–480 THz. It is also the sense of red for physiology, which considers red to be the interaction of photons with cone sensory receptors in the retina of the eye and visual processing systems in the brain. Red in the scientific attitude aspires to an experience of red without a human experiencer – what the American philosopher Thomas Nagel has called the view from nowhere.
The phenomenologists thought that philosophies which emphasised the mechanics of sense perception (so-called sensationalist philosophies) were mistaking the experience of red in the scientific attitude for being the only experience of red or the primary experience of red. In the scientific attitude, one constructs red in intellectual experience using ideas of electromagnetic spectra, photons, sensory apparatus and visual information processing systems which are not themselves red. Scheler was at pains to point out that we only come to the scientific attitude after considerable effort is made to extract ourselves from the natural attitude, where we do have an experience of red as red (though an experience of red from somewhere). Trying to experience red by starting with the scientific attitude rather than the natural attitude was not something human beings could do and, by attempting it, sensationalist philosophies were fated to get the phenomenology of redness wrong.
The phenomenologists thought there was a third experience of red as a pure phenomenological fact rather than as a fact in the natural or scientific attitudes. This pure phenomenon they thought was given in the act of experience itself. This is a tricky idea, but it is basically a philosophical elaboration of the psychological insight that in making connections in our lived experience we depend on an ability to find resemblance between experiences, and that in doing this we are aided by an ability to intuit categories (or pure phenomenological facts) immediately rather than build them up piecemeal from scraps of images or impressions.
In the case of red we can hone this ‘categorial intuition’ by suspending judgement on the existence of all instances of the experience of red in our natural attitude. Think of the red raspberry, the red evening sky, red wine, blood, a red brick, tiger lily, a piece of red coral. Then suspend, or bracket, the individual existences. Note that in doing this a category of red survives – indeed, emerges from - this bracketing of the natural attitude.
Furthermore, we can vary, in our imagination, our experiences of red, adding or subtracting this or that quality or quantity to arrive at an idea of red. Lastly, we can note the ways in which across our experiences of varied red things (a red tomato, a red flag, a red bus) and their changing contexts (when tired, or hungry or merry, or when background illumination or contrast changes) there is a general ‘redness’ condition on the possibility of identifying these experiences. Husserl supports this point by drawing attention to how we are always perceiving outline or sketch images of colour – what he calls ‘adumbrations’:
the colour of the seen physical thing … is not a really inherent moment of the consciousness of colour; it appears, but while it is appearing the appearance can and must … be continually changing. The same colour appears ‘in’ continuous multiplicities of colour adumbrations.
Husserl is pointing out that we see colour ‘in’ adumbrations of colour.
Finally, we can note that the condition of the possibility of experiencing red ‘in’ colour adumbrations is inherent to the experience itself rather than in things which have no direct reference to that experience, such as electromagnetic wavelength ranges.
Husserl uses abstract terms (respectively, ‘bracketing or epoché’, ‘imaginative variation’ and ‘transcendental reduction’) for these methods of showing pure phenomenological facts to convey their conceptual rather than empirical or sensory nature and how the perception of phenomenological facts may be honed with special training. However, the central idea is that the access to phenomenological facts is a basic human capability rather than a highbrow academic one and that there are pure phenomenological facts across a whole range of experiences (the experience of red being just one example).
Husserl devoted much of his best work to the pure phenomena of logic, but Scheler and Heidegger extended phenomenology to the fuller flow of mental life, including areas which they thought had been concealed by modern philosophy such as emotion, mood and value, temporality, sociality (intersubjectivity) and embodiment. In their varied explorations they carried forward the basic phenomenological commitment to finding phenomenological facts or invariant categories/structures of human experience, and their works have given psychiatry a rich – albeit complex and somewhat heterogeneous – set of texts with which to understand human experience.
Some of these philosophical ideas relating to the bracketing or filtering out, or suspension of, the natural attitude will be put to work in Chapter 3 (‘Phenomenological Approach to Presentations of Bizarreness’) to try to gain some understanding of bizarre symptoms in schizophrenia. Other ideas, relating to temporality, will be put to work in Chapter 3 to try to gain better understanding of agency in mood disorder.
Let us now switch approach and look at what phenomenology means in psychiatry.
Phenomenology in Psychiatry: Signs and Symptoms
Psychiatry started with clinical practice rather than with physiology (a fact that we will discuss further). This means it started with presentations of human suffering to clinicians. And that, in turn, means starting with a concern that the suffering is unnecessary – that it represents something the matter with the organism (pathology) rather than suffering in the sense of problems with living or bad choices or a spiritual plight.
As psychiatry became a speciality within medicine in the early nineteenth century, we see a preoccupation with describing and classifying the ‘phenomena’ of mental illness. This constitutes descriptive psychopathology and it works towards understanding how phenomena may indicate (as symptoms and signs) disease entities and, ultimately, pathophysiology and the casual mechanisms of disease.
Signs and Symptoms
The sense of psychiatric phenomenology as symptoms and signs – or clinical description – is an important part of what ‘phenomenology’ means to psychiatry. It predates the phenomenological movement and has a potentially tense relation with it. To see that tension, consider this dictionary definition of phenomenology:
A philosophy or method of inquiry concerned with the perception and experience of objects and events as the basis for the investigation of reality.
I think most psychiatrists will be puzzled by that definition if they try to relate it to their understanding of clinical phenomena. Phillippe Pinel, Emil Kraepelin and Sigmund Freud – all amongst the founders of modern psychiatry, and all talented describers of clinical phenomena – would certainly have been puzzled. The revolutions in thinking they helped to bring in seem in conflict with the idea that phenomenology is a method of inquiry based on the premise that reality consists of objects and events only as they are understood in human consciousness.
Understanding ‘reality’ for Kraepelin was understanding how forms of very distressed and disturbed human consciousness consist in events and processes going wrong in the brain – an organ which could be studied in the laboratory after death. Similarly, for Freud the ‘reality’ of his cases could only be understood by taking the emphasis off conscious life and postulating the ‘unconscious’ as an object and as a series of psychic events outside of awareness that could go wrong. More recently, cognitive therapy is interested in understanding the ‘reality’ of information processing biases which may not be apparent to conscious awareness.
So, from a clinical concern with human suffering there developed an interest in descriptive phenomenology or psychopathology as a shared language for the symptoms and signs of disease or dysfunction. The historian of psychiatry German Berrios [Reference Fichte13] has argued that the most rapid advances in descriptive psychopathology occurred in French psychiatry in the first half of the nineteenth century, with descriptions that mixed careful and sensitive observation of patient behaviour with some of the theoretical assumptions of the day about how the human mind worked. The theoretical assumptions were mainly those from the ‘associationistic’ model of the mind (similar to the ‘sensationalist’ philosophies mentioned earlier, which viewed mental life as built up from mind-independent sensations and the associations of ideas) and from the ‘faculty psychology’ model of mind (which considered mind as comprising distinct domains of attention, concentration, perception, memory, etc.).
Descriptive psychopathology has over the years been packaged up by psychiatry into free-standing symptoms and signs, clusters of symptoms and signs (syndromes) and postulated disease entities. These form core parts of psychiatric textbooks and handbooks and have increasingly been brought into conformity with the classificatory efforts of the ICD and the DSM. In Chapters 4 and 5, we explore in more detail how descriptive psychopathology has not flourished in a context where some are emphasising that neuroscience displaces the need for description (because description is non-explanatory), some are emphasising pragmatic description for professional classification purposes (with a conservative fear about inter-professional disagreement) and some are emphasising that oppressive power imbalances lurk in the language of descriptive psychopathology, however neutral that language aims to be.
However, learning symptoms and signs and schemes for recording findings in the mental state examination remains a key part of any training in clinical psychiatry and is necessary for professional communication. The following is the scheme which has been taught at the Maudsley Hospital where I trained.
Abnormal Experiences –
Including abnormal perceptions such as hallucinations (visual, auditory, olfactory, etc.)
Interviewer’s Reaction to the Patient –
Reflections on how the interviewer is affected by the patient.
From this scheme we can see the influence of faculty psychology (e.g. the categories of attention, perception, memory) and even the persistent influence of association psychology (e.g. the ‘derailment of associations’ in speech). One can also note language that will attract the attention of a social scientist who critiques power. For example, ultimately it is the institutions of psychiatry that are calibrating whether a behaviour is ‘manneristic’ or an idea is ‘overvalued’.
Some of the descriptive units (e.g. ‘flight of ideas’, ‘delusion’, ‘hallucination’, ‘insight’) are complex and do not correspond cleanly to constructs in any school of psychology or model of the mind. Nonetheless, they have been part of the stable of descriptive psychopathology since the nineteenth century and continue to have use. Description and theory thus have some degree of independence from one another, and what can stand the tests of time as good symptomatology of mental illness may remain in a sort of theoretical limbo or vacuum from the point of view of philosophy or psychology or explanatory science. So, phenomenology in psychiatry, though open to critique, does have a sort of descriptive autonomy of its own.
The World of the Patient
The ‘symptom and sign’ approach to psychiatric phenomenology assumes that the clinician will identify both the symptoms and the disease ‘objectively’ – that is to say, they will not need to engage in human ‘subjectivity’ (other than as a means to identify symptoms). However, the symptom-based understanding of psychiatric phenomenology is always going to be one side of the coin. This is because it is possible to view people with distressed or disturbed behaviours as presenting expressions of their existence, and it is possible to view people’s unusual ideas and emotions as conveying meanings and values which afford communication. R. D. Laing put this well using the gestalt figure of the Rubin vase:Footnote 3
Now it seems clear that this patient’s behaviour can be seen in at least two ways, analogous to the ways of seeing a vase or face. One may see his behaviour as ‘signs’ of a ‘disease’; one may see his behaviour as expressive of his existence … what is he ‘about’ in speaking and acting in this way?
When this expressive aspect is emphasised by psychiatric phenomenology, ‘subjectivity’ becomes the key pole, and approaches which discount subjectivity become easy to criticise – or even to parody. Consider this caricature which Laing presents of Kraepelin’s clinical mode of observing one of his patients during a clinical grand round or case conference:
The construction we put on [the patient’s] behaviour will … depend on the relationship we establish with the patient … What does the patient seem to be doing? Surely, he is carrying on a dialogue between his own parodied version of Kraepelin, and his own defiant rebelling self. [The patient says] ‘You want to know that too? I tell you who is being measured and is measured and will be measured. I know all that and could tell you but do not want to’. This seems to be plain enough talk. Presumably he deeply resents the form of interrogation which is being carried out before a lecture room of students. He probably does not see what it has to do with things which must be deeply distressing to him. But these things would not be ‘useful information’ to Kraepelin except as further ‘signs’ of a ‘disease’ …
If one is adopting such an attitude towards a patient, it is hardly possible at the same time to understand what he may be trying to communicate to us … if I am sitting opposite you and speaking to you, you may be trying (1) to assess any abnormalities in my speech, or (2) to explain what I am saying in terms of how you are imagining my brain cells to be metabolising oxygen, or (3) to discover why, in terms of past history and socio-economic background, I should be saying these things at this time. Not one of the answers that you may or may not be able to supply to these questions will in itself supply you with a simple understanding of what I am getting at.
Psychiatry has always had examples of romantic practitioners who were strongly interested in the expressive aspect – those who were more interested in sympathising with their patients than observing or explaining them. But in relation to phenomenology in psychiatry there was a significant breakthrough when, in interwar Europe, a small group of psychiatrists started to draw specifically on the phenomenological movement in philosophy. Their motto was similar to ‘back to the things themselves’. They thought psychiatry had become, to use John Cutting’s characterisation, ‘too clinical, too organic and too psychological’ ([Reference Lukes16], p. 145), and they wanted to reconnect with their patients’ lived experience or their ‘worlds’.
The founding figures in this psychiatric phenomenological movement were the French–Polish psychiatrist Eugene Minkowski and the Swiss–German psychiatrist Ludwig Binswanger. A key difference from the phenomenological movement in philosophy was that this psychiatric movement was not primarily doing first-person phenomenology. Minkowski and Binswanger were not examining the structures of (their own) consciousness, but rather making inquiries into the structures of consciousness of their patients, using phenomenological philosophy as a resource to gain new understanding of these structures. The aim was to engage with the possibility that there were deeper phenomenological facts to find in psychopathology, and that psychiatric phenomenology should not be bypassing these facts via mere descriptive symptoms and signs.
So, this was a ‘vicarious phenomenology’ [Reference Scruton17], or a phenomenology of second-personal experience (a shared exploration of consciousness between psychiatrist and patient), and a phenomenology which aimed to extend meaning to what was otherwise merely a discourse of symptoms and signs, disease and dysfunction. In other words, in believing that psychiatry had become ‘too clinical, too organic and too psychological’, this group of psychiatrists were pointing out that the clinical symptom and sign framework, the biological disease framework and the psychological dysfunction framework were concealing the manner in which their patients’ experience could hang together as whole worlds or fields of meaning.
These psychiatrists did not think that by understanding the deeper lived experiences of their patients they would necessarily be normalising them.Footnote 4 They thought there could be highly anomalous kinds of experience wherein a psychiatrist could understand what the person is expressing without thereby rendering it into a framework of health. In Chapter 3, we will draw on some of their ideas about the worlds or modes of people with severe mental illness.
