Book Review: Contexts of Suffering: A Heideggerian approach to psychopathology

Whilst attending a pre-pandemic conference in Buffalo, I managed to spend some time with Kevin Aho, the author of this book, catching up on various events and experiences since we had last spoken. Our eventual parting after a few days left me promising him that I would write a review of this publication.

In brief, the book is a rewarding read but also challenging, for reasons that will become apparent to the reader. Very much in keeping with the author's admirable ability to render more complex Heideggerian ideas into clear and understandable language, I found the text at all times easy to absorb, illuminating those aspects of Heidegger's work that might seem intractable and even disorienting. But I also carried a certain hesitation in reading a – or any – publication that explores and reassesses the domains of psychopathology and psychiatry, even if through a Heideggerian lens. This, I think, is for two closely related reasons: the sense that the book seems not to be really relevant to, nor address, the existential therapeutic approach, and also that its aim is to engage with – and problematise – the medicalisation of the psychiatric and psychologist professions, which holds only a limited interest for me. This is also shaped by the fact that the Zollikon Seminars themselves already offer a rejection of the application of such medically-oriented terminology to the human being, even if there are some passages that seem to cross this line. Nevertheless, I was sufficiently motivated to engage with its contents for other reasons, and these proved to be educative for me as I progressed through the chapters.

The book is divided into two parts: Part I is entitled, 'Phenomenological Psychopathology', while Part II focuses on 'Hermeneutic Psychiatry'. As is obvious from these titles, Aho attends more to an application of Heideggerian phenomenology in the first part, whilst providing more directly hermeneutic analyses in the second part. Each part is composed of four chapters, with an important afterword that completes the book with a deeply personal and relevant account that links strongly to the overall subject matter itself.

The first chapter of Part I takes us into an introduction of the historical basis of the dominance of traditional, medically-oriented and biologically-based psychiatry, the role and trajectories that the various editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) have taken, and the ways in which the human being is mis-treated through certain assumptions that effectively fail to grasp the kind of being that we are. Aho's aim is not to dismiss psychiatry but to alert us to the sense in which it itself is blind to the fact that we, or the 'mental', cannot be reduced to

something physico-chemical, because we are characterised by the underlying structures that constitute our experience (p11), that is, the existentialia, which are actualised in the human being's concrete, existentiell mode of being. Aho devotes a section in this chapter to Heidegger's contributions to this discipline, attending specifically to those key terms that are found in his earlier work, namely moods, embodiment, spatiality, relationality, temporality and understanding. I strongly recommend this section of the book to those who are particularly interested in Heidegger and wish to gain a clearer understanding of his ideas as they may relate to therapy. By the end of this chapter, we already come to see the benefit of adopting a phenomenological approach to any given phenomena. In fact, this is also the basis of Aho's approach in the following chapters on depression (chapter two), anxiety (chapter three) and death as it relates to suffering and healing (chapter four). These chapters, too, bring the reader to a certain level of understanding of Heidegger's ideas using language that dismantles any sense of opaqueness that we generally might find in Being and Time.

Part II brings an explicitly hermeneutic focus to human phenomena, such as shyness, stress and rage, by prefixing these terms according to their situatedness, since we are always already 'contextual' beings who are in-the-world and not, somehow, objects or subjects that are detached and separate from the meaning-structures within which we are embedded. Aho here also draws on Gadamer, and this is where a more explicitly therapeutic focus comes into clearer view. For example, on page 74, the dialogical element is brought out so that it sharply distinguishes itself from any more medically-oriented discourse. As I was reading this section of chapter five, which addresses 'mental illness', I felt that there was much here that was worthy of a book-length excursus on its own, based on a study of the existentiale, being-with and its existentiell modes of possible concrete actualisation. However, more generally, much more could be said about the richness of Part II, whether it be the way in which Aho manages to show how a hermeneutic way of exploring a phenomenon can actually be enacted, or the way in which he introduces such centrally important figures in existential thought as Dostoevsky, for us to see how we have arrived at a way of being that reflects our own current age. That is, in our current technological world, in which we always already understand being as Ge-stell, we are prone to respond in all-too-understandable ways – in this case, anger and rage – such that any strong feelings, emotions and moods do not equate to a diagnosable malady, ailment or illness.

The last part of the book, the afterword, is a deeply personal hermeneutic account of Aho's heart attack. The author provides a short narrative account of this experience, from initially being out on a sixty-mile bike ride, having the attack, being hospitalised twice and his final release from intensive care. He explores his experience from the perspectives of the altered body, the

spatial, temporal and hermeneutic and relational wounds, with a last word on healing. This resonated strongly for me, given my own gradual and painful recuperation from a severe cardiac event several years ago. There is much here that can open us to more of an appreciation of the how of what we all experience at times when we undergo the disruptions, disturbances, breakdowns and collapses of our everyday worlds at any time.

The book affords us the opportunity to see both some of its therapeutic relevance and also the challenges. Firstly, many terms that are introduced in Aho's book are in need of further hermeneutic unravelling. Think of the way in which 'individual', 'person', 'subject' and even 'human' all still out from a certain conception of ourselves that grossly mis-characterises the way in which our kind of being, in actual fact, 'sways' or moves. These are all ontic abstractions that actually identify us in terms of substance, that is, something static, fixed, rational at its core and 'worldless'. All this is a way of saying that we need to dismantle or conduct a destruktion of so many terms that we find in these language domains, be this in psychiatry, psychology or therapy. We can see an example of this in Heidegger's critique of the more recent neologism, 'empathy', as rendered originally in English through Titchener, which has been so relevant to Carl Rogers' approach in person-centred psychotherapy, but also in such terms as 'illness', 'mental', 'psychic' and 'pathology', that we find in Aho's book. This is because these terms do not conform to a Heideggerian approach to human being.

This leads me on directly to my second point. It seems to me that there is room to question whether the constitutive structures of our being, those that Heidegger names existentialia, have themselves undergone a breakdown or collapse, and that accounts for certain conditions, as Aho claims. Rather, I contend that it is only the existentiell actualisations of those existentialia that are vulnerable to breakdown and collapse, since existentiell as being-in-the-world, being-towards-death, das Man, Befindlichkeit, being-with, Understanding and so on, cannot themselves collapse, as such. To claim that being-in-the-world, for example, can undergo collapse would be tantamount to saying that I am no longer Dasein, which is false, unless Aho wants to push this claim too.

A third point is one that reflects my agreement with Aho, but I believe it could be further amplified in this work. This is in relation to the way in which we investigate phenomena or, in more popular terms, employ methodology or method. Woven into our current search for answers, and one that I think distinguishes therapy from psychiatry, is the way in which it is the exploration itself that is central to therapy, and not the attempt to provide certainty and answers or solutions to what brings about suffering for us. This is a Cartesian attempt to eradicate doubt, in the search for something certain, timeless and universal, rather than the recognition that we are unique in our way of living through moments of existence and that we alone are the narrators of what

is meaningful to us. Looked at in another way, a Cartesian approach attempts to effectively close down enquiry by eliminating what is open to doubt and being questionable, rather than keeping the sense of enquiry open-ended, which invites the unexpected. It also engages us in our existentiell mode of actualising those existentialia such as being-with, being-in, Befindlichkeit and so on that are relevant to our finding ways to reckon with an existence that includes suffering and unease.

My fourth point relates to Aho's focus on American culture and those who live in it. The second part of the book moves towards an analysis of the American understanding of being, in terms of the valorisation of the much-vaunted extrovert who is expressive, garrulous, self-sufficient and goal-oriented, rather than the introverted, quiet, vulnerable and sensitive kind of person, who is prone to be marginalised and even labelled with certain conditions such as shyness, if this behaviour is viewed as a debilitating affliction and is in need of treatment. This strikes me as a way of approaching this through a Heideggerian lens that is based on his own pursuit of an articulation of German Dasein in the early thirties, and which others pursue, such as the Mexican philosopher, Emilio Uranga, in his own An Analysis of Mexican Being (1952), but that we discern, too, in the work of the Spanish philosopher, José Ortega y Gasset. This goes somewhat against the project of Being and Time, since Heidegger there analyses Dasein in terms of its being structural, that is, cross-cultural, universal and trans-historical, and not existentiell (psychological, metaphysical) in character. As is also obvious from his later work, Heidegger rejects this early understanding of Dasein but retains the later use of the term to indicate our kind of being only as one that is mortal, rather than somehow divine in character. In other words, Aho employs a metaphysical, ontic analysis of Dasein as it applies to the American character, though I do also think that this turns out to be an informative and productive account of the way of being American, as understood in terms of its worldly character.

Perhaps as a last comment, I offer the following anecdote that comes from my own past. Aho mentions on page 86 the emergence of large group awareness programmes (LGAT) such as est and the Landmark Forum, in the seventies and eighties, both created and run by Werner Erhard, as technological approaches to the human being, in the attempt to foster a sense of 'self-actualisation' and 'self-mastery' in its participants. Whilst on a holiday in California in September 2009, I was granted a visit to meet with Bert Dreyfus, the noted Heidegger scholar, at his campus office in the University of Berkeley. The conversation went in various directions, which complemented my own disposition, as well as the many personal self-disclosures on his part that were so unexpected and humbling. At one point, without any prompting on my part, Dreyfus spoke about a collaboration between himself, Fernando Flores and Erhard in designing and writing the

content for the est training programme over an intense period of two weeks. As is well-known, there is a significant element of Heidegger's philosophy in this programme, even if moulded from a certain pragmatist understanding that Dreyfus had developed in his reading of the German philosopher. This revelation greatly surprised me, and I mention this here because it reminds me of the need to maintain a sense of care and rigour in not succumbing to Cartesian and metaphysical (that is, technological, calculative thinking) when we aim to bring out and articulate Heidegger's ideas. In Aho's hands, this is not an issue, since his writing carries us along with admirable skill and understanding in a way that one can only come to expect of a Heidegger scholar of the first order.

Mo Mandic

Mo Mandic