Thursday, March 15, 2012
Who Killed Ellen West? A Philosophical-Psychiatric Investigation of Ludwig Binswanger’s Case of Existential Analysis
The philosopher’s treatment of a question is like the treatment of an
—Ludwig Wittgenstein, Philosophical Investigations (1953)
One cannot understand psychological disturbances from the outside, on the basis of a positivistic determinism, or reconstruct them with a combination of concepts that remain outside the illness as lived and experienced.
—Jean-Paul Sartre, Foreword, Reason and Violence by Ronnie Laing & David Cooper (1964)
Who Killed Ellen West?
In 1944-45, Ludwig Binswanger (1881-1966), a Swiss psychiatrist, published The Case of Ellen West, the founding case of existential analysis and one of the most famous cases in modern psychiatry. Searching for a meaningful alternative to the reductive models of contemporary psychiatry, I began reading this case and entered a labyrinth where I investigated the founders of clinical psychiatry, questioned phenomenology, discovered a “whodunit” mystery and triggered a crisis of conscience as a psychiatrist.
With his account of the treatment of a “non-Swiss” Jewish woman at Bellevue, the private sanatorium he directed at Kreuzlingen in Switzerland, Binswanger proposes an analysis of “the existential Gestalt to which we have given the name Ellen West” (1888-1921). To do this, he consults the patient’s clinical notes as well as her private journal, poems and letters to grasp the “totality of her existence.” Her two psychoanalysts are quoted—one sees hysteria, while another pronounces her a severe obsessional neurotic with manic-depressive oscillations. After two suicide attempts, a series of consultations with the founders of modern psychiatry begins. Emil Kraepelin (1856-1926), architect of today’s psychiatric classification, diagnoses melancholy (a profound depression akin to psychosis) while an unnamed “foreign” psychiatrist, finds simple psychasthenia (obsessive-compulsive disorder). Binswanger has another idea—schizophrenia—confirmed by Eugen Bleuler (1857-1939), who named this emblematic condition of psychiatry.
Ellen West’s melancholy and suicide attempts persist, accompanied by serious eating problems. Convinced of her incurable diagnosis, more hopeless than ever, Ellen West demands to be released from hospital. After three days with her family, she appears transformed: she has breakfast, at midday she eats well for the first time in 13 years, in the afternoon she goes for a walk with her husband, reads poems and writes letters; all heaviness is lifted from her. In the evening, she takes poison. The next day, at the age of 33 years, Ellen West is dead.
Writing more than 20 years after her death, when the principals of the case are dead, Binswanger assures us no less than 17 times that her suicide is “authentic.” Who was he trying to convince? Was her death an “authentic suicide” as he insists, an “assisted suicide” (see Akavia, 2008) or a case of “psychic homicide,” a kind of soul murder (see Lester, 1971)? Stripped down, little in Binswanger’s account supports the diagnosis of schizophrenia, then an incurable disease. Against her family’s wishes, Binswanger consults “a foreign psychiatrist” who can now be named, Alfred Hoche (1865-1943), known to support euthanasia for life unworthy of life; all therapy is suspended; and, in spite of her suicidal plans, she is discharged home where her husband provides the poison that kills her.
In spite of the efforts of many great 20th century thinkers—from her psychiatrists to later psychiatric readings (Mara Selvini Palazzoli, 1982; R.D. Laing, 1982; Salvador Minuchin, 1984) and even philosopher Michel Foucault (1954)—“Ellen West” remains an enigma. The case of “Ellen West” is a mirror of 20th century psychiatry but the issues and the risks that we find there are still relevant for us (Di Nicola, 2011). And they speak to the debates about the state of psychiatry today.
After 25 years as a practising psychiatrist, this case makes me wonder: What is the mission of psychiatry? Is it to understand (Binswanger’s goal with existential analysis), to classify (Kraepelin’s and Bleuler’s contribution) or to heal (Freud’s contribution through psychoanalysis)? Are these different goals compatible or mutually exclusive? Critics of the case of Ellen West assert that she was misunderstood and mistreated. What lessons does she demand that we learn, at last? Can we let her find a voice to express her suffering, as Minuchin tries to do in his family drama about her?
About Me: Vincenzo Di Nicola
I am an academic psychiatrist with interests in the history of psychiatry, phenomenology and philosophy. By chance, I had a relationship with three psychiatrists in this story: Ronnie Laing was my therapist in London, I trained with Mara Selvini Palazzoli in Milan and know Sal Minuchin. All three wrote extensively about families. Selvini Palazzoli and Minuchin are also family therapists and specialists in eating disorders (a key aspect of Ellen West’s predicament). Like my mentors, I specialized in family therapy and eating disorders. Currently, I am doctoral candidate in philosophy in Switzerland, which makes the case more poignant for me. I have presented versions of this research at the Culture and Mental Health Research Seminar at McGill University and Clinical Grand Rounds of Maisonneuve-Rosemont Hospital and will soon present it at the Institute of Mental Health of the University of Montreal. Parts of this research will be integrated into my doctoral thesis and I am working on a book and a documentary film about this case.
Binswanger’s “Case of Ellen West”
Binswanger, Ludwig (1944-45). Der Fall Ellen West. Schweizer Archiv für Neurologie und Psychologie, 1944, 53: 255-277, 54: 69-117; 1945, 55: 16-40. (Original in German.)
---- (1958). The case of Ellen West: An anthropological-clinical study (trans. Werner M. Mendel & Joseph Lyons). In: Existence: A New Dimension in Psychiatry and Psychology (Rollo May, Ernest Angel & Henri F. Ellenberger, eds.). New York: Basic Books, pp. 237-364. (Complete translation in English.)
Akavia, Naamah (2008). Writing “The case of Ellen West”: Clinical knowledge and historical representation. Science in Context, 21: 119-144.
Berlinck, Manoel Tosta & Magtaz, Ana Cecília (2008). Reflexões sobre O caso de Ellen West: estudo anthropológico, de Binswanger. Revista Latinoamericana de Psicopatologia Fundamental, 11(2): 232-238.
Di Nicola, Vincenzo (2011). The enigma of Ellen West. In: Letters to a Young Therapist: Relational Practices for the Coming Community. New York and Dresden: Atropos Press, pp. 121-125.
Foucault, Michel (1954). Introduction et notes. Le Rêve et l’Existence par Ludwig Binswanger (trans. Jacqueline Verdeaux). Paris: Desclée de Brouweret.
Ghaemi, S. Nassir (2001). Rediscovering existential psychotherapy: The contribution of Ludwig Binswanger. American Journal of Psychotherapy, 55 (1): 51–64.
Laing, Ronald D. (1982). The Voice of Experience: Experience, Science and Psychiatry. New York: Penguin Books.
Lester, David (1971). Ellen West’s suicide as a case of psychic homicide. Psychoanalytic Review, 58: 251-263.
Marceau, Jean-Claude (2002). La question de la corporéité dans le cas Ellen West de L. Binswanger. L’Évolution Psychiatrique, 67(2): 367-378.
Minuchin, Salvador (1984). The triumph of Ellen West: An ecological perspective. In: Kaleidoscope: Images of Violence and Healing. Cambridge, MA: Harvard University Press, pp. 195-246.
Selvini Palazzoli, Mara (1982). L’anoressia mentale: Dalla terapia individuale alla terapia familiare. Nuova edizione interamenta riveduta. Milano: Feltrinelli Editore.
Vandereycken, Walter (2004). Book review: A. Hirschmüller (ed.), Ellen West. Eine Patientin Ludwig Binswangers zwischen Kreativität und destruktivem Leiden. Heidelberg-Kroning: Asanger, 2003. History of Psychiatry, 15(1): 125-126.