15Chapter 12. The Phenomenological School: How to Learn to Be a Patient
In 1911, Karl Jaspers (1883–1969), a 30-year-old assistant at the psychiatric clinic of Heidelberg University, who had suffered from severe congenital heart disease and bronchiectasis since childhood and knew each day was a gift, published a short article. It was modestly titled “The Phenomenological Approach in Psychopathology.” Just over twenty pages. No one, including the author himself, expected this article to revolutionize global psychiatry.
Yet that was precisely what happened.
Two years later, in 1913, Jaspers expanded the article into a hefty monograph: General Psychopathology (Allgemeine Psychopathologie). By the last edition published in his lifetime in 1959, the book had grown to nearly a thousand pages. A staggering number: a thousand pages from one man, one mind, one obsession. This volume, without exaggeration, became the most influential psychiatry textbook of the 20th century in the German-speaking world. It was translated into dozens of languages. Generations of psychiatrists read it. It is still cited in academic journals today.
All of this—with one curious detail. Jaspers was never a clinical psychiatrist in the strict sense. He had a medical degree, but he worked in psychiatry for only a few years, as an assistant in Heidelberg. He later moved into philosophy. He was Hannah Arendt’s teacher, Martin Heidegger’s interlocutor, and one of the greatest existentialist philosophers of the 20th century. His philosophy was shaped by the issues of limit situations, borderline experiences, and interpersonal communication.
It was precisely this unconventional journey—first through medicine, then into philosophy, and finally back to psychopathology—that enabled Jaspers to achieve something no pure clinician ever could.
What exactly did he do?
He posed a simple yet revolutionary question: How do we psychiatrists actually know what we think we know about mental illness?
Before Jaspers, psychiatrists described symptoms: hallucinations, delusions, anxiety, depression. They classified diseases: schizophrenia, manic-depressive psychosis, hysteria. However, they rarely questioned the method by which they obtained this knowledge. What does it mean to “describe” a hallucination? What does it mean to “understand” a delusion? How do we distinguish one from the other?
Jaspers took the methodology developed by the German philosopher Edmund Husserl (1859–1938) and applied it to psychiatry. Husserl taught that to study consciousness, one must doubt all theories, all preconceived explanations, all prejudices—and return to the experience itself, as it is given. Zu den Sachen selbst—“To the things themselves.”
Jaspers stepped into psychiatry as if entering a dark labyrinth. He brought with him one rule. Before explaining psychotic experiences—through libido, the unconscious, neurology, anything—one must learn to describe them accurately. Why? The answer lies within the patient. Approach them. Without theory. Clear the mind of all dogma. Listen to them. Try to understand how they experience their own world. Feel their distorted reality, see their universe from within. And only after this—after precise description—ask questions about causation.
It was a revolutionary shift. Psychiatry turned its focus to the patient.
Jaspers’ second key contribution is his distinction between two types of understanding in psychopathology.
He called the first type “understanding” — Verstehen. It is the capacity of one consciousness to penetrate the armor of another and reach its inner experience. Picture this: the person before you says his mother has died. And you feel that grief. Not because your mind has constructed a theory of grief, but because you yourself are made of flesh and blood. Your body remembers from its own inner experience what loss is. This kind of understanding requires no proof. It is intuitive, empathic, immediate.
The second type Jaspers called “explanation” (Erklären). It is the causal establishment of connections between phenomena. When we say, “This patient is depressed because his synaptic serotonin levels are reduced,” we are not understanding his depression from within — we are explaining it from without, through a cause-and-effect chain supported by research.
For Jaspers, these two methods did not contradict each other but belonged to different domains of knowledge. Understanding operates where meaning-connections within the psyche are at issue: how one experience leads to another, how a thought gives rise to an emotion. Explanation operates where bodily, biological, neurochemical processes are at issue.
And here Jaspers made a striking observation about schizophrenia. He argued that the psychotic experiences of schizophrenic patients — in their delusional essence — defy understanding. That is, a psychiatrist cannot, by a simple effort of empathy, enter into what it is like to believe that the FSB is sending you messages through the wires in your walls. It is not like grief. It is not like anxiety. It is something fundamentally other, with no analogue in normal human life. Schizophrenic delusion is ununderstandable, “incomprehensible.”
Jaspers’ statement would later become one of the most debated ideas in the philosophy of psychiatry. Some of his disciples would agree with it. Others—particularly Binswanger, whom I’ll discuss later—would challenge it. The debate continues to this day.
But the fact that such a debate is even possible is a testament to Jaspers’ contribution. He pulled psychiatry out of the positivist self-assurance of the 19th century and confronted it with philosophical questions that it continues to grapple with to this day.
Jaspers was the first but not the only one. The phenomenological approach spawned an entire movement in early 20th-century psychiatry.
One of its most brilliant representatives was Eugène Minkowski (1885–1972). This unusual man was born in Warsaw to a Jewish family. He studied medicine in Germany, Switzerland, and France. He worked as an assistant to Bleuler at Burghölzli. In 1914, when the First World War broke out, Minkowski — despite being a citizen of the Russian Empire — volunteered for the French army as a military doctor. He later settled in France, became chief psychiatrist at the Sainte-Anne hospital in Paris, and lived there for the rest of his life. During the Second World War, he and his wife took part in the activities of the Jewish Resistance, saving children from deportation.
In 1927, Minkowski published his book Schizophrenia (La Schizophrénie). Then, in 1933, he released an even more renowned work: Lived Time (Le Temps Vécu). In these writings, he introduced one of the most profound concepts in the history of psychopathology: trouble générateur—the “generative disorder,” the core disturbance from which all else stems.
Minkowski’s idea is a detective’s scheme. Hallucinations. Delusions. Emotional flattening. Oddities of behavior. All these symptoms of schizophrenia are not a random collection of fragments. They grow from a single deep fracture. But where is the root? What exactly has been destroyed? Minkowski found the breach. In the schizophrenic patient, something fundamental in the very structure of his existence is disrupted. In particular — what Minkowski called “vital contact with reality” (contact vital avec la réalité). It sounds abstract. But behind this formula lies a catastrophe of the body. It is the capacity to be in the world spontaneously, pre-reflectively, with one’s entire being. To breathe it in, to touch it. To interact with other people. To feel the flow of time pulsing. To have an intuitive, animal “presence.” They have lost this connection. They are torn from the fabric of being.
Minkowski believed that in schizophrenia, this vital connection with life is disrupted or lost. The patient seems severed from the flow of reality. Time for them either stops or flows strangely. The intuitive understanding of others disappears. The world becomes formal, mechanical, alien. All other symptoms stem from this fundamental break.
This is an exceptionally beautiful and profound idea. It also had practical significance: it helped psychiatrists communicating with patients diagnosed with schizophrenia understand that they weren’t merely dealing with someone exhibiting peculiar symptoms, but rather with a person undergoing a fundamental transformation in their very way of being in the world.
Minkowski introduced another concept. Dangerous. Elusive. The “praecox feeling” — sentiment de précocité, sometimes praecox-Gefühl. What is it? A subjective sensation that arises in an experienced psychiatrist when encountering a patient with schizophrenia. Difficult to grasp, nearly indescribable—yet unmistakable. The doctor looks at the person, and a chill runs down their spine. A tightening in the throat. Instinct screams of danger. The psychiatrist senses this person’s strangeness. Their otherness—even before they can articulate it in clinical terms, in words, in diagnosis. The physician’s body registers what the mind has not yet grasped. Minkowski called this “diagnosis through penetration” — diagnostic par pénétration. An intuitive capture of the schizophrenic disposition.
In modern psychiatry, this idea is often dismissed as “unscientific” and “subjective.” But many seasoned clinicians—myself included—will tell you: the praecox feeling is real. We do sense something distinctive when we meet a patient with schizophrenia. Science has yet to figure out how to formalize it. Perhaps someday it will.
The third major figure of the phenomenological school was the Swiss psychiatrist Ludwig Binswanger (1881–1966). He served as director of the elite Bellevue Sanatorium in Kreuzlingen, Switzerland—the very institution where Anna O., the famous patient of Josef Breuer and an early figure in the history of psychoanalysis, was treated.
Binswanger moved from Freud to Heidegger. He began as a psychoanalyst, a close friend of Freud, corresponding with him for nearly forty years. But gradually, Binswanger came to feel that psychoanalytic language was insufficient to describe psychotic patients. Something deeper was needed—more philosophical.
He found it in the philosophy of Martin Heidegger (1889–1976) — specifically, in Heidegger’s seminal work Being and Time (1927). Binswanger developed his own method, which he called Daseinsanalyse — “analysis of presence,” drawing on Heidegger’s concept of Dasein, or “being-here.
Imagine: to understand a madman, it is not enough to study their brain. One must grasp the very structure of their being in the world. Each of us exists in our own way—each has their own relationship with space, time, their own body, and others. This is their way of being. And when this way is disrupted, psychopathology emerges. Binswanger did not just treat. He dissected the very fabric of human existence. Schizophrenia, mania, melancholy—these are not illnesses in the conventional sense. They are different modes of distorted being-in-the-world. That is the key.
In 1957, Binswanger published Three Forms of Failed Existence (Drei Formen missglückten Daseins), where he analyzed three cases: severe depression with [suicide], schizophrenia, and extreme eccentricity. Each case was described not through “symptoms” but through the patient’s way of being—how they inhabited space, time, and relationships.
This is perhaps the most philosophical approach to psychiatry in all of history. It’s difficult to apply “technically.” It demands from the psychiatrist a profound philosophical education, literary sensitivity, and patience. But—when properly employed—it yields an understanding of the patient deeper than any other school of thought.
The debate between Jaspers and Binswanger was a pivotal moment in phenomenological psychiatry. Jaspers insisted: schizophrenia is incomprehensible through empathy. Binswanger countered: schizophrenia is a specific mode of being-in-the-world, and if we analyze the structures of this mode deeply enough, we can understand it. Not as isolated symptoms, but as an entire form of life.
Both viewpoints contain a kernel of truth. Both remain relevant in contemporary psychiatry.
What makes the phenomenological school valuable to us today, in an age of tomography, psychopharmacology, and big data?
Above all, she left psychiatry the art of listening.
In modern medicine, increasingly built on brief consultations, standardized questionnaires, and quick diagnoses based on ICD or DSM criteria, there lies a significant danger. The danger of reducing psychiatrists to mere operators who check boxes on clinical forms without truly listening to the unique, individual, and often strange experiences of the person sitting before them.
The phenomenological tradition reminds us: a patient is not merely a collection of symptoms. A patient is a person experiencing the world in their own way. This unique way of experiencing—that itself holds clinical significance. If a physician doesn’t listen, they don’t truly see the illness. They only see what’s been checked off in the questionnaires.
Every time a modern psychiatrist asks a patient a question that isn’t from a standardized clinical scale but stems from genuine curiosity—such as, “What does this feel like for you?”, “Could you describe what you’re experiencing right now?”, or “Does time feel normal to you, or is it different?”—they are working within the tradition established by Jaspers, Minkowski, and Binswanger.
In this sense, the phenomenological legacy endures. Not as a distinct school of thought, but as the conscience of psychiatry. As a reminder that behind clinical categories lie living, experiencing individuals.
But here too—just as with Freud, just as with Jung—we need to be clear. The phenomenological school did not solve the problem of treating schizophrenia. Neither Jaspers nor Minkowski nor Binswanger developed a method that could produce therapeutic results comparable to antipsychotic drugs. Their contribution was to understanding, not to treatment.
And here I want to make one very important point, one that brings us back to the central theme of this book.
Phenomenological psychiatry is a rigorous academic discipline that requires years of both philosophical and clinical training. When Binswanger analyzed cases like “Ellen West” or “Lola Voss,” he drew on a profound understanding of the works of Heidegger, Husserl, Scheler, and Bergson. He read philosophy in its original language, spending years writing and editing his own works.
This is not the same as modern commercial “existential psychotherapists” who’ve read a couple of translated books and now offer paid workshops on “Heidegger for business.” It is not the esoteric “constellation facilitators” who occasionally mention Binswanger as their predecessor. Nor is it the schools where the word “existential” serves as a marketing slogan. No. These are all imitations—and dangerous ones at that. Because behind them lies a real story. A different one. A terrifying one. A story where philosophy isn’t for sale but serves as salvation—or fails to, leaving a person to pay with their very being.
Genuine phenomenological psychiatry is rare, demanding, and not particularly “marketable.” This is why it’s almost absent in today’s commercial landscape. Instead, there are imitations that use terms like “phenomenology,” “presence,” “being-in-the-world,” and “authenticity” without their philosophical and clinical foundations.
When you hear these words in the advertisement for a “therapeutic retreat,” ask yourself: Does the facilitator understand what Husserl meant by epoché? Have they read Jaspers in the original or in an academic translation? Have they undergone clinical training? Nine times out of ten, the answer will be no. What you’re seeing is not the phenomenological tradition. It’s the commercial exploitation of its terminology.
This is one of the most widespread mechanisms of the modern pandemic of madness: borrowing the language of serious academic disciplines to cloak methodologically hollow practices.
By the mid-20th century, psychiatry had developed three robust theoretical traditions: Kraepelin’s clinical approach, Freudian-Jungian depth psychology, and phenomenological philosophy. They complemented each other, debated one another, and enriched the field as a whole. Together, they formed the intellectual framework that psychiatry had in place by the time the first antipsychotics emerged in the 1950s.
Yet there was a fourth tradition, still in its infancy during the first half of the century, that by century’s end would become psychiatry’s dominant paradigm - the biological approach. This path sought to decode schizophrenia through neurochemistry, genetics, neuroimaging, and immunology. Its journey proved long and arduous, riddled with false hopes and dead ends. The following chapter will explore this “biological turn” in psychiatry - its winding path and present-day implications.