Home Psychology Psychiatric Diagnosis Revisited: From DSM to Clinical Case Formulation
What About Suffering: Verstehen or Gardez- vous de comprendre?
If diagnosis comes down to constructing case formulations in which symptoms are framed in the context of a person’s broader functioning, such that the impairing impact of symptom and context, the logic of functioning, as well as strengths and aspects of resilience are mapped, the main question remains as to which position the clinician should take in dealing with the highly subjective material obtained about the patient’s functioning. Some clinicians will stress that obtaining genuine understanding of what the patient lives through is crucial, while others clearly have reservations regarding such an attempt to understand.
According to Karl Jaspers (1912), who is a key figure in phenomenological approaches to psychiatry, building a deliberate and effortful understanding of what the patient lives through is crucial. In his approach the diagnostician should not only describe the patient’s problems, but aim at understanding them, and thus at getting hold of why and how given symptoms come hand in hand with the experience of suffering. Just as Ricoeur did in his wake, Jaspers states that by using standardized measurement instruments one cannot adequately assess mental processes. To get hold of the precise nature and of the impact of mental health symptoms we have to build on people’s speech, and on the opinions they have about their own experiences. In doing so a three-step trajectory needs to be explored.
In the first step, clinicians should adequately describe complaints and related experiences: “We must begin with a clear representation of what is actually going on in the patient, what he is really experiencing, how things arise in his consciousness, what are his own feelings, and so forth” (Jaspers 1912, p. 1316). Along this way an inventory of painful aspects in the patient’s experience is made. Important to this phenomenological approach is that the clinician does not “translate” the patient’s speech in professional discourse (“you have a depression, sir”), but explores it in terms of the patient’s meaning-making activities: “the aim of phenomenological investigation is the description of the lived experience, a description of phenomena just as they present themselves or are given in experience” (Parnas and Zahavi 2000, p. 12).
Jaspers indicates that in the next step, the clinician should map the context and circumstances in which the described mental phenomena are embedded: “We have to be led, starting from the outside, to a real appreciation of a particular psychic phenomenon by looking at its genesis, the conditions for its appearance, its configurations, its context and possible concrete contents” (Jaspers 1912, p. 1316). In this second step, descriptively mapped phenomena can be contextualized, starting from the patient’s perceptions and appreciations of specific symptoms.
While these first steps reflect an overall clinical attitude that connects well with the biographical tradition in nineteenth-century psychiatry (Berrios 1992), the third step Jaspers envisions is quite specific to phenomenological approaches, and consists of creating a deep empathic understanding (Verstehen) of what the patient lives through. The clinician should not only “know” what goes on in the patient, but also “see” the patient’s perspective by actualizing it in his own mind: “Just as sense-perceptions are evoked by the demonstration of an object, so this meaningful empathic actualization will be evoked in us by the above- mentioned hints and indications, by our immediate grasp of expressive phenomena and our self-immersion in other people’s self-description” (Jaspers 1912, p. 1317). By being a mirror for the other’s intimate experiences, the phenomenologically working clinician aims at grasping the patient’s mental symptoms and suffering. Such empathic understanding comes down to an imaginary identification: the clinician builds an image of what the other lives through, and identifies with this image, such that the other’s state of being can be experienced. The French philosopher Emmanuel Levinas (1982) even adds a step to the threefold process Jaspers describes, suggesting that understanding is not enough. In his view we should not only comprehend the patient’s suffering, but also suffer ourselves with the patient, which is the only way to get hold of the patient’s distress (Gantt 2000).
On a critical note it could be added that not all clinicians are equally enthusiastic about such an effort of empathic understanding. Lacan’s (1955-1956) criticism is in this context illustrative. In his view deliberate empathic actualization does not necessarily result in a better appraisal of patients’ difficulties, but might as well have a reverse effect. After all, a fundamental problem with it is that it takes the clinician’s experience as the standard, and always starts from the clinician’s ideas on what plausibly goes on in the patient, while nothing guarantees that the clinician can adequately grasp the patient’s mind. For example, this is also what a study on empathic accuracy in psychology students shows (Barone et al. 2005). Researchers videotaped a therapy session, and subsequently asked the patient what she thought and felt at different moments during the ses?sion. After watching the session students also had to describe what, in their view, the patient was living through. The results indicate that while students’ appraisals of emotions were sometimes similar to those the patient revealed, the patient’s thoughts could not be grasped properly. Subsequent training sessions had a positive effect on both facets of empathic understanding, but the net result is that empathic accuracy remains limited.
Clearly, the effort of empathic understanding has a number of positive effects. It creates a bond between the clinician and patient, and the quality of this relationship predicts recovery (Blatt and Zuroff 2005). Through its use of imaginary identification empathic actualization often creates a link, thus engendering the belief that the patient and clinician share the same ideas. In Lacan’s (1955-1956) view, such a process of attunement is inherently limited since it might well blind the clinician to inconsistencies in the patient’s functioning, and make her neglect peculiarities that the patient and/or clinician prefer to set aside. Characteristic of imaginary functioning is that it tends toward building comprehensive Gestalt-like ideas, which misrecognizes incomprehensible or less imaginable elements. Empathic understanding exclusively bears witness to synthesis-oriented tendencies in mental functioning, which the clinician should temper with the aim of getting hold of symbolic and real components in the patient’s functioning too (see Chap. 3). Hence Lacan’s dictum (1956a, p. 394): “Beware of understanding” (Gardez-vous de comprendre), which does not imply that the clinician should explicitly not try to understand the patient, but denotes that effortful understanding should not be thought of as the ultimate tool or the final aim in clinical work. Indeed, by addressing imaginary, symbolic, and real components in patients’ suffering a more adequate case construction can be made.
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