Philosophy, Psychiatry, & Psychology 3.1 (1996) 61-69
Key Concepts: Hermeneutics
Keywords: psychoanalysis, philosophy of science, nosology, classification
Hermeneutics is a concept whose breadth and significance have continued to grow in contemporary thought--and in psychiatry. Since its scope can be best appreciated through an historical overview of its development, I will begin there and then proceed to a discussion of its place in psychiatry. Derived from the Greek verb hermeneuein, which means "to interpret," and the noun hermemeia, "interpretation" (and both associated with the god Hermes), the word was first used in the seventeenth century to mean biblical exegesis (Palmer 1969). The Protestant Reformation created a need to interpret the scriptures without the aid of church authority, and with the plurality of possible interpretations for any biblical text, a need arose to establish the principles of correct interpretation. Hermeneutics was the study of such principles. While the scope and content of the hermeneutical enterprise have changed vastly since these beginnings in biblical exegesis, the concept of hermeneutics retains its initial reference to the art and science of interpreting. In Palmer's words, "Whenever rules and systems of explaining, understanding, or deciphering texts arise--there is hermeneutics" (1981, 458).
The scope of hermeneutics was broadened significantly in the nineteenth century through the philosophers Friedrich Schleiermacher and Wilhelm Dilthey, who moved the focus of hermeneutical understanding from texts to all human productions--verbal and nonverbal, historical and current. For Dilthey the task was to respond to the nineteenth-century challenge that all knowledge must follow the model of the burgeoning physical sciences. He sought to secure for the humanist or cultural disciplines such as literature and history (the Geisteswissenschaften) a status that was different from but on par with that of the physical sciences (the Naturwissenschaften). To accomplish this he set about formulating the principles of understanding in each of the two kinds of disciplines. The methodology of understanding in the cultural sciences was modeled on the interpretation of a text and became the expanded notion of hermeneutics.
For Dilthey the core difference between the natural and cultural sciences lies in their respective objects of study--on the one hand an object in the world, on the other hand another person--and in the way we understand each. He summarized the difference with his categories of "explanation" (Erklären) and "understanding" (Verstehen). "The sciences explain nature, the human studies understand expressions of life" (1924, 144). Explanation [End Page 61] in the natural sciences comprehends its object through causal connections; it "knows" its object from the outside. The object remains alien to the human scientist. In contrast, understanding "knows" its object, a human being or a human production, from the inside. That is, I can know the inner life of another person because I also am a person. This is not a knowledge of causal connections but rather of a network of meanings, analogous to the network of meanings by which I understand myself (Dilthey 1883/1989).
Two points must be underlined about Dilthey's treatment of hermeneutics as the methodology of understanding in the humanities. The first is that the understanding does not take place through introspection or intuition. I do not understand myself through introspection, and I do not understand the other through intuition. Rather, it is the nature of life to express itself, and it is through an understanding of these objectifications of inner life that we understand ourselves and others. Hermeneutics is then the study and method of understanding human expression. For Dilthey the triad of "life, expression, and understanding" defines the field of the human sciences. The second point is that because human life, lived experience, is temporal, the categories by which we understand man and human productions will have to involve this temporality. Self-understanding in the present, for instance, involves a historical reflection on those fixed expressions of others that form our common past.
Hermeneutic methodology as developed by Schleiermacher and Dilthey generated a series of unique concerns that characterize the hermeneutic approach to understanding. The first is that of the hermeneutic circle or round. At each level of hermeneutic investigation--a literary text, a historical monument, a person's life--there is a part-whole structure in the understanding of meaning networks that is different from the causal analyses of the natural sciences. That is, in the meaning gestalt that comprises a novel, for instance, the part is understood in terms of the whole and the whole in terms of the part. We are not inclined to say that one chapter causes another but rather that it is related to it, and to the whole novel, in such-and-such ways. The same is true of the coherence of a human life. The apparent contradiction of the hermeneutic circle--understanding part and whole in terms of the other--is overcome by the way in which we in fact do plunge into a work, somehow grasping the part and the whole in terms of one another and at the same time. Other specifically hermeneutic concerns are a focus on the historical and psychological context of the author or agent and an emphasis on the individuality of the object of study.
The ever-widening scope of hermeneutics was taken to a new level in the twentieth century by the philosopher Martin Heidegger and his pupil Hans-Georg Gadamer. While influenced by his reading of Dilthey, Heidegger moved beyond hermeneutics as the method of the human studies and in his Being and Time (1927/1962) gave it an ontological dimension by describing understanding and interpretation as essential features of man's (Dasein's) being. He could then say both that Dasein is hermeneutic in his very nature or being and that he, Heidegger, in his analysis was offering a "hermeneutic of Dasein."
It was left to Gadamer to develop the full implications of Heidegger's ontological reformulation of hermeneutics. He did this in his magnum opus, Truth and Method (1960/1975). For Gadamer the emphasis in hermeneutics falls on historicity. The interpreter does not interpret and understand from an Archimedean point but is always immersed in his or her own historicity. Hermeneutics is an encounter between the researcher of the present, aware of his or her historically conditioned categories of understanding, and a past that presents itself for interpretation. From this perspective the very notion of an "historical object," separate from myself as the interpreter, does not make sense. In Gadamer's words, "a text is understood only if it is understood in a different way every time" (1975, 275276). In Truth and Method this process of hermeneutic understanding is described as a "fusion of horizons." A horizon is "the range of vision that includes everything that can be seen from a particular vantage point" (1975, 269). Abstractly, there is a horizon of the present, the categories of understanding which we cannot see beyond, and [End Page 62] a horizon of the historical epoch that is being studied, the standpoint of the historical figure. But this is an abstraction. We do not disconnect ourselves from the past. The horizons of present and past overlap and fuse into one great horizon. Finally, the fusion of horizons is framed in terms of what Gadamer calls the logic of question and answer. The text engages us in a dialogue about its subject matter. The text, as a response to an implicit question, challenges us to address the same implicit question that it has confronted. Hermeneutic understanding of the past is then not a simple reconstruction of the context in which the historical text emerged; it is rather a conversation with the tradition in which the issues that exercised the particular epoch continue to exercise us.
The direction in which Heidegger and Gadamer took hermeneutics has been debated in recent decades. However, this debate does not represent the final chapter in our historical overview of hermeneutics. That distinction goes to the recent changes that have occurred in the philosophy of science. What has been called the "post-empiricist philosophy and history of science" (Hesse 1980) was initiated with the publication of Thomas Kuhn's enormously influential The Structure of Scientific Revolutions in 1962 (1962/1970). Kuhn challenged the traditional view of scientific progress as unidirectional and progressive with his distinction between "normal science," in which science advances incrementally within the established procedures, and "revolutionary" science, in which anomalies occurring in the accepted practices prompt scientists to question those practices and, in breaking with the usual procedures to accomodate the anomalies, create new norms by which science is done. The moment of crisis thus occurs when an innovative scientist encounters a problem that cannot be resolved within the current disciplinary matrix. Science then becomes revolutionary as new norms and a new disciplinary matrix are formulated. A significant part of any scientific tradition is the existence of exemplary problem-solving models--paradigms in the sense that Kuhn wishes to reserve for this term (1977, 293)--that provide training exercises and standards for students working within a particular disciplinary matrix. The discovery that generates the new disciplinary matrix will also generate new exemplars or paradigms for doing science. Of great significance is the fact that the terminology of the earlier tradition is not commensurate with the one that replaces it, and some kind of translation is therefore called for.
With his theory Kuhn rejected the traditional view that later scientific theories offer "progress" or a more truthful representation of reality and replaced it with the more modest position that later theories offer better solutions to certain puzzles. From this he drew the logical conclusion that progress in science is similar to, not different from, progress in nonscientific fields. In science as in the humanities the practitioner works out of a particular perspective and does not fully transcend his or her own history. In his first book Kuhn acknowledged borrowing notions of progress from the humanist disciplines, and in his later writings he declared his method to be hermeneutic. "What I as a physicist had to discover for myself, most historians learn by example in the course of professional training. Consciously or not, they are all practitioners of the hermeneutic method. In my case, however, the discovery of hermeneutics did more than make history seem consequential. Its most immediate and decisive effect was instead on my view of science" (1977, xiii).
With Kuhn's assertion that scientific progress is historically contingent and thus hermeneutic, the rigid Diltheyan opposition of science and the humanities was shown to be invalid. The perspectivism that was felt to be unique to the human studies was found in the natural sciences as well. With the collapse of a rigid distinction between hermeneutics and the scientific method, Kuhn's conclusions called for a revised understanding of hermeneutics. This was accomplished by the philosopher Richard Rorty in his (also quite influential) Philosophy and the Mirror of Nature (1979). Rorty argued that hermeneutics is not at all about the difference between science and the humanities but rather about incommensurability in any domain. Echoing Kuhn's conclusion that there is no single "correct" scientific account of reality, Rorty issued a challenge to [End Page 63] "epistemological foundationalism" in philosophy--that is, the conviction that one can reach a neutral ground from which to judge differing positions in epistemology. Rorty generalized Kuhn's distinction between normal and revolutionary science to that of normal and abnormal discourse in any discipline. Normal discourse is that in which there is agreement about terms and rules of adjudication. A disagreement can be resolved by reasonable people. Abnormal discourse, on the other hand, is that in which there is not agreement about terms and rules of adjudication. Abnormal discourse means incommensurability, and hermeneutics is now simply the effort to communicate, and continue to communicate, in the face of incommensurability. As a corollary of this redefinition of hermeneutics, "objectivity" for Rorty no longer carries an ontological claim of correspondence to reality but refers simply to the agreement among discussants.
As we turn from this historical review to the matter of hermeneutics in clinical theory and practice, it will prove useful to distinguish hermeneutics in psychoanalysis from hermeneutics in general psychiatry. The discussion regarding psychoanalysis has been fairly explicit (Phillips 1991; Strenger 1991), while the discussion concerning hermeneutics in general psychiatry remains inchoate and often more implicit than explicit.
The consideration of hermeneutics in psychoanalysis has transpired in three stages. The first was the challenge issued to traditional psychoanalysis three decades ago by psychoanalytic theoreticians like George Klein (1976) and Merton Gill (1976), who, while not working formally within the European hermeneutic tradition, questioned psychoanalysis' status as a natural science and argued that it had more to do with the understanding of meaning and purpose than with causal analyses. This effort to reformulate psychoanalysis rested on making a distinction between the clinical theory and the metapsychology in Freud's writings. The metapsychology was judged to be a superstructure of pseudoscience, while the clinical theory was considered to retain what is important in psychoanalytic experience. For Klein especially, the clinical theory is an explanation of behavior in terms of meanings, purposes, and intentions that is linked "more closely to the humanistic disciplines than to a natural science" (1976, 30). This effort to purify psychoanalysis of its pseudoscientific, metapsychological trappings is thus quite close to Dilthey's view of hermeneutics in the human sciences.
A second stage in the treatment of hermeneutics in psychoanalysis was the formal assimilation of psychoanalysis to the hermeneutic disciplines by the major philosophers Jurgen Habermas (1968/1971)--together with his associate Karl-Otto Apel (1979/1984)--and Paul Ricoeur (1965/1970, 1969/1974, 1981). It is to be noted, however, that while each of these philosophers argued for the hermeneutic status of psychoanalysis, each argued also that psychoanalysis is only partially a hermeneutic discipline, that it also contains features that are better treated with the categories of the natural sciences. For Ricoeur this means that the patient is not only someone involved in a network of meanings but also someone caught up in a field of mechanistic forces. The patient is thus to be treated both like a text to be interpreted and like an organism that is subject to causal mechanisms. For both Ricoeur and Habermas, then, psychoanalysis becomes a paradigm of the disciplines that contest any rigid separation of the hermeneutic and scientific methods.
A third stage in the hermeneutics/psychoanalysis discussion is represented by a more open recognition of hermeneutic principles by working psychoanalysts. A significant document in this regard is the final 1994 issue of The International Journal of Psycho-Analysis (Tuckett 1994). For the 75th Anniversary Edition of the Journal the editors organized a symposium on the subject of "The Conceptualization and Communication of Clinical Facts in Psychoanalysis." Given the assumption of virtually all the articles in this 300 page issue that there are no theory-free facts in psychoanalysis, this document might be regarded as the official death notice of positivism, and the official birth announcement of hermeneutics in psychoanalysis (Phillips 1995). Within the psychoanalytic community, Roy Schafer (1983, 1992) has stood out as the psychoanalytic theoretician who has most openly and articulately espoused a hermeneutic point of view. He has encompassed [End Page 64] all the complexity of the hermeneutic discussion in his writing: on the one hand a treatment of psychoanalysis as involved in the interpretation of meaning that carries the older view of hermeneutics, and on the other hand a discussion à la Kuhn and Rorty that addresses the theoretical pluralism--with competing and possibly incommensurable models--that has beset psychoanalysis. Focusing on the analyst's reworking (along with the patient) of the presenting narrative into a more psychoanalytically framed narrative, Schafer recognizes, one, that narratives are meaning structures and not force fields, and two, that the narrative developed by each psychoanalyst will be determined by the model from which he or she is working.
The consideration of hermeneutics in clinical psychiatry is more varied than the discussion in psychoanalysis. To begin with, hermeneutics entered psychiatry early with Karl Jaspers' adoption of Dilthey's concept of understanding (Verstehen) as the primary mode of comprehension for some psychiatric conditions, such as reactive states and some of the neuroses (Jaspers 1963). Then there is the fact that issues central to hermeneutics have emerged in psychiatry throughout the modern era, albeit not always in the explicit language of hermeneutics. One route of entry has been general medicine, where a humanist tradition has always accorded the "art" or "craft" of medicine a status equal to that of the "science" of medicine, and where a considerable literature in the philosophy of medicine has associated the "art" dimension with the hermeneutic tradition (Wulff, Pedersen, and Rosenberg 1986; Leder 1990). The same humanist tradition has of course been present in modern psychiatry and has given voice to aspects of clinical psychiatry that are here being labeled hermeneutic. In contrast, then, to the case of psychoanalysis, where it is relatively easy to review the major signposts in its dialogue with hermeneutics, the dialogue in general psychiatry has been more complex, and we will have to settle for a representative sampling of its encounter with hermeneutics.
It will aid our discussion to bear in mind the distinction made above between hermeneutics in the older sense, focused on the uniqueness of the human studies as contrasted with the positive sciences, and hermeneutics in the sense developed by Kuhn and Rorty, focused on the differences among researchers in any discipline. A particular discussion in psychiatry may emphasize one or the other of these approaches.
To begin with the older hermeneutic tradition, its Jasperian expression has been sustained throughout the decades, most forcefully in recent years by Schwartz and Wiggins (1987, 1988), who have argued for the continuing relevance of Jasper's use of ideal types (borrowed from Weber) in psychiatry, as well as Jaspers' distinction between conditions that require a causal, disease-oriented explanation and those that lend themselves to interpretative understanding of meaning structures. Also in this tradition are the publications of McHugh and Slavney (1986, 1987) on perspectives in psychiatry, in which they differentiate a life-story perspective (a dimension of meaning) from a perspective of disease. While these writers all provide a contemporary voice for the tradition of Dilthey and Jaspers, they also point to the limitations of a Diltheyan hermeneutics resting on a rigid distinction between causal explanation and interpretation of meaning. As they note, we cannot in fact divide psychiatric conditions neatly into those that call for a purely causal approach and those that require a meaning-oriented approach. We do find much to talk about with our schizophrenics and bipolars, and we find biological vulnerabilities in our neurotic and personality-disordered patients. Rather than holding on to the neurotic and personality disorders as meaning-oriented conditions and turning over the major psychotic disorders to the biologists, the task of hermeneutics is to sort out, in each of these groups, where is the place for understanding of meaning and where is the place for causal explanation.
But while it is not useful to maintain a rigid distinction between disorders on the basis of "cause" versus "meaning," a case can still be made--contra Kuhn and Rorty--for the uniqueness of the human studies, including psychiatry--and thus for the continuing relevance of Diltheyan hermeneutics. Unlike the object of scientific investigation, the object of the human studies comes [End Page 65] pre-interpreted. That is, people have ideas about themselves before we reinterpret them. Charles Taylor has developed this theme at length, distinguishing psychology from the natural sciences by virtue of the fact that the "object" of the former, human beings, are "self-interpreting animals" (Taylor 1985). Anthony Giddens has described this feature of the human studies as a double hermeneutic (Giddens 1977). That is, the human subject is always involved in self-interpretation, and this interpretation is then subjected to a second-level interpretation by the "professional" interpreter.
The application of these issues to clinical practice in psychiatry can be spelled out a bit. In situations in which questions of biological disorder, causal mechanisms, etc., are minimal, the clinical experience may take place virtually entirely at the level of psychodynamics and meaning structures. Much of the hermeneutic discussion in psychoanalysis is applicable here. The patient brings in a life-story, a self-interpreted narrative, that is intimately involved with his or her suffering. How the patient organizes his or her world meaningfully and what makes him or her suffer are virtually the same question. The goal of the therapy becomes then the reorganization of these meaning structures. With and through the therapist a new set of meanings, a new narrative, is developed.
In contrast to this situation is that in which there is a heavy biological loading in the patient's condition. The obvious examples are schizophrenia and bipolar illness. In this kind of clinical experience, issues of meaning are still relevant albeit different. The illness, although biologically loaded, still means something to the patient; it comes pre-interpreted. Questions of meaning and psychodynamics are thus relevant to how the patient regards the psychiatric condition. An obvious issue--and one that is evaluated differently in each case--is the extent to which the patient can take distance from the illness and talk about it. Is the meaning the patient gives the illness somewhat independent of the illness or is it a product of the illness? In still other terms, is the patient's thinking always thought-disordered? There is an obvious difference between a schizophrenic who can discuss his or her illness and another whose thinking is so invaded by the illness that such discussion is not realistic. It is also the case that a seemingly more disturbed schizophrenic may be more able to take distance from the illness than a character-disordered patient who cannot step back from his or her lying and self-deception. It is the clinician's task to sort out these questions, since issues like compliance with treatment hinge on them.
In contrast to this discussion arising out of the Diltheyan tradition in hermeneutics, a different set of issues emerges in association with the sense of hermeneutics that I am associating with the names of Kuhn and Rorty. Conscious of the radical historicity of any psychiatric enterprise, hermeneutics now becomes the art of recognizing (and exposing) different perspectives and assumptions, the art of promoting "conversation" among the different perspectives, and finally the art of navigating among the perspectives and models in the concrete situation, with the ability to switch from one model to the other and to integrate them into an optimal treatment plan.
One aspect of this hermeneutic inquiry is the question whether we can formulate definitions of mental illness (and of particular psychiatric conditions) that are not value-laden. In this regard Fulford has attempted to demonstrate the inevitable injection of current values into any conception of mental illness (Fulford 1989, 1991). Another aspect of this hermeneutics is the effort to bring multiple perspectives to bear on the individual patient. An example is Engel's work with the biopsychosocial model (Engel 1977, 1980), in which he attempts to make room for these three dimensions in the understanding and formulation of each clinical case. In still another approach to this hermeneutics of multiple perspectives, namely the tacking among different models, Sadler and Hulgus (1991) have offered an exemplary exposition of hermeneutics in action, showing with a specific case study how different theoretical orientations generate different data and different treatment protocols, but also how a flexibility in switching from one model to the other can result in a successful, more nuanced treatment.
Nowhere in contemporary psychiatry does this hermeneutics of historicity, of multiple perspectives, [End Page 66] and of the exposure of hidden assumptions, emerge more forcefully than in the area of diagnosis. It is appropriate then that the first AAPP sponsored monograph should be entitled Philosophical Perspectives on Psychiatric Diagnostic Classification (Sadler, Wiggins, and Schwartz 1994). Indeed, psychiatric nosology and the DSMs provide a vast arena for what are, explicitly or not, hermeneutic deliberations. The progression from one DSM to the next is itself a strong reminder that these are historical documents that do not transcend their historical conditions. Hermeneutic considerations are engaged at the opening bell with the famous (or infamous) statement that the DSM's diagnostic statements are atheoretical. The notion of an atheoretical diagnosis is, of course, an oxymoron hermeneutically. Appropriately, the statement has been challenged vigorously (Agich 1994; Goodman 1994). Then there is the hidden bias in favor of biologically based illnesses, as well as that in favor of individual pathology, as opposed to family or societally located disorders. Issues such as a multi-axial approach, the particular axes of DSM-III and DSM-IV, a categorical versus a dimensional approach, the use of operational definitions and diagnostic criteria, the privileging of reliability over validity, and of objective signs and isolated symptoms over subjective unities of experience--all are decided in a manner that is inevitably arbitrary and value laden. All must be the subject matter of ongoing discussion, for there is nothing inherently right about the position taken by the DSMs regarding any of these issues. Regarding the DSM-IV, one can take either of two positions: that it represents the best conclusions of a group of historically conditioned experts engaged in conversation à la Rorty about how best to classify psychiatric disorders; or that it represents the prejudices of a group of experts who currently hold power in the psychiatric establishment. Certainly we want it to be more the former than the latter. The position we cannot take is that the DSM-IV--or any other possible diagnostic system--is, purely and simply, the truth. Which is to acknowledge that we cannot transcend the hermeneutic discussion.
Finally, in addition to the two dimensions of hermeneutics in psychiatry just presented, I would like to underline a third aspect of a hermeneutic orientation, namely that of psychiatry as practical knowledge. Remember, after all, that psychiatry like the rest of medicine is involved in the treatment of individuals; all psychiatric theory and knowledge ends up, figuratively speaking, at the bedside. This aspect of hermeneutics has been emphasized by Gadamer, for whom hermeneutics involves not only understanding and interpretation but also application. For him application is not an add-on that may or may not accompany understanding and interpretation; the three form an indissoluble unity. Hermeneutic understanding is thus in its essence practical. To understand and interpret something is to see its relation to praxis. It is because of this integration of application into the process of understanding and interpretation that Gadamer accords to legal and theological hermeneutics a priority over literary hermeneutics as models of understanding in the human sciences. And it is this issue of application and praxis that brings Gadamer (1960/1975, 278) to Aristotle's Nicomachean Ethics and the latter's notion of "practical knowledge," or phronesis--for Gadamer an early forerunner of hermeneutics.
According to Aristotle (1941), what is unique about practical knowledge is that it deals in particulars--how a particular man should act in a particular situation. Practical knowledge always involves a dialectic of the general principle and the particular case, and practical wisdom is precisely the ability to accomplish this application. Finally, Aristotle notes that since each kind of knowledge enjoys the degree of exactness that its subject-matter allows, practical knowledge, because it deals with particulars, admits of only inexact knowledge.
The relevance of these ideas to psychiatric practice is clear; psychiatry is practical in the sense both of Gadamer and Aristotle. Psychiatric theory is oriented toward application and practice, and the psychiatrist is dramatically engaged in a dialectic of the general and the particular. The latter is indeed even more true of psychiatry than medicine (which Aristotle takes as an example of practical knowledge). If the internist can at times legitimately remain at the level of the universal, treating the patient as a case of such-and-such illness, this is rarely true of the psychiatrist. Treating [End Page 67] the patient, for instance, as a borderline, rather than as this person with this life and borderline pathology, will not make for good treatment. Knowing the diagnosis is generally a small part of knowing (and treating) the patient. This is of course the reason why courses and chapters on "The Treatment of Diagnosis X" are always of limited value. Finally, following Aristotle, we must recognize that the practical, individual-directed nature of psychiatric practice renders psychiatry an inexact science. It is as inexact as people are different. As practical knowledge, this inexactness is not a defect that can be overcome with more progress in the field.
In concluding this review I would like to summarize what I consider the major features of a hermeneutic orientation in psychiatry. (1) A hermeneutic approach will focus on those conditions, and those aspects of any condition, that call for an interpretation of the meaning structures that play a significant role in the condition. It will also evince a sensitivity to the boundaries between meaning-oriented and other explanatory modalities. (2) This approach will emphasize the historicity of any theoretical point of view, any diagnostic system, and any therapeutic modality in psychiatry. This involves a recognition that there is no value-free or presuppositionless orientation in this field. One of the challenges of the hermeneutic effort is to promote "conversation" among the differing approaches, both at theoretical level and at the level of treatment of the individual patient. (3) The hermeneutic approach will subordinate the universal to the particular--that is, theory takes second place to the understanding and care of the individual patient. Psychiatric knowledge is thus practical and organized for treatment of the individual patient. (4) Finally, as a practical discipline, directed toward the care of the individual patient and allowing an inevitable plurality of perspectives in the provision of that care, psychiatric knowledge is finite, limited, and subject to ongoing revision.
James Phillips, Associate Clinical Professor of Psychiatry, Yale School of Medicine, New Haven, CT 06520, USA.
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