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Philosophy to Psychotherapy, Edwin Hersch undertakes an enormous project.
His task is no less than grounding the theory and practice of psychotherapy on
its ultimate ontological and epistemological foundations. He goes further,
finding that a number of apparently insoluble struggles in metapsychology can
be resolved if we stop trying to ground psychology in Cartesian subject/object
dualism and opt instead for a phenomenological approach which dissolves the
dualistic gap. The capstone of his project is the "Beams of Light Through
Time" model of interaction between therapist and patient. This allows an
elucidation of the philosophical anatomy of the psychotherapeutic situation.
He does this in elegant, readable prose, shunning jargon, in a book aimed at a
clinical audience. Though problems develop with the way his account links up
with psychological theory and clinical work, I consider his account a
noteworthy accomplishment in the philosophy of psychiatry and psychology.
project begins with an exhortation: Know Thy Philosophical Self. Any
psychological theory implies a certain philosophical stance, whether
acknowledged or not. Good psychological theory is either consistent with, or
well-grounded in, good philosophy. Since good psychotherapeutic practice is
grounded in the best available psychological theory, it behooves the
practitioner to make conscious the unconscious philosophical implications of
psychological theory and see whether these withstand scrutiny.
outlines his hierarchical method of theory analysis and development, in seven
levels. Levels A and B address ontology. First, is anything real at all?
Second, what is our position in relation to that reality? Levels C and D
address epistemology: what can we know; and then, how do we validate this
knowledge? Level E looks at field-specific knowledge: what can we know
within, for instance, the psychotherapeutic dialogue? Level F looks at how
knowledge within a particular discipline can be validated. Level G is the
realm of psychological theory proper: how do people feel, think, behave, and
how can we best help them psychotherapeutically?
Parts I and II
of Hersch's work (chapters 2 through 5) cover his Levels A through D, and he
does an elegant job of laying out the major stances in ontology and
epistemology within the analytic tradition. These he traces back to Descartes,
particularly where such traditions involve the "radical separation of subject
and object" (p. 26). He starts in Level A with a discussion of realism
and anti-realism as the two possible answers to the question, "Is anything
real at all?" I wonder if he doesn't give too short a shrift to
anti-realism in chapter 2, dismissing it with a reductio ad absurdum,
namely, how could one assert the truth of the statement, "There is no
truth?" However, his principal task lies elsewhere, and it assumes
Realism, so this brief refutation can be allowed for the sake of the argument.
The chapter also contains a clarifying discussion of confusing terms frequently
used in philosophical literature.
devoted to Level B--our relationship to reality--is where Hersch really begins
to warm up to his task, pitting Cartesian subject/object dualism against
phenomenological "Being-in-the-World." He suggests that a Cartesian
model implies a fundamental barrier between subjects and objects. Our primary
relation (as subjects) to objects is via knowing, or "the cognitive
apprehension of an object by the knowing subject" (p. 40). Hersch points
to phenomenological critiques of this distinction. If res cogitans is
completely isolated from res extensa, how is knowledge possible?
Furthermore, how can the cogito control the body? Hersch points out that, as
clinicians, while we might say we find such distinctions naive, our language
betrays us. In the phenomenon of conversion, for instance, we speak as if
mental conflicts have been converted into somatic symptoms. What are we
For Hersch, a
foundational idea, beginning with Husserl and elaborated by Heidegger, is to
attend to the phenomena of what it is to be human. We find ourselves motivated
by "cares" defined not as "worries" but as "things we
care about." Cares lead to the undertaking of particular projects. The
world is the instrument in which we execute our projects, using the objects of
the world as tools. Being is not simply isolated. It takes place in the world
fundamentally. For example, if you're trying to put up a tent, and you have
forgotten a hammer for the pegs, a nearby stone which would ordinarily have
gone ignored becomes a hammer. Thus, reality is "co-constituted" (p.
58). Objects have qualities which are given, which are unyielding to our will,
but those objects are also interpreted by our perceptions of them, influenced
by our cares at the time of perception. Thus, separateness of subjects and
objects is not primary. Relatedness is primary. We inevitably and constantly
relate to objects via a mingling of their properties and our cares. Reality is
both given and made (p. 60).
continues in this vein through his Levels C to F. He examines the Cartesian
stance, demonstrates the inadequacies which result from separateness, and shows
how much more elegant he believes epistemology becomes from a phenomenological
perspective. The reading of Parts I and II is worthwhile as a plain language
explication of phenomenological ontology and epistemology, and it could stand
alone as a competent, introductory text to the field.
contribution to phenomenological thought is his metaphor of the "Beam of
Light Through Time," which he begins in chapter 4 and elaborates through
the rest of the book. Think of a person as a beam of light shining on a
world. The lit field is co-constituted between the properties of the light
itself (its direction, intensity, beam-width, colour, and horizon) and the
properties of the objects upon which the light falls. Through time, the beam
can move, or the objects in the lit field can move or change. This
relationship between light and objects is irreducible according to Hersch.
Again, relatedness, not separateness, is the fundamental ontological condition.
To bring this
into the psychotherapy situation, Hersch generates his master metaphor, not
just one beam, but "Beams of Light Through Time," the result of two
beams interacting (color plate between pages 134 and 135). The patient and
therapist both have cares and projects in a world of objects which includes the
other individual. The world isn't just equipment, but also other people, whom
"I sense can look back at me" (p. 134). I become aware that I am an
object in this person's phenomenal field, and I begin to care about the
impression I make. Therapy has three co-constituting sources: the patient's
beam, the therapist's beam, and the things they experience in common. Hersch
invites us to consider a blue beam for one individual, and a red beam for the
other. The convergence of the beams creates a phenomenologically distinct zone
of purple. Within this purple zone is the philosophical anatomy of the
psychotherapy situation, which Hersch divides into three zones. The zone of
'encounter' is where the Other is experienced as another beam of light through
time. Next is the zone of the 'world in common,' the shared history between
patient and therapist. Finally is the relatively 'object-ive' or 'world-based'
zone, common to both, but experienced by neither, such as the unnoticed movings
of the clock.
that the interactional "purple zone" solves numerous problems
entailed by various Cartesian (dualist) stances. Ontologically, the cogito is
not isolated from the world or from other thinkers. Epistemologically, since
truth is co-constituted, objectivist correspondence stances and subjectivist
coherence stances can both be avoided, along with the conundrums they imply.
Truth is neither totally in the world nor totally in the mind.
Psychologically, emotions and thoughts need not be seen atomistically, as encapsulated
entities contained in either patient or therapist. Feelings and thoughts are
seen to occur interactionally, in interpersonal encounters.
In Chapter 9, Hersch
recasts some psychodynamic concepts interactionally, and contrasts these with
their Cartesian formulations. In particular, he analyses transference,
counter-transference, conflict, defense, internal representation, representationalism,
consciousness, unconsciousness, and mind versus body. Although I could see
subtly nuanced differences between a phenomenological versus Cartesian
understanding of these core psychodynamic concepts, the analysis appeared
procrustean at times. Transference, for instance, may well not be discretely
isolatable and reliably detected and understood by the therapist, but did we
really need phenomenology to tell us this? It doesn't take much experience as
a therapist to realize that patients bring feelings of their own into the room
and that their resistance can frustrate therapists who then, in that frustrated
state, can subtly or overtly irritate the patients in turn. So, which is
transferred anger, and which is conscious irritation against an over-zealous
therapist? Hersch's phenomenological analysis does not help the therapist
parse these problems, which do have technical importance psychotherapeutically,
and the phenomenological analysis may even blur these difficult lines further.
phenomenological approach to the Mental Status Examination, the psychiatric
version of the physical examination, offers an alternative to the standard
approach. A patient is examined as a "Being-in-the-World" in six
categories: relatedness to one's world; temporality; interpretiveness and
perspective; care-fullness; and embodiment. Hersch's case of the depressed
English professor demonstrates how deep an understanding may be obtained with
this phenomenological approach, by revealing not just a list of symptoms but a
patient's world view of horizons in imagination, action, emotion and
interpersonal experience. I found the patient's suffering did indeed come
alive for me in a way that the conventional MSE does not convey, being limited
strictly to a dualistic description of objectively (or at least independently
verifiable) observed phenomena. The question must be asked, though, whether
the phenomenological MSE gives us more than good case formulation would. I am
not convinced this is so.
explores the philosophical foundations of various branches of psychology and
psychiatry. Hersch looks at several psychoanalytic schools: Freudian drive theory,
Kleinian object relations, Kohutian self-psychology, intersubjectivity theory,
and narrative constructionism. He attempts to show their philosophical
commitments at Levels A through F of his hierarchy. It's an intriguing
analysis, and the ease with which he arrives at his conclusions regarding the
various fields is a payoff of the hard labor he underwent building his
hierarchy. He also looks at cognitive theories and biological psychiatry to
see where they fit on the hierarchy. I'm not sure if his analyses are correct,
but they are clear and defensible.
He finishes the
book by repeating his admonition that philosophy is unavoidable and that good
theory can enhance good practice. Fair enough, but has Hersch offered us good
philosophy? I really believe he has. Exposing the perhaps untenable Cartesian
assumptions underlying psychological theory can only encourage deeper
reflection by philosophically minded psychologists, psychiatrists, and
psychotherapists. Offering an alternative from the phenomenological
perspective will be satisfying for some, and to others it will show that a
positive account can be given which tries to take better stock of the
psychological phenomena as they truly seem to be. It is a pity that Hersch's
effort to recast some theoretical concepts and clinical tools fell flat, but as
he himself states, "perhaps others will take up the task of developing and
improving it" (p. 350). Any decent effort at providing a completely
satisfying philosophical model for psychotherapy which also attempts to
elegantly recast complex clinical concepts is almost certainly going to have
weaknesses. Despite this, I recommend this book very highly. It is readable,
tackles tough problems elegantly, explains technical terms clearly (including
in a marvelous glossary at the end), and manages to sketch a broad
philosophical history of Cartesian and phenomenological thought. Above all, Hersch
does some good philosophical work, an admirable achievement for a full-time clinician.
2004 Robert Tarzwell
M.D., B.A. is a third year psychiatry resident at Dalhousie University in
Halifax, Nova Scotia, Canada. He is interested in dynamic psychotherapies
which focus on emotional experiencing as the primary therapeutic mechanism of
action. He is also interested in evolutionary approaches to psychiatry.