The Existential and the Interpersonal Ludwig Binswanger and Harry Stack Sullivan by Roger Frie
ROGER FRIE is currently a university fellow in the professional psychology department of George Washington University and holds a doctorate in phenomenological psychology, psychoanalytic theory, and philosophy from Cambridge University, England. He has taught at the New School for Social Research, Harvard, and Northeastern Universities, and has trained in interpersonal psychoanalysis at the William Alanson White Institute. He has written widely about the interface of philosophy, psychoanalysis, and psychology, and is the author of Subjectivity and Intersubjectivity in Modern Philosophy and Psychoanalysis (Rowman and Littlefield, 1997).
Summary The Swiss psychiatrist Ludwig Binswanger is commonly known as the founder of “existential analysis.” The purpose of this article is to introduce the larger scope and relevance of Binswanger’s work by drawing, above, all on untranslated texts. The author shows how Binswanger developed a contemporary perspective on self-other interaction with important clinical implications for our understanding of the therapeutic process. The article examines the interaction between the psychotherapist and patient that forms the therapeutic matrix, and argues that Binswanger used elements of Martin Heidegger’s thought and Martin Buber’s dialogical philosophy to develop an original approach to psychotherapy that has considerable parallels with the work of Harry Stack Sullivan and more recent interpersonal and relational theory.
The Swiss psychiatrist, Ludwig Binswanger, is known as the founder of “existential analysis,” yet his work is not commonly studied today. Binswanger was introduced to English-speaking audiences in the late 1950s by Rollo May in Existence: A New Dimension in Psychiatry and Psychology (May, Angel, & Ellenberger, 1958). A few years later, Jacob Needleman translated a selection of Binswanger’s essays and case studies in Being-inthe-World: The Selected Papers of Ludwig Binswanger (Needleman, 1963). During the 1960s and into the 1970s, Binswanger achieved a measured popularity within the burgeoning movement of humanistic psychology, but now he is relatively unknown. Given the changes in the mental health profession, this is not altogether surprising. Training in clinical psychology has often become very narrow in focus. As a result, the philosophical nature of Binswanger’s writings is often deemed too abstract or too distant from the concerns of contemporary psychology. There is also another factor at work. Most of Binswanger’s writings, including his chief text on the nature of human interaction, have not been translated into English. Thus, what we generally know of Binswanger is almost exclusively based on dated commentaries and translations that are frequently imprecise. The situation is quite different in current-day Germany and Switzerland, where there is a renewed interest in what Binswanger has to say. This is most apparent in the recent publication of his Selected Works (1992, 1993a, 1993b, 1994) and in the publication of a series of monographs and articles that examine the significance of his psychology (Herzog, 1994; Hoffman, 1997; Holzhey-Kunz, 1990; Passie, 1995; Vetter, 1990). Binswanger’s work continues to be implemented and expanded on in private practice, clinic, and hospital settings, particularly in Heidelberg, Marburg, Reihenau, Würzburg, and Zürich. Clearly the full range and importance of Binswanger’s work has yet to be appreciated by English-speaking clinicians. The purpose of this article is to “reintroduce” Binswanger to a contemporary audience. To achieve this aim, I will draw on and discuss previously untranslated work. Although some of the sources I use originally appeared in May et al. (1958) and Needleman (1963), I have gone back to Binswanger’s original texts to provide a consistent and more precise translation of his writings; all translations of Binswanger are my own. To acquaint the reader with what Binswanger has to say, it will be necessary to provide a philosophical grounding in his work. Implicit in Binswanger’s writings are such contemporary humanistic concerns as “authenticity,” “self-other interaction,” and the “total human being.” Indeed, Binswanger was the first to conceptualize many such ideas in a psychological framework, which makes revisiting his work all the more important. I will seek, above all, to show the ways in which his ideas can help us think about and understand the nature of interpersonal interaction, particularly within the therapeutic dyad. I will argue that Binswanger developed a contemporary theory of the self that accounts for the primacy of human relations and has important clinical implications for the theory and practice of psychotherapy. Binswanger’s shift from Freudian psychoanalysis to existential analysis is a shift from an intrapsychic to an interpersonal theory of human nature, and from an impersonal to an interpersonal therapeutic technique. In elaborating Binswanger’s perspective, I will therefore pay particular attention to parallels between existential analysis and Harry Stack Sullivan’s interpersonal psychoanalysis. The recent ascendancy of interpersonal and relational perspectives in psychotherapy and psychoanalysis (Aron, 1996; Mitchell, 1988) make such parallels especially noteworthy (Portnoy, 1999).
FROM FREUD TO PHILOSOPHY Binswanger bridged the divide between psychiatry, psychoanalysis, and philosophy with relative ease. Early in his career he worked closely with Sigmund Freud and Eugen Bleuler. As his interests in philosophy grew, he initiated personal contact and entered into a substantial correspondence with Edmund Husserl, Martin Heidegger, and Martin Buber. Each would have a direct impact on the development of Binswanger’s ideas. Yet Binswanger never became a follower of a particular thinker or school of thought. Instead, by drawing connections between different ways of thinking, Binswanger originated a philosophical approach to psychiatry. Binswanger thus belonged to a continental European tradition of intellectual thought that freely combined insights from philosophy and clinical practice (Passie, 1995). He was born in Kreuzlingen, Switzerland in 1881 into a family of prominent psychiatrists. Binswanger attended the universities of Lausanne, Heidelberg, and Zürich, and received his medical degree from Zurich in 1907. He trained as a psychiatrist under Bleuler and Jung at the Burghölzli Hospital in Zürich. It was there that he became acquainted with the burgeoning field of psychoanalysis and, in 1907, accompanied Jung to Vienna to meet Freud for the first time. Binswanger developed a friendship with Freud that continued through personal visits and large correspondence until the latter’s death in 1939 (Fichtner, 1992). Binswanger was offered the directorship of the Burghölzli Hospital when Bleuler stepped down (Spiegelberg, 1972), but chose instead to remain director of his family’s Bellevue Sanatorium in Kreuzlingen, which was founded by his grandfather in 1857. As director from 1910 to 1956, Binswanger dedicated much of his time to the integration of theoretical and clinical insights from philosophy, psychoanalysis, and psychiatry. Binswanger retired in 1956 but remained an active writer, publishing his last work just one year before his death in 1966. Binswanger’s broad theoretical interests were reflected in his personal associations with major thinkers of the time. Among the prominent figures who visited Binswanger in Kreuzlingen were Freud, Husserl, Heidegger, Buber, Karl Löwith, Ernst Cassirer, Alexander Pfänder, and Max Scheler. Bellevue Sanatorium itself became a famous center for psychiatric treatment. Included among its patients were such well-known personalities as the German actor Gustaf Gründgens, the Swiss artist Ernst Ludwig Kirchner, the Russian dancer Vaslav Nijinsky, and the German sociologist Max Weber. The Bellevue Sanatorium finally closed in 1980 due to financial constraints and the changing nature of mental health care. Binswanger’s early association with Freud had a significant impact on his theoretical and clinical pursuits. Binswanger was initially attracted to psychoanalysis because of the insights it provided into human behavior. In 1909, while working at the University of Jena, Binswanger published the first psychoanalytic case study at a German university psychiatric clinic. In 1910, he was president of the Zürich Psychoanalytic Society. However, even in this early period, Binswanger had reservations about Freud’s ideas. Binswanger cautioned Freud against scientific reductionism and was critical of the proto-physiological basis on which Freud’s drive theory and models of the mind were based. Nor did he think that psychoanalysis sufficiently accounted for the role of the other people in the development of the personality. In a later recollection of his friendship with Freud, Binswanger (1957b) remarked that his entire scientific development, in positive and negative respects, was determined by his effort to formulate a philosophical and scientific basis for psychoanalysis. Although Binswanger never questioned the explanatory potential of natural science, he sought above all to develop an account of human nature that was not reductionistic. This project culminated in his first book, Introduction to the Problems of General Psychology (1922). Although the book was dedicated to “my teachers, Bleuler and Freud,” it also marked the turn toward philosophy in Binswanger’s work. Binswanger argued that the object of investigation must always be seen in its full phenomenal reality. His purpose was to understand and explain human beings in the totality of their existence, not simply as natural objects constructed from various parts. Husserl’s phenomenology provided Binswanger with a method to explain the “visual reality” of his patients. It was, however, Heidegger’s move beyond Husserl in Being and Time (1927/ 1962) that influenced Binswanger’s thinking most directly. Heidegger’s fundamental ontology, particularly the notion of being-in-the-world, enabled Binswanger to develop a philosophically oriented approach to psychiatry that could account for the human being’s total existence.
BEING-IN-THE-WORLD Binswanger was the first to recognize the contributions that Heidegger’s philosophy could make to psychiatry. Heidegger was initially intrigued by Binswanger’s work and the two men entered into a correspondence in the late 1920s (Frie, 1999a), which was punctuated by personal visits over the next four decades. Binswanger began sending Heidegger his texts in the early 1930s, and the philosopher responded in kind. In the early 1940s, following Heidegger’s example, Binswanger adopted the term Daseinsanalysis—translated by May et al. (1958) as existential analysis—to describe his approach. From the late 1940s onwards, however, Heidegger worked closely together with another Swiss psychiatrist, Medard Boss. Today the term Daseinsanalysis is commonly used to refer to the work done by the Daseinsanalytical Institute in Zürich, which was founded by Boss. In contrast to Boss, Binswanger was critical of some aspects of Heidegger’s philosophy. Binswanger’s interpretation of Being and Time (Heidegger, 1927/1962), which for a time set the standard for interested psychologists and psychiatrists (Weigert, 1949), did not remain loyal to the philosopher’s text. In addition, Binswanger drew on other thinkers to develop a theory of human interaction that he felt was missing in Heidegger’s fundamental ontology. This led to Heidegger and Boss’s later critique of Binswanger’s work in the Zollikoner Seminare (Boss, 1957; Heidegger, 1987). Though the Binswanger-Boss-Heidegger debate is outside the scope of this article (see Frie, 1997, 1999a), I will demonstrate that the question of philosophical interpretation in no way les- sens the importance of Binswanger’s ideas for contemporary psychotherapy. According to Binswanger, Heidegger’s fundamental ontology provided an analysis of the primary structures of human existence and constituted a necessary foundation for the human sciences. Binswanger was primarily interested in Heidegger’s analysis of existence, which is oriented toward an ontological end. In Being and Time (1927/1962), Heidegger calls for the return to the meaning of Being as such. Heidegger refers to the human being that questions the meaning of Being as Dasein. Heidegger argues that Dasein is neither autonomous nor self-contained, but always already situated in the world. Thus, Dasein exists as being-in-theworld. As interpreted by Binswanger, the notion of being-inthe-world signified that we are not isolated, encapsulated egos but beings who are always in relation to other humans and the world around us. This implies that there is neither a subject-object dichotomy nor a division between subjective and objective experience. According to Binswanger, Heidegger’s conception of world—the matrix of relations in which Dasein exists and discovers meaning—thus provides the clinician with a key conceptual tool for understanding and describing human experience. Binswanger enlarged Heidegger’s ontological conception of world to include the horizon in which human beings live and through which they understand themselves. At the same time, Binswanger recognized three simultaneous modes of being-in-the-world: the Umwelt, constituting the environment within which a person exists; the Mitwelt, or world of social relations; and the Eigenwelt, the private world of self. According to Binswanger, the three modes together constitute a person’s world-design—the general context of meaning within which a person exists. In the first of his existential analytic studies, Dream and Existence (1930/1993c), Binswanger described dreams in terms of the dreamer’s world-designs rather than psychic processes. Similarly, in his studies on mania (1992) and schizophrenia (1957a), Binswanger used the notion of world-designs of patients to elaborate manic experience and the spatial, temporal, and verbal structures of schizophrenic existence. Binswanger argued that the main goal of psychopathology studies was to achieve knowledge and scientific description of world-designs, that is, to see how patients relate to the people and social environment around them and thus to understand how patients structure the world in which they exist. In other words, Binswanger does not interpret the patient’s experiences in terms of a mental apparatus. Nor does he simply elaborate the physical reality of the patient’s world. Rather, from Binswanger’s point of view, person and world are one. It is thus a question of attempting to understand and explain the human being in the totality of his or her existence, which always includes his or her relationship to others. The parallels between Binswanger and Sullivan on this point are clearly evident. Like Binswanger, Sullivan (1953a, 1953b) concentrates on the way in which the patient structures reality, not on building structure within the personality. Rather, for Sullivan, psychotherapist and patient attempt to achieve “consensual validation” of the patient’s experience of relating to others and the world. Consensual validation signals the arrival of the patient at a “syntaxic” or interpersonally verifiable view of reality. The goal of interpersonal psychoanalysis is to identify and elaborate the patient’s “parataxic” mode of relating: the arbitrary, private, and frequently distorted mode of interpersonal experience. For Binswanger and Sullivan, the aim of psychotherapy is not to make the unconscious conscious in the traditional Freudian sense, but to free patients from distorted modes of relating to others and the world around them. Binswanger’s critique of Freud played an important part in developing a more comprehensive account of human nature. Indeed, Binswanger rejected the whole Freudian mental apparatus. In criticizing Freud’s structural account of the psyche, Binswanger (1955) argues “when the self is objectified, isolated and theorized into an ego, or into an id, ego and superego, it is driven out of its authentic sphere of being, namely existence” (p. 181). Binswanger was particularly opposed to the concept of causality that Freud derived from his model of mental functions—namely, the idea that human behavior is causally determined by the instinctual energy of the id. In a particularly significant passage, Binswanger (1992) states that Human existence never becomes apparent exclusively as mind or exclusively as instinct; it is always both, instinct and mind. Only theoretically and abstractly can “the mind and the instincts” be differentiated. . . . If Nietzsche and psychoanalysis have shown that instinctuality, especially in the form of sexuality, reaches up to the highest pinnacle of human consciousness, I have tried to show the degree to which consciousness extends its reach down to the deepest ground of “vitality.” In other words, religious, moral, and aesthetic life must be acknowledged where the human being until now appeared to be dominated entirely by the vital or instinctual spheres. . . . One speaks of religion, morality and aesthetics not only where the human being has achieved in a clear self-awareness, a permanent sense of self, but everywhere where there is a self—though not always a permanent or constant self—intending an object. As is readily apparent, this is concerned with the positive clarification of the term, an “unconscious” mind. (p. 221)
For Binswanger, the psychoanalytic conception of an unconscious, as the source of psychic energy and center of repressed mental processes, was not compatible with the conception of being-in-theworld. Binswanger makes this point most sharply when he argues that Freud betrays his most profound insight by making the unconscious into an “it” (the literal translation of Es). Binswanger (1947) states that It was after all precisely Freud who taught us that the “I-cannot” of patients must always be understood as an “I will not,” in other words, that the “I-not-I” relationship must be understood as an “I-I myself” relationship. . . . Psychoanalysis in general has its existential justification only in so far as this translation is possible or at least meaningful. Yet Freud transforms, with a literally suicidal intention, the “I will not” to an “it can not.” (p. 117)
Binswanger did acknowledge the role of unconscious processes as an explanatory hypothesis for human behavior. However, in his view (Binswanger, 1955), although the unconscious may refer to a part of the human mind, it does not exist as a “world” of its own, nor does it relate to itself through a world. Rather, Binswanger’s view of the unconscious can be understood along the lines of Sullivan’s (1953a) notion of “unformulated experience.” The unconscious refers to experience that has yet to be articulated, elaborated, and fully understood. The dilemmas that stem from Freud’s attempt to demonstrate that a part of the self can determine the whole also form the basis of Binswanger’s critique of the psychoanalytic theories of libido and instinct. Although the concept of libido experienced numerous reformulations, it refers generally to instinctual or sexual energy. Freud’s theories of libido and instinct also form the basis for a conception of interpersonal relations that is instinctually oriented. In Freud’s metapsychology, other people primarily take the role of objects for the gratification of instinctual desires. Interpersonal relations thus have their origin in the discovery that other people can aid in the reduction of tensions. This mechanistic view especially determines Freud’s understanding of the love relation. Though he discusses various forms of love, it is nevertheless true that for Freud, the libido underlies all aspects of love. The diverse forms of loving can ultimately be traced back to the instincts, whose function is to provide instinctual satisfaction. Whereas Freud attempts to account for love though a causally determined theory of instincts, Binswanger’s aim is to elucidate love’s anthropological and phenomenological dimension. Binswanger’s rejection of any form of biological determinism leads him to dismiss outright the protobiological basis of the libido. To this end, Binswanger (1942/1993a) remarks, “The monstrous difference between the genetic derivation of all forms of love from a single source and the disclosure of love as a unified anthropological originary phenomenon, forbids any attempt to even compare our concept with that of psychoanalysis” (pp. 234-235). Referring to the psychoanalytic explanation of love, Binswanger states further that if love were simply an “illusion, in the explanatory sense of . . . Freud, then it would be difficult to conceive how love can constitute a ‘reality’; a reality cannot be based upon something ‘unreal’ ” (p. 135). In Binswanger’s view, Freud’s theory of libido plainly fails to account for the phenomenological reality of love, which is central to the interpersonal field of psychotherapy. Binswanger initially turned to Heidegger in search of developing a more satisfactory conception of human interaction. However, just as he dismissed Freud’s concept of libido, Binswanger also found Heidegger’s conception of interpersonal interaction to be lacking. In his chief theoretical work, Basic Forms and Knowledge of Human Existence (1942/1993a), Binswanger argues that Heidegger’s treatment of social dimension in Being and Time (1927/ 1962) does not sufficiently account for the role of other human beings in the achievement of authenticity and entirely omits the notion of interpersonal love. Binswanger’s argument follows the earlier critique made by Heidegger’s one-time student, Karl Löwith (1981), and has more recently been elaborated by such thinkers as Michael Theunissen (1977) and Jürgen Habermas (1985). The problem, as Binswanger saw it, was not that Heidegger overlooked human sociality. Rather, the difficulty lay in the fact that Dasein achieved its authenticity in essential isolation from others. As Binswanger (1942/1993a) states, Heidegger “sees only the inauthentic They-self besides the authentic self, and omits the authentic positive possibility of Being-with-one-another: that is, the being in one another of first and second person, of I and Thou, the We-self” (p. 217). As we shall see, it is precisely the I-Thou relationship that Binswanger sees as crucial to the psychotherapeutic process. As a clinician, he believed that psychotherapy was dependent on the emergence of a type of loving I-Thou relationship between therapist and patient. In contrast to Heidegger, then, Binswanger’s specific concern was to show that self-realization can be achieved through engagement in a reciprocal, authentic relation. Though Binswanger acknowledges that in certain situations authenticity may follow from a confrontation with the possibility of one’s own death, he believes that authenticity is also achieved through the I-Thou relationship, which he refers to as the dual mode of love. As Binswanger (1993a) states, “we do not agree that the ‘authentic truth of Dasein’ can be achieved only in this manner of resolute ‘authentic self,’ because this truth lacks love—the original beingwith-one-another” (p. 218). His objective was thus to supplement Heidegger’s project of fundamental ontology with a theory of reciprocal love.
THE I-THOU RELATION Binswanger’s critique of Heidegger provided the stimulus for his own elaboration of the interpersonal dimension. To this end, Binswanger turned to the philosophy of dialogue, whose chief proponent is Buber. Binswanger entered into a lifelong correspondence and friendship with Buber. As early as 1936, Binswanger wrote to Buber, I not only follow in your every step, but see in you an ally, not only against Kierkegaard, but also against Heidegger. Although I am methodologically deeply indebted to Heidegger, [I take exception to] . . . his conception of Dasein (as mine). . . . It is very important [to me] that you want to achieve a conceptualization of the public which is not limited to the multitude and the They. (Buber, 1973, p. 621)
The impact of Buber’s philosophy on Binswanger’s theory of the self is most apparent in Basic Forms and Knowledge of Human Existence (1942/1993a). In fact, in the preface to that text, Binswanger acknowledges an equal indebtedness to Buber’s short treatise, I and Thou (1923/1970), and to Heidegger’s Being and Time (1927/1962). The problem of relation, or dialogical life, is central to Buber’s entire philosophy. He argues that the human being can never be fully understood apart from relation. As Buber (1965) states, each component of a relation “considered by itself is a mighty abstraction. The individual is a fact of existence insofar as he steps into a living relation with other individual. . . . The fundamental fact of human existence is human being with human being” (p. 203). The character of a relationship is always determined by which of the basic words is spoken: When I-Thou is said, the I is different from the I that speaks the primary word I-It. As Buber (1923/1970) puts it, the “I-Thou can only be spoken with the whole being. The primary word I-It can never be spoken with the whole being” (p. 54). Dialogue, in this sense, is not only a mode of linguistic communication but denotes the interhuman dimension generally. According to Buber, the primacy of relation also implies that authenticity is constituted in relationship to an other. Acknowledgment of the other person (not as a means to an end but in his or her totality) as a Thou is the condition of possibility for authentic existence. In contrast to Heidegger, Buber insists that authentic selfhood can only be comprehended in terms of the reciprocity of I and Thou. The German philosopher, Michael Theunissen (1984), elaborates this point when he states that While according to Heidegger, the self can only come to itself in a voluntary separation of itself from the other self, according to Buber, [the self] has its being solely in the relation. . . . Personal subjectivity does not possess its substantial fullness beyond the relationship to the Other in the same sense as the subject its being present-at-hand. Rather, its fullness is entirely encompassed by the relation. (p. 284)
From this perspective, then, Buber’s theory of relation provides Binswanger with a more adequate conceptual underpinning from which to elaborate his conception of self-realization in a loving I-Thou relationship. SELF-REALIZATION THROUGH THE OTHER Like Buber, Binswanger emphasizes the dialogical nature of human existence. The human being develops and exists through interaction with others. In Basic Forms and Knowledge of Human Existence (1942/1993a), Binswanger delineates different forms of social existence—dual, plural, and singular modes—that are oriented toward the achievement of authenticity in loving dialogue with another person. Binswanger’s aim is to elaborate the anthropological structure of a loving I-Thou relationship, which permits that achievement of authenticity. And for Binswanger, it is precisely in and through a loving I-Thou relationship that growth and change become possible.
Whereas some may dismiss the manifestations of interpersonal love as unrealistic, for Binswanger the I-Thou relation is characterized by mutuality, openness, and immediacy. Sullivan (1953a) makes a closely related point, stating that “when love occurs, another person matters as much to you as do you yourself”; under such conditions, “it is quite possible to talk to this person as you have never talked to anyone before.” For Sullivan, “the relatively uncomplicated experience of love is entirely ennobling. Sympathy flows from it. Tolerance as a respect for people—not as an intellectual detachment from prejudice—follows it like a bright shadow” (p. 43). Binswanger’s proximity to Sullivan also underscores his divergence from Buber. Binswanger professes an allegiance to Buber, but works out his own theory of I-Thou interaction. Thus, in contrast to Buber, Binswanger brackets the theistic dimension of the I-Thou relationship; he understands it as existing only between human beings. Binswanger’s aim throughout is to emphasize the notion of self-realization, achieved through a loving relationship with the other. As such, he pays little attention to Buber’s concept of confirmation, which includes opposing the other to help the other find his or her personal direction (Friedman, 1998).
Indeed, in contrast to Buber and the movement of dialogical psychotherapy, Binswanger uses the concept of I and Thou in the context of a more general “interpersonal” or “intersubjective” theory of human interaction (Frie, 1997), which always includes what Buber calls the I-It relation. Although Binswanger’s theory of love has an obvious affinity with Buber’s “interhuman” dimension, his approach is perhaps closer to the perspective on the self and other developed in interpersonal and relational psychoanalysis. Binswanger’s theory of self-realization is itself indebted to Hegel’s dialectic of recognition. Indeed, Binswanger (1942/1993a) suggests that “recognition, in Hegel’s sense, not only is very similar to love, it is . . . a special form of love. In this sense, what Hegel says about the unity of two self-consciousnesses, which continue to exist each for themselves, is definitive” (p. 390). In Hegel’s masterslave dialectic (1977), the need for recognition conflicts with the need for absolute independence. The nature of this tension is paradoxical. Self-consciousness must not only win the recognition of the other, but also acknowledge the other as existing for himself or herself. Thus, for Hegel, each self-consciousness must exist for itself and for the other, with the result that both selfconsciousnesses recognize themselves as mutually recognizing one another. Relational theorists have recently taken up and expanded on the Hegelian dialectic to explain the nature of analytic interaction (Benjamin, 1988; Modell, 1993). In an analogous fashion, Binswanger seeks to demonstrate that the idea of mutual recognition is implicit to the I-Thou relation. He argues that within the we-dimension of love, each partner has the need to recognize the other as both distinct from, and similar to, himself or herself. The significance of this model for understanding the process of selfrealization is elaborated by Jessica Benjamin (1988), who suggests that the need for recognition gives rise to a contradiction: recognition is that response from the other which makes meaningful the feelings, intentions, and actions of the self. It allows that self to realize its agency and authorship in a tangible way. But such recognition can only come from another whom we, in turn, recognize as a person in his or her own right. (p. 12) In other words, recognition must always be accompanied by acknowledgment of difference. As Binswanger (1942/1993a) puts it, the “paradox between the ‘relative’ recognition of the singular and particular, and the moment of existence as we . . . implies that the being of love, the loving being-with-one-another, is thoroughly dialectical” (p. 459). Only thus can “the we” become a basis for the achievement of self-realization. It is this “we” that makes “possible myself and yourself in the sense of loving self hood and autonomy” (p. 116). It is important to note that in Binswanger’s conception of the I-Thou or interpersonal love relation, the other person is not simply a means to an end, but a participant in the process of self-realization. When the other person is described simply as an object for self-reflection or as the means to self-discovery, the relationship is drained of attachment, intimacy, and engagement. When applied to the therapeutic relationship, this insight suggests that therapist and patient meet face-to-face and come to know each other as two interacting human beings. If this is not the case, then the self, though placed in a context of a relationship, is defined only in terms of separation. Indeed, whereas classical psychoanalysis stresses separation and autonomy from the other, the emphasis in the existential-interpersonal approach I am outlining is on deepening our understanding of our continuing relationship to others. Binswanger wrote relatively little about actual therapeutic technique. However, he published numerous studies of his work with schizophrenics (1957a) that demonstrate the way in which he interacted with his patients. The best known of Binswanger’s studies is undoubtedly The Case of Ellen West (Binswanger, 1958). However, because Binswanger uses the case to exemplify the descriptive and explanatory potential of Daseinsanalysis, it unfortunately fails to shed light on his actual approach to working with patients (Chernin, 1981; Laing, 1982). Binswanger’s case studies stem primarily from the 1920s and 1930s, when schizophrenics were often seen simply as medical objects to be observed and treated in whatever way possible. Unlike many of his contemporaries, Binswanger viewed his schizophrenic patients as sentient human beings who had lost their sense of relatedness. Like Sullivan, who is similarly known for his work with schizophrenics, Binswanger usually became well acquainted with his patients. As Binswanger (1955) states, “it is of the essence of being a psychiatrist, therefore, that he (or she) reach beyond all factual knowledge and the abilities that go with it, and that he (or she) reach beyond scientific knowledge found in the fields of psychology, psychopathology, and psychotherapy.” For Binswanger, psychotherapy is properly to be understood not as a curative technique, but as a type of friendship. To this end, he writes that what is crucial in working with a patient is the relationship itself—“a relation based equally in care and love” (p. 277). We can infer, therefore, that Binswanger’s emphasis on the I-Thou relation was generated not only by his rejection of the traditional psychiatrist-patient relationship, but also by the classical psychoanalytic relationship. Whereas classical analysts attempt to remain neutral and therefore can be distant, existential analysts tend to interact with their patients and engage them to the best of their ability. Seen from this perspective, Binswanger’s approach to the therapeutic encounter has intriguing similarities to the work of recent interpersonal and relational theory. In what follows, I will sketch the ways in which I think Binswanger’s concept of interpersonal love and self-realization translates into a therapeutic context. I do this in the belief that the best compliment we can pay a thinker is to expand on his or her ideas to demonstrate their continued relevance. The mutuality and directness of the I-Thou relation described by Binswanger is seen as crucial to the therapeutic process by many recent theorists. Thus, for example, the British object relationist, Harry Guntrip, argues that the vehicle for substantive change is a nurturing relationship between the psychotherapist and patient that is both highly personal and interpersonal. Guntrip (1969) states that Psychotherapy can only be carried on by those who are prepared to be exposed to all the subtle reactions that go on between two human beings who meet on an emotional rather than on an intellectual plane; and who are prepared to accept awareness of these reactions as essential to treatment. . . . What is therapeutic when it is achieved is “the moment of real meeting” of two persons as a new transforming experience for one of them, which is as Ronald Laing said, “Not what happened before (i.e. transference) but what has never happened before (i.e. a new experience of relationship).” (p. 353)
The contemporary interpersonal theorist, Darlene Ehrenberg (1992), refers to such moments as “the intimate edge” of therapy. She states that [therapeutic] work does not stop when contact is made or when each is truly touched in some profound way by the other and by their interaction; rather, it takes on new dimensions as the affective complexity of what gets activated in the moments of meeting can be clarified and explored in an endless progression. (p. 40)
As we have seen from what Binswanger has to say about the nature of the I-Thou relation, the moment of face-to-face meeting is both an end in itself and what enables future meetings to take place with others outside of the therapeutic context. The moment of face-to-face meeting also allows for an ongoing interaction between the therapist and patient, which generates new experiences of mutuality and self-awareness. And for Binswanger, expanded awareness achieved through an authentic, reciprocal relation is crucial for self-realization. In this way, the I-Thou relation also helps us to understand that genuine therapeutic work always requires the active involvement of both participants. As Binswanger points out, the aim in the I-Thou relationship is not to dissolve the sense of individual self in its participants, but to enhance it through mutual interaction. Like Buber (1965), Binswanger cautions against the naive belief that the therapist can ever be entirely equal with the patient. For Binswanger, the goal of the therapeutic relationship is not to transcend distance or achieve fusion. Differences between the therapist and patient in terms of their roles, functions, and power must be responsibly honored. Indeed, two-person interaction is only possible if personal boundaries are respected and individual difference is recognized. As Ehrenberg (1992) points out, “in effect, an authentic encounter can be facilitated by acknowledging the limits of what may be possible at any given moment, where ignoring these or pretending these do not exist precludes a more genuine and penetrating kind of engagement” (p. 39). Of course, maintaining an I-Thou dynamic between therapist and patient will not always be possible or even desirable. Yet I am suggesting that by remaining attuned to the patient within the therapeutic context, the therapist can help to generate a constructive engagement that can, in turn, lead to increased mutuality and a better understanding of the dynamics of interaction. Binswanger’s conception of the I-Thou relation and therapeutic encounter thus reflects a general shift in emphasis from the intrapsychic to the interpersonal dimension. Indeed, from this perspective, clinical phenomena can only be understood in the inter-personal contexts in which they take form. Patient and therapist together form an indissoluble dyad, and it is this relationship that becomes the domain of therapeutic inquiry.
Thus, phenomena that have been the traditional focus of psychotherapeutic investigation are not understood as products of isolated intrapsychic processes but as having been formed in an interpersonal field of existence (Atwood & Stolorow, 1984). The role of therapy, in my view, is to reach an understanding of such phenomena as they emerge in the interaction between therapist and patient.
THE PRIMACY OF RELATEDNESS
Once the interpersonal field becomes the focus of therapy, the question of what happens to intrapsychic and individual experience may fairly be raised. Binswanger’s critique of the Freudian unconscious suggests that intrapsychic experience must always be seen as secondary to the interpersonal field. And alongside the shift from an intrapsychic to an interpersonal theory of human nature, Binswanger sees individual experience as subordinate to relational experience. Thus, Binswanger suggests that in contrast to the fullness of being experienced in the I-Thou relation, the individual self must constitute a deficient mode of existence. To express the relationship of love to individual existence, he quotes a phrase from the young Hegel (1948): ”the raging of love against individuality” (p. 306). This reference to Hegel is symptomatic of a certain antiindividualistic tendency in Binswanger’s work. A similar tendency can be found in Sullivan’s work. Like Binswanger, Sullivan (1950) argues that the content of consciousness is always socially derived and therefore gives rise to an illusory sense of self: “no such thing as the durable, unique, individual personality is ever clearly justified” (p. 221). On another occasion, Sullivan (1953b) notes that “the unique individuality of the other fellow need never concern us as scientists” (p. 12). For both thinkers, human activity and the human mind do not reside in the individual, but are continually generated within the interpersonal field. Human nature, then, is only comprehensible within the complex interactive process in which it is shaped. Psychotherapy itself is conceived of as a form on interaction, in which the therapist is a “participant observer” and the therapeutic matrix provides a way to understand how the patient’s personality is shaped. In other words, because the individual is in continual interaction with other people, the personality does not reside specifically “inside” the individual but appears in interactions with others. This perspective on individual experience also has important implications for Binswanger and Sullivan’s understanding of mental health. To explain and elaborate the myriad experiences of the self, Binswanger (1942/1993a) uses a scale on which he distinguishes between the I-Thou relation on one end, and individualized existence without relatedness to someone or something on the other end. Human nature, according to Binswanger, finds its highest fulfillment in the I-Thou relation. The opposite of an I-Thou moment can be understood as the frozen isolation of schizoid detachment or a psychotic delusion. In the process, however, Binswanger and Sullivan both tend to neglect the way in which our individuality identities constitute a central feature of our sense of self. And although Binswanger allows for the possibility of achieving happiness through self-reflection or introverted creativity, he nevertheless sees such experiences as secondary to the shared moments of an I-Thou relationship. Binswanger’s discussion of an utterly individualized existence is replete with metaphor. He describes the experience in which I exist without relation to someone or something else as “naked horror” (1942/1993a, p. 402). It is a state in which I am absolutely helpless; I cannot be helped, nor can I help myself. In naked horror, existence loses even a sense of self hood. The self is not simply “beside itself,” as it is in the rages of passion, although intense passion can threaten existence. Instead, according to Binswange, the experience of naked horror leads almost inevitably to suicide. Binswanger also relates his discussion of individualized existence to the experience of severe loneliness, which is sometimes characterized by a state of utter hopelessness. As Frieda FrommReichman (1990) states in her essay on loneliness, “I think that Binswanger has come nearest to a philosophical and psychiatric definition of loneliness when he speaks of it as ‘naked existence,’ ‘mere existence,’ and ‘naked horror,’ and when he characterizes lonely people as being ‘devoid of any interest in any goal’ ” (p. 318). This type of loneliness is not merely physical but emotional. It renders people who suffer from it emotionally paralyzed and helpless, because it carries the threat of being entirely incommunicable. As Sullivan (1953b) states, abject loneliness is “the exceedingly unpleasant and driving experience connected with an inadequate discharge of the need for human intimacy, for interpersonal intimacy” (p. 290). Indeed, Binswanger sees the loss of relatedness as central to mental disorders. In regard to the experience of manic-depressive disorder, Binswanger (1992) states that “manic existence swings up to dizzy heights in which no stand is taken and no self-sufficient decision is possible. Love and friendship have, in these airy heights, lost their power. Human interaction is reduced to the level of psychiatric care” (pp. 245-246). Binswanger develops a similar argument in his exploration of schizoid and schizophrenic states. He argues that schizoid or schizophrenic existence “is only possible where Dasein is ‘despairingly’ exiled from the home and eternalness of love and friendship . . . where it has isolated itself from interaction or traffic with others, and from the challenge and understanding that is only possible from such continued interaction.” For Binswanger, the descent into madness is characterized by the concomitant experience of essential isolation: “Dasein is withdrawn into mere interaction or traffic with itself alone, until even this peters out and becomes a sheer Medusa-like stare, a psychotically rigidified problem, an ideal, or the ‘nothingness of anxiety’ ” (pp. 246-247). In the development of psychotic states, contact with others thus becomes meaningless, determined by neither desire nor will. The loss of relatedness described by Binswanger is also closely associated with Jacques Lacan’s (1977) conception of “the Real,” in which psychotic experience is characterized by the loss of meaningful speech. Like Lacan, who suggests that the psychotic still resides within language even if the ability to communicate is temporarily lost, Binswanger maintains that the psychotic continues to exist as being-in-the-world, however delusionally distorted that world may be (Frie, 1998; 1999b). In a similar sense, Sullivan (1953a) considers the loss of relatedness that, as he says, “actually menaces one’s survival” the core of psychotic symptom formation. For Binswanger and Sullivan alike, the psychotic is able to return from a state of delusion only through the repair of his or her relations with other people and the world. On this basis, then, Binswanger shows us the way in which relatedness is crucial to human existence and to mental health. He suggests that the psychiatrist or psychotherapist is not simply treating a patient but sharing in the existence of a person. Only thus is it possible for psychotherapy to provide the patient with the opportunity to experience the “duality of existence.” The dual experience of therapy works to enable the patient to actualize his or her own existence within the context of a loving I-Thou relationship. This is also the point at which the perspectives of Binswanger and Sullivan are most similar. Both see psychotherapy as a process of expanding interpersonal relationships. The therapeutic relationship can help the patient to establish and experience a form of intimacy with another person. It is through such intimacy that one becomes sensitive to the needs, possibilities, and limitations that characterize interpersonal existence. Binswanger thus moves beyond Freud’s understanding of love to include a conception of personal growth and self-realization, achieved through increased intimacy and relatedness to others.