The case of "Ellen West," reported by Ludwig Binswanger as the foundational case of "Daseinanalyse" or existential analysis, is revisited and shown to be a mirror of 20th century psychiatry’s core dilemmas
4. The Enigma “Ellen West” Ludwig Binswanger’sfoundation case of existential analysis
5. The Enigma “Ellen West” Ludwig Binswanger’sfoundation case of existential analysis “A mirror of twentieth-centurypsychiatry”
6. Vincenzo Di Nicola Doctoral candidate EuropäischeUniversitätfürInterdisziplinäreStudien (European University for Interdisciplinary Studies) Saas-Fee, Wallis, Schweiz
15. Psychiatres, psychologues et psychanalystes suisses Henri Ellenberger Jean Piaget BärbelInhelder Elisabeth Kübler-Ross Alice Miller Carlo Strenger Auguste Forel Hermann Rorschach Carl Gustav Jung Oskar Pfister Eugen Bleuler Ludwig Binswanger
16. The Case “Ellen West” Ludwig Binswanger’sfoundation case of existential analysis
22. Der Fall Ellen Westby Ludwig Binswanger 1944-45: Der Fall Ellen West. Schweizer Archivfür Neurologie und Psychologie, 1944, 53: 255-277, 54: 69-117; 1945, 55: 16-40. 1957: Schizophrenie. Pfullingen: Neske. 1958: The Case of Ellen West: An Anthropological-ClinicalStudy (trans. by Werner M. Mendel & Joseph Lyons, pp. 237-364), in Existence: A New Dimension in Psychiatry and Psychology (ed. Rollo May, Ernest Angel & Henri F. Ellenberger). New York: Basic Books.
23. Der Fall Ellen West résumé en français Storch, Alfred (1958). « À propos de Schizophrénie de Ludwig Binswanger. » L’Évolution Psychiatrique, 3 : 577-602. Ellenberger, Henri F. (1974/2001). À la découverte de l'inconscient, Paris : SIMEP. Réédité sous le titre Histoire de l'inconscient, Paris : Fayard. Postel, Jacques (1993/2003). Dictionnaire de psychiatrie et de psychopathologie clinique. Paris : Larousse.
24. Ellen West: childhood, youth Born in 1888 into a Jewishfamily, Ellen arrives in Europe at the age of 10 As a child, she expresses hercharacterearly: stubborn, mischievous, disobedient Also: a good student, lively, ambitious, sheappliesherselfintenselyintoeverythingsheundertakes Intelligent and sensitive, shetakes the matura and then passes the exams to become a teacherwhichallowsher to enter university Ellen reads a great deal – notably R.M. Rilke and J.W. von Goethe Afterthesereadings, shebecomes an atheist and adopts a rebellious attitude towards bourgeois life
25. Ellen West: attachments Ellen falls in love numerous times Forbiddeneach time by her parents who oblige her to break up her engagements At the age of 28, withher parents’ permission at last, she marries a cousin
26. Ellen West: embodiment Around the age of 20 Ellen begins to beafraid to gain weight Sheexperiencesstrongcravings for food, accompanied by the fear of getting fat All of whichbringsher to feeldepressed Ellen’s solution: taking laxatives to staythin, up to 60 packets a day
27. Ellen West: embodiment (ii) She has a miscarriagefollowing a vigoroushikeduringwhichshe has a haemorrhage She suspends taking laxatives as shewants a baby Her intense desire to loseweightreturns: Ellen refuses to eatnormally and startstaking laxatives again Hermenstrualperiodsdisappear, yetsheismotivated to staythinwhichattenuateshersadness/depression At the age of 30, shebecomes a vegetarian
28. Ellen West: psychiatriccareer At31, after 3 years of marriage, nowamenorrheic, havingendedsexual relations for 2 years, Ellen decides to sharehersufferingwithherhusband In thisperiod, shemakes 8 suicidal“gestures” Ellen encountersmedicalspecialists, visits Sanatoria, beginspsychoanalysis and meets the psychiatricelite of the time: Eugen Bleuler, Emil Kraepelin and Ludwig Binswanger … The psychiatrists are not in agreement about the diagnosis
29. Ellen West: subjective experiences Ellen almostconstantlyexperiences a pervasivedreadwhichisat once generalized and connected to weight gain Sheexhibits an obsession withthinness and a fear of gainingweight Shefeels an “emptiness,” an “existential anxiety”
30. Ellen West: subjective experiences (ii) Ellen lives a dichotomy: a split betweentheethereal world and thetomb-world(according to Binswanger) The spiritual versus the physicaltranslated/experienced by Ellen as the ideal of the soul (pure and empty) versus the fear of herownembodiment (the heaviness/gravity of feeling full, pregnant, a bourgeoise)
31. Ellen West: explication philosophique « Tout le mouvement de son existence s’épuise dans la peur phobique d’une chute dans la tombe, et dans le désir délirant qui planerait dans l’éther et cueillerait sa jouissance dans l’immobilité du mouvement pur. Mais ce que désignent cette orientation et la polarité affective qu’elle implique, c’est la forme même selon laquelle se temporalise l’existence. L’avenir n’est pas assumé par la malade comme dévoilement de sa plénitude et anticipation de la mort. La mort, elle l’éprouve déjà là, inscrite dans ce corps qui vieillit et que chaque jour alourdit d’un poids nouveau ; la mort n’est pour elle que le pesanteur actuelle de la chair, elle ne fait qu’une seule et même chose avec la présence de son corps. » —Michel Foucault (1954). « Introduction ». Le rève et l’existence, L. Binswanger
32. Ellen West: philosophical explication « Tout le mouvement de son existence s’épuise dans la peur phobique d’une chute dans la tombe, et dans le désir délirant qui planerait dans l’éther et cueillerait sa jouissance dans l’immobilité du mouvement pur. Mais ce que désignent cette orientation et la polarité affective qu’elle implique, c’est la forme même selon laquelle se temporalise l’existence. L’avenir n’est pas assumé par la malade comme dévoilement de sa plénitude et anticipation de la mort. La mort, elle l’éprouve déjà là, inscrite dans ce corps qui vieillit et que chaque jour alourdit d’un poids nouveau ; la mort n’est pour elle que le pesanteur actuelle de la chair, elle ne fait qu’une seule et même chose avec la présence de son corps. » —Michel Foucault (1954). « Introduction ». Le rève et l’existence, L. Binswanger
34. Ellen West: philosophicalexplication (ii) « La mort, elle l’éprouve déjà là, inscrite dans ce corps qui vieillit et que chaque jour alourdit d’un poids nouveau ; la mort n’est pour elle que le pesanteur actuelle de la chair, elle ne fait qu’une seule et même chose avec la présence de son corps. » —Michel Foucault (1954) See: Simone Weil (1947), La Pesanteur et la grâce/Gravity and Grace Wassheanorexic? Simone Weil isconsideredanorexic in the eatingdisorders and feministliterature
36. Ellen West: “enforcedseparations” Ellenexperienced a quite impressive list of “enforcedseparations” (RD Laing): Herfatherorderedher to break her first engagement. Her second engagement was“temporarilydiscontinued”at the instigation of herfather and mother. Her first analysisisterminated for “externalreasons.” Her second analystorderedherhusband to leaveher. A psychiatristorderedher to end her second analysis.
50. Être et Temps/ Being and Time (1927) Emmanuel Lévinas : « Heidegger est pour moi le plus grand philosophe du siècle, peut-êtrel’un des trèsgrands du millénaire ; mais je suistrèspeiné de cela, parceque je ne peuxjamaisoubliercequ’ilétait en 1933, mêmes’il ne l’étaitque pendant unecourtepériode. Cequej’admiredans son œuvrec’estSein und Zeit. C’est un sommet de la phénoménologie. Les analyses sontgéniales …. Rassurez-vous : je ne suis pas ridicule, je ne sauraisméconnaître la grandeur spéculative de Heidegger. »
66. Freud Psychotherapy Psychoanalysis Biology/clinicalpsychiatry “Body” Binswanger Existential analysis Phenomenology/clinicalpsychiatry “Existence” Bühler, Karl-Ernst (2004). Existential analysis and psychoanalysis: Specificdifferences and personalrelationshipbetween Ludwig Binswanger and Sigmund Freud. American Journal of Psychotherapy,58 (1): 34–50.
67. Existential Psychiatry Eugène Minkowski (1885-1972) « Je donne une œuvre subjective ici, œuvre cependant qui tend de toutes ses forces vers l'objectivité. » I amoffering a subjective workhere, whichaimsneverthelesstowardobjectivitywith all its force. FoundedL’Évolution psychiatrique
68. Existential Psychiatry Binswanger RD Laing Binswanger’saccountis not about the person of Ellen but rather“of the existential Gestalt to whichwe have given the name of Ellen West” based on documents written by Ellen and her husband Hismethodis to lay out beforehim all of the life-history of Ellen in as muchdetail as possible, leaving out as far as possible all moral, aesthetic, social, medical or anykind of judgements, free of all pre-judgements. He will direct his gaze at the finishedform of her existence in the world, dissecting a deadbutterfly of hisfancy, not depicting the pathetic life of a defeatedperson. … exactly“becausehedid not know herpersonally” the “conditions wereparticularlyfavourable to an existential analysis” “No need to pass time in the presence of a personwhosepresence in the world issototallyunfortunate and miserable. “The existential Gestaltthatis Ellen Westisunable to ‘relate.’ Hisstudy exemplifies exactlywhatheattacks.”
70. Evolution of CriticalPsychiatry Systems Gregory Bateson RD Laing Whitaker/Andolfi Minuchin SelviniPalazzoli Culture Frantz Fanon Wittkower, Murphy, Prince Arthur Kleinman Georges Devereux/Tobie Nathan
71. Evolution of CriticalPsychiatry Feminism MaraSelviniPalazzoli Susie Orbach Kim Chernin Julie Kristeva Luce Irigary Politics Frantz Fanon Gilles Deleuze/Félix Guattari Franco Basaglia RD Laing/David Cooper Thomas Szasz
72. Ellen West: interventions Internalmedicine Psychiatrists – “psychoanalysts” Psychiatric consultations Hospitalization Interventions Medical care, management vonGebsattel, vonHattingberg Kraepelin, Hoche, Bleuler, Binswanger Bellevue Sanatorium Closed unit vs discharge, assisted suicide, existential analysispost hoc
73. Ellen West: diagnoses Duringhertreatment Readings of the case Melancholia(Kraepelin) Hysteria(vonGebsattel) Obsessionalneurosiswithmanic-depressive oscillations (vonHattingberg) Psychasthenia(Hoche) Schizophrenia Simplex (Bleuler, Binswanger) Anorexie hystérique (Charles Lasègue) Anoressia mentale (MaraSelviniPalazzoli) Folie hystérique (Jean- Claude Maleval) Anorectic(Salvador Minuchin) Bulimiawithobsessive-compulsivephenomenology, dysphoriaassociatedwith borderline personalitydisorder(NassirGhaemi) Anorexia, melancolia, neurosenarcísica (ManoelBerlinck& Ana CecíliaMagtaz) Insécurité ontologique, honte du corps (Jean-Claude Marceau)
74. Ellen West: diagnoses Duringhertreatment Readings of the case Melancholia(Kraepelin) Hysteria(vonGebsattel) Obsessionalneurosiswithmanic-depressive oscillations (vonHattingberg) Psychasthenia(Hoche) Schizophrenia Simplex (Bleuler, Binswanger) Thesolepsychiatristwhoresisted to diagnosisher? R.D. Laing, The Voice of Experience (1982) He concentrateshis critique rather on Binswanger’smethod Hisstudy of Ellen West contributed to distancinghimselffromtraditionalpsychiatry, from the diagnostic perspective and from the concept of simple schizophrenia
75. The Gestalt“Ellen West” Psychiatricphenomenology Existential Relational Sociocultural Phobia/obsession/delusion? Emptiness, ontologicalinsecurity All relationships/Rxinterrupted A woman in a traditional/patriarchalfamily/society A Jewish patient in an antisemiticsociety
77. Janet’s Case of Nadia Chapter:« L’obsession de la honte du corps »The obsession withbodilyshame Young woman of 27 yearswhoadopted a bizarre eating pattern for fear of gainingweight (twosoups, an eggyolk, a spoon of vinager and a cup of strongteawithlemonjuice) Shealternatedbetweenbulimic crises and hours of rumination on food and eating as torture Dx:“anorexie hystérique” – hysterical anorexia Janet, Pierre (1903). Les obsessions et la psychasthénie. Paris : Alcan.
78. “Ellen West” Binswangerdiscusses the question of embodiment in psychosis Dressedexclusively in pants until the age of 16 years Deathis for herisjust the heaviness of herflesh, Ellen speaks of the ethereal world “Nadia” Cited by Binswanger Seeks to hidehersex/gender by dressing like a man; shewouldreallylike to bewithoutanysex, withoutany body Beyondbeingthin, Nadia wishes to no longer be in her body and speaks of the existence of an angel
79. TheSchizophrenias Kraepelin Dementia praecox oderGruppederSchizophrenien(1911) Dementia Praecox or The Group of Schizophrenias Bleuler introduces the new termschizophrenias for dementiapraecox Klinische Psychiatrie (1899) ClinialPsychiatry Kraepelin proposes the dichotomybetweendementiapraecox etmanic-depressiveillness Bleuler
81. TheDeath of “Ellen West” I becamefascinated by the question of responsability. Whocausedherdeath, directly or indirectly? —Salvador Minuchin (1984)
82. Aftertwo suicide attempts by Ellen West, begins a series of consultations with the founders of modern psychiatry: Emil Kraepelin (1856-1926), architect of today’spsychiatricnosology, diagnoses melancholiafinds a simple psychasthenia. Alone in perceivingwhat the Gestalt revealsisBinswanger, confirmed by the authority of Eugen Bleuler (1857-1939)whonamed the emblematic condition of psychiatry: SchizophreniaSimplex(simple schizophrenia), a progressive schizophrenicpsychosis
83. Their opinions notwithstanding, Ellen’smelancholy and her suicide attemptspersist, accompanied by seriouseatingproblems. Convinced of the grave and incurable diagnosis, withouthope, all therapiesinterrupted, suspended or withdrawn, Binswangeraccedes to the patient’srequest: Ellen isdischargedfrom the Sanatorium.
84. After 3 dayswithherfamily, Ellen appearstransformed: she has breakfast, atnoonsheeatswell for the first time in 13 years, during the afternoonshegoes for a walkwithherhusband, readspoems and writesletters. All the heavinessisliftedfromherbeing. That night, shetakes poison. The nextday, at the age of 33 years, Ellen West isdead.
85. Binswangerreassures the reader not lessthan 17 times thather suicide is“authentic.” Laing concludes his reading with bitter irony: Poor little rich girl.
86. The Death of “Ellen West” Asuicide? - authentic? An assisted suicide? A psychic-ontological homicide?
87. The Deathof “Ellen West” « An authenticsuicide » according toBinswanger(1944-45) Binswanger, Ludwig (1944-45). « Der Fall Ellen West. » Schweizer Archivfür Neurologie und Psychologie, 1944, 53 : 255-277, 54 : 69-117; 1945, 55 : 16-40.
88. The Death of “Ellen West” « An assisted suicide » according toAkavia (2008) Akavia, Naamah (2008). « Writing “The Case of Ellen West” : ClinicalKnowledge and HistoricalRepresentation. » Science in Context, 21 : 119-144.
89. The Death of “Ellen West” « A psychic homicide » according toLester (1971) Lester, David (1971). « Ellen West’s suicide as a case of psychic homicide. » PsychoanalyticReview, 58 : 251-263.
90. The Death of “Ellen West” An assisted suicide The authenticity of whichisprecisely question A psychic homicide in which suicide as a solution wasinducedfrom the outside An ontological annihilation by the family, herhusband et herphysicianssuppported by the psychiatrist Alfred Hoche and hisjustfication to “annihilate life unworthy of life”
91. The Death of “Ellen West” A psychic homicide, an ontological annihilation Binswangererrswith the diagnosis of schizophrenia, heconsults Alfred Hoche, a psychiatristknown for histextwith the jurist Karl Bindingjustifying suicide and euthanasie for “life unworthy of life” He takes away her hope for living and collaborates with her husband to induce her suicide After—more than 20 years later, he reconstructs The Case Ellen West to justify himself: he tries to convince us that his distance helps him to understand and insists 17 times in the text that the suicide was authentic
92. The Doctor-Patient Relationship Von Gebsattel Littleknown in the English or French literature He speaks to the doctor-patientrelationship He insists on the presence of the person in boththe patient and the doctor to resist the dehumanization of medicine (what Foucault will call desubjectivation) Welie, Jos VM (1995). Viktor Emil vonGebsattel on the Doctor-Patient Relationship. TheoreticalMedicine, 16: 41-72.
96. Medscape 2010 PhysicianEthics Survey “Palliative care is one thing, but suicide is not within the scope of acceptable physicianbehavior.” “I do not believe in assisted suicide, but I do believe in withdrawal of support. If the patient isterminallyill and suffering and thereisabsolutely no hope to survive, then I withdraw the support (eg, antibiotictreatment, bloodtesting, or transfusions).” “Assisted suicide ismurder.”
97. Medicine and the GermanJews There are verydeephistorical and socioculturaltiesbetweenGermans, Jews, and medicinesince the Middle Ages In the evolution of Germanmedicine, a language of the degenerating body and the metaphor of regenerationwaselaborated and inscribedintotheories and practices, to whichJewishphysiciansthemselvesadhered and withwhichtheydescribedthemselves The Jewish body wasperceived as sick and diseased, the sign of a national disease due to theirpowerlessness as a people with a country (adopted by the earlyZionists) This perception—let’s call it an episteme or discoursefollowing Foucault—becomesdistorted and abused by the Nazis whospeakincessantly of racial purity and the degenerateJews John M. Efron (2001). Medicine and the GermanJews: A History. New Haven : Yale UniversityPress.
98. Ellen West : victim of herself, of life, of assisted suicide? How could a sophisticated and brilliant man likeBinswanger,comingfrom a medical tradition of great distinction (practically noble) on severallevels—nationally (Switzerland), culturally (German) and in hisfamily, and havingJewishfriends, mentors and interlocutors (notably Freud) bringhimself to consult a man like Hoche as a consultant for a patient whowasJewish, suicidal and in despair due to the diagnosis of an incurable illness? Wenow know that Ellen West and herhusbandcontestedthischoice of consultant and did not findhim acceptable knowingverywellhisreputationbased on hisideas about euthanasia and assisted suicide, whichacceleratedherdepartturefrom Bellevue Sanatorium Hoche’s and Binding’stextwillbecome the inspiration and justification for the final solution of the Jewish question, thatis to say, the extermination of the Jews of Europe, declared by the Nazis at the WannseeConferencenear Berlin in 1942
99. Reflections In spite of the efforts of manygreatthinkers of the 20th century – fromKraepelin, BleulerandBinswanger to SelviniPalazzoli, LaingandMinuchininpsychiatry and Foucault en philosophy– « Ellen West »remains an enigma for us. Whatremainspossible for us is to undertake a philosophicalarchaeologyto create new constructions of this case in order to integrate the phenomenological, systemic, sociocultural and ethical dimensions of her life.
100. Reflections « Ellen West »is a mirror of 20th centurypsychiatry but the issues and the riskswefindthere are stillpresent and salient Whatis the central task of psychiatry: to comprehend, to classify or to cure? Is it possible to accomplishit (or them) objectively and atwhatprice? Whitherthensubjectivity?
101. Reflections Is contemporarypsychiatry more in the spirit of Kraepelin who inspires the thinkingbehind the DSM and evidence-basedmedicine or ratherthat of Bleuler, disciple of Freud, whoinspireddynamicpsychiatry? Is it the critical and humanistic spirit of Laing whoinspired the family and communitypsychiatrymovement in Britain and beyond or that of Minuchinwhodeclaredthatfamilytherapywouldtake over psychiatry in the US?
102. Reflections So thatourhumanencounters in the clinical do not become or stayenigmatic (seevonGebsattel, Sartre, Foucault),we have the choice to practice our profession – thisimpossible profession according toFreud – in a waythatisalways more human and empathic.
103. Réflexions « On ne peut comprendre les troubles psychiques du dehors » mais par « un effort constant pour saisir la situation de base et pour la revivre », ce qui nous rapprochera au « temps où la psychiatrie sera, enfin, humaine.» —Jean-Paul Sartre à l’avant-propos de Raison et violence (Laing et Cooper, 1964)
104. Reflections “One cannotunderstandpsychologicaldistubancesfrom the outside, on the basis of a positivisticdeterminism, or reconstructthemwith a combination of concepts thatremainoutside the illness as lived and experienced … without a constant effort to grasp the basic situation and to reliveit, without an attempt to rediscover the response of the person to that situation …whichwillbringcloser the daythatpsychiatrywill, at last, become a trulyhumanpsychiatry.” —Jean-Paul Sartre, Foreword, Reason and Violence (Laing & Cooper, 1964)
105. Alain Badiou (né 1937) Pour guérir quelle blessure, pour ôter quelle écharde dans la chair de l’existence suis-je devenu ce qu’on appelle un philosophe? – Alain Badiou Préface, Après la finitude de Quentin Meillassoux (Paris, Éditions du Seuil, 2006)
106. Alain Badiou “What wound was I seeking to heal, what thorn was I seeking to draw from the flesh of existence when I became what is called ‘a philosopher’?” “It may be that, as Bergson maintained, a philosopher only ever develops one idea. In any case, there is no doubt that the philosopher is born of a single question, the question which arises at the intersection of thought and life at a given moment in the philosopher's youth; the question which one must at all costs find a way to answer.” Preface, After Finitude, Quentin Meillassoux (Continuum, 2008)
107. Ludwig Wittgenstein (1889-1951) The philosopher’streatment of a question islike the treatment of an illness.– §255 Ludwig Wittgenstein, Philosophical Investigations (1953)
108. Bibliography Agamben, Giorgio (2008). Signaturarerum. Sur la méthode (trad. de Joël Gayraud). Paris : Vrin. Akavia, Naamah (2008). « Writing “The Case of Ellen West” : ClinicalKnowledge and HistoricalRepresentation. » Science in Context, 21 : 119-144. Basaglia, Franco (1965). « Corps, regard et silence. L’énigme de la subjectivité en psychiatrie. » L’Évolution Psychiatrique, 1 : 11-26. Berlinck, ManoelTosta & Magtaz, Ana Cecília (2008). « Reflexões sobre O caso de Ellen West : estudoanthropológico, de Binswanger. » RevistaLatinoamericana de PsicopatologiaFundamental, 11(2) : 232-238.
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