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HPY0010.1177/0957154X17715414History of PsychiatryMessas et al.

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History of Psychiatry
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A meta-analysis of the core © The Author(s) 2017
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DOI: 10.1177/0957154X17715414
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phenomenological psychiatry

Guilherme Messas
Santa Casa de São Paulo School of Medical Sciences, Brazil

Melissa Garcia Tamelini

Hospital das Clinicas of University of São Paulo Medical School, Brazil

John Cutting
Institute of Psychiatry, London, UK

Abstract
Two fundamentally different approaches among phenomenological psychopathologists can be discerned. One
is what we call fixed essentialism, where the pathognomonic element of, say, schizophrenia is conceived of as
a single, enduring and intrinsically morbid way of grasping all entities in the world, including self and body.
The other, which we call dialectical essentialism, accounts for the same manifestations of, say, schizophrenia,
but through a process which is not life-enduring, and, most critically vis-à-vis the former formulation, is not
in itself a single morbid defect: a morbid pattern of world, self and body is achieved by an imbalance between
two or more otherwise healthy constituents of the ‘normal’ human being, whose imbalance and attempts to
resolve this – the dialectic – induce the ‘morbidity’.

Keywords
Melancholia, phenomenology, psychopathology, schizophrenia

Introduction
The origin of phenomenological psychopathology can be precisely dated to a meting in Zurich in
1922 between four psychiatrists – Minkowski, Binswanger, Straus and von Gebsattel (Tatossian,
1979/1997). Each of these took as their task to search for a single psychopathological deficit

Corresponding author:
Guilherme Messas, Santa Casa de São Paulo School of Medical Sciences Rua Sabara 213 apt. 1 – Higienopolis, CEP
01239 – 011 – SP, Brazil.
Email: guilherme.messas@fcmsantacasasp.edu.br
2 History of Psychiatry 00(0)

underlying one of the diagnostic entities which had entered the psychiatric lexicon in the previous
50 years. Moreover, each was committed to the notion that any such psychopathological deficit
would have to be specific to each diagnostic category – none held to the unitary psychosis theory.
Each, furthermore, eschewed extant psychopathological terms and psychological theorizing in
their quest. They were in pursuit of a ‘phenomenological’ solution, unlike, say, Carl Schneider
(1930), for whom most schizophrenic psychopathology was thought disorder, or the generation of
clinical psychologists in the last half of the twentieth century, who formulated schizophrenia in
terms of a single psychological defect (attention disorder, perceptual disorder, etc.), or indeed
Bleuler and Freud, who, respectively, applied associationism and psychoanalysis. What this meant
in practice is the theme of this article, but at the outset the agreed programme of the group of four
was set out in a negative way. In fact, as well as being non-descriptive and non-psychological,
whatever explanation they were looking for had to be non-organic too. There was a flourishing
neurologically-oriented school of psychopathology at that time, exemplified by Kleist (1930/1987),
which emphasized similarities between thought disorder and aphasia or made other psychopatho-
logical-neurological analogies.
The original venture soon bore fruit in the form of single terms which each of the pheno­
menological psychopathologists thought best encapsulated what was at the root of any diagnostic
condition – e.g. trouble générateur (Minkowski, 1933/1970), Struktur (von Gebsattel, 1954), and
breaking up of passive temporal synthesis (Binswanger, 1965). There were also hypotheses as to
what underlay specific diagnostic entities – e.g. loss of vital contact with reality in the case of
schizophrenia (Minkowski, 1927/1987). Subsequent psychopathologists who aligned themselves
with the phenomenological school contributed further generic terms for what they were doing, e.g.
uncovering ‘pheno-phenotypes’ (Stanghellini and Rossi, 2014); or proposed new terms for what
they thought epitomized some specific condition, e.g. Verlust der natürlichen Selbstverständlichkeit
(loss of natural attitude) (Blankenburg, 1971); or broadened the field of enquiry to melancholia
(Tellenbach, 1974/1980), neurotic states (Charbonneau, 2010), personality disorders (Kraus, 1991)
and even clinical medicine (von Weizsäcker, 1950).
Two further trends were apparent from an early stage in the development of phenomenological
psychopathology. One was its heavy reliance on the phenomenological school of philosophy, the
sharing of whose name has been the cause of much confusion. The three acknowledged fathers of
that movement – Husserl, Scheler, Heidegger – each had devotees among phenomenological
psycho­pathologists. Phenomenological psychopathology, though not synonymous with applied
phenomenological philosophy, is nevertheless a close cousin and, in the view of one of the authors
(JC), is better the closer it is.
The other trend, apparent among all phenomenological psychopathologists, is an exquisite sensi-
tivity to the temporal dimension in psychopathology. Partly based, we assume, on their awareness of
the extraordinary preoccupation with time in the philosophy of Husserl and Heidegger, but partly, we
suspect, on their own clinical and phenomenological acumen, there is a rich sense of a psycho­
pathological entity such as schizophrenia or melancholia being better characterized by its eccentric
life course or blocked momentum than by any cross-sectional snap-shot. What is morbid is how
things turn out rather than what is going wrong at any precise moment in time. This temporal perspec-
tive, in the case of schizophrenia at least, was not a new insight of phenomenological psychopathol-
ogy. The difference between Kraepelin’s concept of dementia praecox and Bleuler’s of schizophrenia,
for example, is largely a function of Kraepelin’s greater reliance on the temporal course of the condi-
tion. Kurt Schneider (1925), in his earliest deliberations on the diagnosis of schizophrenia, was aware
of this. Nevertheless, phenomenological psychopathologists brought time, and its dilapidation in the
forms of stalled and perverted human existence, into the limelight of psychiatric concern. The psycho­
pathologist as a film-maker not a photographer would be their slogan.
Messas et al. 3

All these matters are well known to those involved in the subject. We wish to stress in this arti-
cle something which has not been remarked upon: a heterogeneity in the writings of phenomeno-
logical psychopathologists. An obvious example is the variety of philosophers who are nominated
as mentor for the psychopathological project, not always one of the phenomenological school of
philosophers, as in the case of Minkowski, who admired Bergson above all other philosophers, or
Straus and Stanghellini, who invoked Aristotle in their deliberations. Internal to the phenomeno-
logical programme, however, we can discern a more crucial heterogeneity in the form of two major
theses.
In one, the core essence of a diagnosable psychiatric disorder or psychopathological entity is to
be found in some unique and fixed morbid state of affairs which is not shared by any ‘normal’
person or by any person afflicted with some other psychiatric disorder. Minkowski’s (1927/1987)
and Tellenbach’s (1974/1980) writings exemplify this position. In the former case a single fault, an
X1, called ‘loss of vital contact with reality’, conditions the psychopathological manifestations of
schizophrenia. In the latter case, another single fault X2 characterizes the premorbid personality of
all those who develop melancholia, something which he calls typus melancholicus and which com-
prises an excessive reliance on their on-going social situation, and which leads to the ‘disease’
melancholia when some life event – e.g. loss of job, flight of child – disturbs the status quo. We call
all such theses, where a single defect is deemed the essential psychopathological cause of a condi-
tion, fixed essentialism.
Consider now an alternative way of approaching psychopathology. Here, the subject diagnosed
with schizophrenia or melancholia, or ascribed any other such label, is not intrinsically deviant
from normal in respect of any psychological or existential way of being – i.e. does not have a
unique, pathogenic flaw – but is simply someone whose versatility in respect of the many ways
there are of being human is compromised in some way. There is no X1, X2, etc., but rather an inap-
propriate or wayward rendition of normal modes of being human. We call all such theses dialecti-
cal essentialism, because psychopathology, according to such formulations, arises when the normal
human repertoire of contradictory ways of grasping the world, self and body is inappropriately
applied and resolved. We give examples below. The overall situation of the subject is that he or she
is party to an epistemological illusion rather than afflicted with an ontological deficit which sub-
sists in fixed essentialism.
In the body of the article we shall trace the variations of our two theses – fixed essentialism and
dialectical essentialism – as illustrated in the phenomenological psychopathology of the past
century.

Fixed essentialism
This is the commoner of our two themes among phenomenological psychopathologists. There are
several identifiable variations, as we shall see, but all share the properties which we outlined in the
introduction.
First and foremost is the notion of a single, intrinsically morbid and pathognomonic fault at the
core of whoever accrues a diagnostic label of schizophrenia or melancholia, and in at least some
neurotic conditions. This fault is specific to the entity in question, being qualitatively different
from anything that is present in a normal human being or any human being with another psycho-
pathological diagnosis. That is why we call it the essence of the condition.
Secondly, the fault resides in some fundamental region of the human being. This is rarely dis-
cussed by the authors in question, but it is clear from the extant proposals – loss of vital contact
with reality, loss of natural attitude – that something pretty serious is being put forward. This sets
phenomenological psychopathology quite apart from other approaches to psychopathology, either
4 History of Psychiatry 00(0)

psychological or organic – for example, where the purported problem is, respectively, a specific
mental dysfunction (e.g. attention disorder) or a specific neuropsychological deficit, in an other-
wise ‘functioning’ human being. The merit of phenomenological psychopathology is recognizing
the ‘craziness’ of its subjects as the expression of something fundamentally amiss with them. Its
demerits are that the proposals put forward are so extreme that, for example, one wonders how any
organism with a loss of vital contact with reality could survive a day, never mind end up as a 20
year-old human with odd ideas. We are not, however, primarily concerned here with the plausibil-
ity of any proposal, only with its position in our thematic scheme.
Thirdly, the fault proposed is an enduring one. Whether it requires a life event to turn a personal-
ity disorder into an ‘illness’, as in Tellenbach’s formulation, or whether it manifests itself over time
as an accumulation of self-destructive and eventually fatal decisions, as in Binswanger’s case-
histories, is immaterial to the issue. Something profoundly rotten at the core of the human being is
persistently interfering with the smooth running of a life. This is why we call all such theses fixed
essentialism, and further characterize them as an ontological deficit.
Variations on the theme abound. We could even give separate labels to several of them, e.g.
descriptive essentialism, where the fault is responsible for similar symptoms and signs at all peri-
ods throughout life, and genetic essentialism, where the fault produces different manifestations at
different phases of someone’s life because of the accumulation of maladaptive ways of being. We
do not wish to labour this distinction, but there is an appreciable difference between Minkowski’s
notion of schizophrenia as temporal stasis and defunct intuition (with, as a consequence, an over-
spatialized and over-intellectualized take on everything), and Tellenbach’s and Binswanger’s con-
ceptions of melancholia and schizophrenia, respectively, as a temporalization of some core deficit
in response to a life crisis or inept social behaviour.
Although we are not evaluating the plausibility of any specific psychopathological model, one
might note here that fixed essentialist theories are mutually inconsistent – one, for example, pro-
moting temporal stasis; another relying on temporalization for the very symptoms of the condition.
Furthermore, there is a lamentable lack of scepticism about the likelihood of any psychiatric condi-
tions being completely explained by some proposed defect. This applies to the late twentieth-­
century psychological suggestions as to the nature of schizophrenia – attention deficit, etc. – as
well as to, for example, Tellenbach’s claim that all 100 of his 100 melancholics had the typus
melancholicus that he maintained.
Altogether, we are highly critical of the fixed essentialist models: they invoke disturbances at
such basic levels of an organism that it is hardly conceivable that any such organism could even
live, crazily or otherwise; they are scientifically naïve as to the sensitivity and specificity of any
proposed cause of a disordered state of mind; and they are mutually incompatible one with another.

Dialectical essentialism
This approach, as we outlined in the introduction, assumes that at the heart of any psychopatho­
logical entity there is a misplacement of a human being’s otherwise normal avenues of knowledge
acquisition, resulting in deviant ways of being.
At first sight, the proposal appears distinctly shaky. How can the bizarre delusions of schizo-
phrenics or the nihilistic ones of melancholics arise through simply mistaking the nature of some-
thing by applying the ‘wrong sort of knowledge’? As we shall endeavour to show, however, this
approach is by no means rare in twentieth-century psychopathology, albeit under different names,
and is largely free of the demerits of fixed essentialism which we listed above.
First, a number of psychopathologists over the century, with different orientations and not all
inspired by the phenomenological movements in philosophy or psychopathology, came
Messas et al. 5

independently to the conclusion that schizophrenic delusions, for example, were precisely this: an
inappropriate application of one mode of knowing something to a realm where some other mode
of knowing is called for. In the case of delusional genesis, all such erroneous projects were deemed
‘epistemological errors’ by Cutting and Musalek (2015). Hedenberg (1927) was the first to recog-
nize this. He saw an analogy between the certainty of a delusion and the way in which a sensation
or perception is passively acknowledged, and saw a further resemblance between delusional cer-
tainty and the strength with which a religious believer holds his or her faith in God. Others (Leeser
and O’Donohue, 1999; Sattes, 1953) discerned an over-zealous scientism in a deluded person’s
world-view. Spitzer (1990) suggested that the delusion obtained its conviction from a surreptitious
metamorphosis from judgement about the external world (dubious, susceptible to interpersonal
validation) to direct, internal perception of mental content (certain, according to Descartes, and
subjectively insulated). What all such theses share is that the misguided take on the world is carried
out through a framework of knowledge acquisition which would be quite legitimate if the topic
were different (sensation, religious faith, scientific investigation, focus on mental contents) but
illegitimate as a means of grasping the world as a whole. They can be deemed prototypes of the
dialectical essentialism whose nature we are building up.
A second strand in phenomenological psychopathology illuminates our theme yet further.
Promoted by Ey in particular (e.g. Ey, 1975), psychiatric disorders are to be conceived of as varia-
tions on ‘la pathologie de la liberté’. According to this line of thought, to be psychotic or neurotic
is to be in a state of compromised freedom. Tatossian (1979/1997), Tellenbach (1974/1980),
Blankenburg (1978) and Kraus (2003) all elaborated this notion. Tatossian’s view was that the
basic problem in being psychotic was that either (a) the sense of transcending oneself was lost – i.e.
God, scientific world view and universality of art were no longer accessible as regions of human
knowledge – and this was the melancholic way of being; or (b) the sense that anything was imme-
diately to hand as a tool was obliterated, and this was the schizophrenic way of being. Both were
available to the normal. Tellenbach, like Tatossian, concluded that in the case of melancholia the
human being could no longer live except as an animal. Blankenburg (1978: 145) gave a more gen-
eral formulation: ‘The essential thing is not the deviant behaviour but an impairment of the being-
able-to-behave, for whatever reason.’ Similarly, Kraus (2003: 210) thought: ‘Psychopathological
disorder is not being able to behave otherwise [which includes] not being able to behave deviantly
[and] not being able to behave otherwise than deviantly.’ In short, the psychopathological way of
being is conceived of here as a compromised repertoire of otherwise normal ways of being. This
complements our first point above concerning the epistemological strait-jacket which afflicts a
psychotic – everything is presented in one way only, sensory or religiose or scientific or internally
mental.
The third stage in the historical advance of what we are calling ‘dialectical essentialism’ are the
writings of Blankenburg (e.g. 1982), who, almost single-handedly, brought out that what is at stake
in psychopathology is precisely a ‘dialectical’ relationship between ways of knowing and ways of
being, within and between each. What Blankenburg saw among his phenomenological psycho­
pathologist predecessors, particularly Binswanger, was an exquisite sense that the human being’s
quality of life is theoretically open to measurement. Contrary to its reputation as a non-scientific
version of the human being, phenomenological psychopathology, according to Blankenburg, is
actually an attempt to extend science into aspects of the human being that have so far been impervi-
ous to such endeavours. Blankenburg subsumes all proposals which purport to quantify the quality
of life under the heading ‘anthropological proportions’. What he means by this has a long philo-
sophical history stretching back to Aristotle and concerns the optimal proportions of some contrast-
ing traits that make for a healthy and well-adapted trajectory through life. Numerous such traits
have been nominated over the years. Blankenburg concentrates on those selected by Binswanger
6 History of Psychiatry 00(0)

in his book Drei Formen missglückten Daseins (1956), the critical passages of which have been
translated as: extravagance, perverseness, manneristic behaviour and schizophrenia (Cutting and
Shepherd, 1987: 83–8). Binswanger’s thesis is that running through all aspects of a human being’s
life there is a tension between what he calls its ‘verticality’ and what he calls its ‘horizontality’,
terms which represent structures, respectively, of personal development and social development.
His terms Verstiegenheit, Verschrobenheit and Manieriertheit, which we translated, respectively, as
extravagance, perverseness and manneristic behaviour, are further depictions of the existential
structures of the anthropological disproportion in schizophrenia – personal development out of
kilter with social development.
Blankenburg himself, in an article entitled ‘Wie weit reicht die dialektische Betrachtungsweise
in der Psychiatrie?’ (2007), uncovers a large number of instances. His overall thesis is that a healthy
state of mind is one in which a subject is aware of the contradictions and ambiguities in their life
and that mental disorder can be viewed as an impoverishment in this. For example, he sees in the
work of Tellenbach and Kraus on melancholics, referred to above as an over-reliance on the status
quo, evidence of an ‘undialectical’ mode of being, because they cannot tolerate ambiguity.
Hysterical conversion, Blankenburg thinks, is also a sign of dialectical inflexibility: the patient –
think Charcot – cannot but obey the will of the physician, whose impositions find no independent
self to counter them. In schizophrenia, by contrast, Blankenburg discerns a different problem, still
within the ambit of dialectical disproportion, but where the subject is rather overly sensitive to the
ambiguities and contradictions in life, hence their ambivalence, which he says Bleuler was right to
emphasize. Yet another thread of dialectical disproportion in psychopathology, which Blankenburg
sees as conforming to the original Hegelian notion of dialectical transformation, are those cases
where some sort of ‘positivity out of negativity’ occurs. He mentions Nietzsche’s and Van Gogh’s
creative achievements when afflicted, respectively, by general paresis and epilepsy, and the alleged
creativity of schizophrenics and their relatives. (This is a controversial area, as he notes, but he
would have been intrigued by patients with fronto-temporal dementia reported by Miller et al.
(1998) who became proficient artists despite grossly impaired cognitive function.)
In short, a survey of the extent to which psychopathological states of mind conform to an altera-
tion in the dialectical versatility enjoyed by the normal person uncovers a rich vein of potential
interest.
Finally, we draw attention to our own contributions to the theme. Quite independently GM and
MT on the one hand and JC on the other had come to the conclusion that psychopathological and
psychiatric nosological entities had been poorly formulated over the previous century. We were of
the view that the non-descriptive, non-psychological and non-organic agenda of the original pheno­
menological psychopathological movement was correct, but we were unhappy with the tendency
of phenomenological psychopathologists to recreate in their own language what they had criticized
in psychological or neurological formulations. We were, furthermore, alert to the arguments of the
anti-psychiatry movement, that, for example, schizophrenia is a socially proscribed way of being
rather than any morbid human state. Moreover, we were of the opinion that the status of any psy-
chopathological or nosological entity has to conform to some philosophical framework of what it
is to be a human being. We were averse to any notion which asserted that the schizophrenic, mel-
ancholic, or anyone with another nosological entity, was a freak of nature.
GM, in two articles (Messas, 2010, 2016), addresses the issue of proportionality as it was por-
trayed in the phenomenological psychopathological literature. In the first article, he tackles two
ingrained viewpoints as to the nature of a psychopathological state of affairs. One is the proposal
of Jaspers (1959/1963) that some psychopathological entities, e.g. primary delusion, are ‘un-
understandable’, whereas others, e.g. depressive conditions, are ‘understandable’. The second is
the causal hypothesis that some psychopathological or nosological entities are brought about by
Messas et al. 7

circumstances inherent in the personality and life situation of the afflicted person, whereas others
are of biological origin. GM argues that both these dichotomies are artefacts of an investigator’s
insensitivity to human proportionality. All such claims, he argues, are one-sided, and all psycho-
pathological entities should be deemed part-understandable and part-ununderstandable, part bio-
logically- and part empathically-grouped.
In the second article he illustrates this theme with a phenomenological analysis of drug intoxi-
cation and drug-induced psychosis. The two cases chosen show the interplay of exogenous and
endogenous factors in the maintenance of an addiction and in the shift to a psychosis, but, above
all, demonstrate how a phenomenological approach is the key to understanding both the addiction
and the psychotic transformation. For example, there is a now well-established phenomenological
finding, in a variety of addictions, that each, despite their individual differences, induces an
‘atemporalization’ on the addict (Di Petta, 2014): their life grinds to a halt and what is present
overwhelms past and future. In the two cases selected by GM, this psychopathological scenario is
exemplified. The atemporalization effect of the drug is shown, through an analysis of the back-
ground of these patients, to be precisely the best solution to his existential situation – i.e. obliterat-
ing both past and future where, respectively, he wants neither to remember nor to contemplate.
Furthermore, his drift into psychosis, particularly the vivid hallucinations characteristic of a drug-
induced psychosis, is, what GM calls a ‘sensorialization’ of experience – a predominance of
‘now-experience’ over past and future. Personal and pharmacological, understandable and non-
understandable, issues gel in a way which make phenomenological psychopathology superior, in
his view, to other ways of formulating psychopathology – psychoanalytical, behavioural, cogni-
tive, organic.
MT (Tamelini, 2015) tackles the fraught issue of what Tellenbach (1974/1980) meant by ‘endo-
geneity’ in both melancholia and schizophrenia. In melancholia it is clear that something vital – our
animality – is at issue: sleep, appetite and sexual urges are all altered. Tellenbach’s formulation of
all this, which is rather opaque, seems to be proposing that the melancholic is reverting to an ani-
mal way of existing. Endogeneity seems to mean, for him, a set of normal vital functions which are
exaggerated in melancholy. They are normal, but, for reasons he nowhere addresses, overwhelm-
ing. His further view that schizophrenia is also afflicted by ‘endogeneity’ is even more proble­
matical. The vitality of a schizophrenic is, to be sure, attenuated, but schizophrenia and melancholia
are like chalk and cheese, so calling both of them endogenous psychoses, when ‘endogeneity’, for
Tellenbach, means recrudescent vitality is nonsense. What the schizophrenic does suffer from is
indeed something at the vital level of being, as Minkowski and Blankenburg were exquisitely
aware of, but this state of affairs is diametrically opposite to what obtains in melancholia. Both
schizophrenia and melancholia can very well be deemed ‘endogenous’ psychoses if this means that
something ‘vital’ is at stake in both (not Tellenbach’s definition but ours), but in one, melancholia,
it is exaggerated and in another, schizophrenia, it is attenuated. There are riddles and false supposi-
tions in phenomenological psychopathology as in any discipline, and MT tries to tease these out.
JC had arrived at a similar notion of psychopathology as anthropological disproportion and
dialectical alteration (without being acquainted with these terms at the time) through study of the
neuropsychological basis of psychopathology, on the one hand, and application of Scheler’s late
philosophy, on the other.
Kapur (1996) coined the term ‘paradoxical functional facilitation’ for the tendency of subjects
with focal brain damage to manifest behaviour and to grasp the world in ways which reflected both
the impairment wrought by what their brain damage no longer allowed them to do (e.g. perceive
the Gestalt of a face) and what this impairment somehow released from healthy parts of the brain
(e.g. focusing on the details of a face) previously inhibited from so doing by what was the dominant
mode of tackling some task. In words which almost exactly mirror our criticism of fixed
8 History of Psychiatry 00(0)

essentialism and our promotion of dialectical essentialism in psychopathology, Kapur castigated

what he referred to as the ‘deficit’ approach to neuropsychology and instead commended a dynamic
approach – any brain-damaged person, relative to normal, knows and behaves with something lost
and something gained.
In Scheler’s late philosophy, the human being is deemed to be a tensed hybrid of animal and
God, Drang (the relentless urge that is life) and Geist (spirit and higher intellect) (Scheler,
1920s/2008). JC (Cutting, 2012) then applied these notions to psychopathology, formulating some,
e.g. melancholia, as an over-reliance on our animality, and others, e.g. schizophrenia, as an excess
of spirituality. In the current framework of dialectical essentialism, each psychopathological or
nosological entity can be delineated, according to JC, by its position in a dialectical formulation of
what anthropological proportions are out of joint and what combination of negative and compensa-
tory positive ways of knowing and being result.

Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit
sectors.

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