Phenomenology is a philosophical movement, founded by Edmund Husserl (1859 – 1938), which concerns itself with direct experiences, the nature of consciousness as it is experienced subjectively in the first person. Through systematic reflection on experiences from the first person point of view, Husserl believed we could better understand the structures of consciousness and the essential features of experiences.
Karl Jaspers (1883 – 1969) imported phenomenology into psychiatry, believing that this method or style of thought was necessary to advance the field of psychiatry. Jaspers taught that psychiatrists should focus on phenomenology before they diagnose and treat their patients. Indeed, by creating a systematically accurate description and understanding of a patient’s experiences, both inner and outer, a psychiatrist could more reliably diagnose a patient’s mental health condition.
One of the major issues in modern psychiatry is that mental illnesses are often misdiagnosed. Borderline personality disorder (BPD), for example, is commonly misdiagnosed as major depressive disorder (MDD), which means many people go without the appropriate treatment, continuing to suffer longer than necessary.
The psychiatrist Nassir Ghaemi argues that modern psychiatry has failed to take seriously the phenomenological approach, with diagnosis hindered by psychoanalytic assumptions. A diagnosis can be carried out remarkably quickly, based on a checklist of symptoms laid out in the Diagnostic and Statistical Manual of Mental Disorders (DMS), otherwise known as the ‘psychiatrist’s Bible’. While it is crucial for clinicians to pinpoint the key symptoms listed in these diagnostic checklists, relying solely on this method of diagnosis may leave out other important aspects of a patient’s subjective experiences. Mental illness is a complex, highly individual experience that requires careful and detailed analysis.
Ludwig Binswanger (1881 – 1966), a Swiss psychiatrist and pioneer of existential psychology, said that psychiatrists need to take four steps in their interview process. The first is an empathic appreciation of a patient’s subjective experiences, without structuring or explaining those mental states. A psychiatrist should focus on the patient’s sense of the world and his or her’s felt relationship to it. The next step is to use that information and combine it with objective observations about a patient in order to describe and catalogue mental states. After these two stages, the collated information can lead to an appropriate diagnosis and, in turn, the right course of treatment.
Ghaemi stresses, however, that modern psychiatrists will completely ignore the first step, while hastily addressing the second. He believes that modern psychiatry will only advance by rediscovering the ideas of philosophers and psychiatrists like Karl Jaspers and Ludwig Binswanger. But phenomenology in psychology is impactful for another reason. It helps to elucidate mental illnesses so that those who don’t experience these conditions can better understand those who do.
A phenomenological outlook on depression can play an important role in combating the stigma associated with the condition. Of course, when we see a list of the symptoms of depression, we know that it must be a challenging and painful illness to live with. And the more we understand the causes of depression, the more we know how misguided it is to attach blame, judgement, and guilt to the condition. Stigma, whether expressed by others or internalised by a patient, is partly rooted in ignorance. Nevertheless, a purely clinical or scientific understanding of depression may not give us the same degree of empathy towards mental suffering that phenomenology can provide.
It will be helpful to examine some essential or common features of depression, and how patients describe these particular phenomena. It is hard to truly communicate the pain of depression, which is why metaphors like ‘dark fog’ are often employed. But by paying close attention to the words of depressed patients, and taking their experiences seriously, we can gain a compassionate insight into the nature of this condition.
The quotes from patients below are responses to a questionnaire devised by the mental health charity sane and Matthew Ratcliffe, a professor of philosophy at Durham University. This was part of the project ‘Emotional Experience in Depression: a Philosophical Study’.
Thomas Fuchs, Karl Jaspers Professor of Philosophy and Psychiatry at Heidelberg University, notes:
The melancholic patient experiences a local or general oppression, anxiety, and rigidity (e.g. a feeling of an armor vest or tire around the chest, lump in the throat, or pressure in the head). Sense perception and movement are weakened and finally walled in by this rigidity, which is visible in the patient’s gaze, face, or gestures.
Andrew Solomon, the author of The Noonday Demon, said:
Such depression [dysthymia] takes up bodily occupancy in the eyelids and in the muscles that keep the spine erect. It hurts your heart and lungs, making the contraction of involuntary muscles harder than it needs to be.
And patients describe how the body feels in depression in similar ways:
- “Very tired and uncomfortable”
- As heavy as lead. I can’t drag it out of bed most of the time.”
- “Tired, aching”
- “Tired and painful. I feel like gravity is pushing me down.”
- “My body seems very heavy and it’s an effort to move.”
- “Exhausted, drained, no energy”
- “Tired but not sleepy. Tight neck and shoulders giving headaches.”
- “It aches. I can feel fluish. My stomach and throat can ache and I feel anxious.”
- “Exhausted, heavy limbs, aching, headaches, tired, space out.”
- “Heavy, arched and with hot and cold sweats. Vulnerable and hollow.”
- “No energy. Just totally run down.”
In Speaking of Sadness, author David A. Karp writes:
A paradox of depression is that sufferers yearn for connection, seem bereft because of their isolation, and yet are rendered incapable of being with others in a comfortable way. Much of depression’s pain arises out of the recognition that what might make me feel better – human connection – seems impossible in the midst of a paralyzing episode of depression. It’s like dying from thirst while looking at the glass of water just beyond one’s reach.
My father would assure me, smilingly, that I would be able to do it all again, soon. He could as well have told me that I would soon be able to build myself a helicopter out of cookie dough and fly to Neptune, so clear did it seem to me that my real life, the one I had lived before, was now definitively over.
In his book Malignant Sadness: The Anatomy of Depression, author Lewis Wolpert writes that his psychiatrist was:
extremely reassuring, telling me again and again that depression is self-limiting and that I would recover. I did not believe a single word. It was inconceivable to me that I should ever recover.
Sally Brampton, in her book, Shoot the Damn Dog: A Memoir of Depression, says:
It is the glass wall that separates us from life, from ourselves, that is so truly frightening in depression. It is a terrible sense of our own overwhelming reality, a reality that we know has nothing to do with the reality we once knew. And from which we think we will never escape. It is like living in a parallel universe but a universe so devoid of familiar signs of life that we are adrift, lost.
Patients have the following to say about the experience of possibility:
- “I remember a time when I was very young – 6 or less years old. The world seemed so large and full of possibilities. It seemed brighter and prettier. Now I feel that the world is small. That I could go anywhere and do anything and nothing for me would change.”
- “It is impossible to feel that things will ever be different (even though I know I have been depressed before and come out of it). This feeling means I don’t care about anything. I feel like nothing is worth anything.”
- “The world holds no possibilities for me when I’m depressed. Every avenue I consider exploring seems shut off.”
- “When I’m not depressed, other possibilities exist. Maybe I won’t fail, maybe life isn’t completely pointless, maybe they do care about me, maybe I do have some good qualities. When depressed, these possibilities simply do not exist.”
The Living Dead
The novelist Larry McMurty fell into a deep depression after his quadruple bypass surgery. Post-surgery, he said:
I became, to myself, more and more like a ghost, or a shadow. What I more and more felt, as the traumas deepened, was that while my body survived, the self that I had been had lost its life.
And Elizabeth Wurtzel, in her highly acclaimed book Prozac Nation, writes:
People talk about the way disembodied spirits roam the world with no place to park themselves, but all I can think is that I am a dispirited body, and I’m sure there are plenty of other human mollusc shells roaming around waiting for some soul to fill them up.
Reality changes dramatically when you suffer from clinical depression. The psychologist William James stated:
In certain forms of melancholic perversion of the sensibilities and reactive powers, nothing touches us intimately, rouses us, or wakens natural feeling. The consequence is the complaint so often heard from melancholic patients, that nothing is believed in by them as it used to be, and that all sense of reality is fled from life. They are sheathed in india-rubber; nothing penetrates to the quick or draws blood, as it were. […] ‘I see, I hear!’ such patients say, ‘but the objects do not reach me, it is as if there were a wall between me and the outer world!’
This disturbing type of experience is conveyed by many patients:
- “It feels as if I am a ghost – I cannot touch or see the world clearly and it all becomes grey and transparent.”
- “I feel disconnected from the rest of the world, like a spectator. I only see I was depressed when it stops. It’s like dust, you don’t notice it until you wipe it off and see the difference”.
- “Often, the world feels as though it is a very long way away and […] it takes an enormous amount of effort to engage with the world and your own life. It feels as though you’re watching life from a long distance. At times it felt as though I was looking through a fish eye lens, and couldn’t see clearly around the periphery, or even very well at all. I felt slightly pulled back from reality, as though there were cotton wool between my brain and my senses. A feeling of exhaustion often prevented me from being able to interact with the world, adding to the inability to process what was going on around me.”
- “I feel like I am watching the world around me and have no way of participating.”
- “Life seems completely pointless when depressed. Depression is the worst feeling in the world and when you’re absorbed in its depths you just don’t even want to be there, anything to stop the numbness and pain. You can’t see far into the future so you can’t see aspirations or dreams. Everything I ever wanted to do with my life before seemed impossible now. I also would think that I would never get out, that I’d be depressed forever. It brings quite irrational thinking because it’s not a rational illness. It makes you think all sorts of things about life and yourself that aren’t true. I thought I’d never escape from the depths of depression and never achieve anything with my life.”
- “The world looks very different when I am depressed, because everything looks dark/black and bleak. To me it looks like the colour and joy has been sucked out of the world and that the world looks completely dull.”
- “I can’t see any future for myself or the rest of the human race.”
- “The world seems pointless because when I am depressed I can’t see the world in a positive way. All I see is a place full of suffering which I often I would be better off escaping from.”
- “See no future or a hopeless future.”
- “When depressed I see life as pointless and sometimes cruel. I cannot see any possibilities for change or improvement.”
- “When I am depressed everything seems so bad. It seems as if there is nothing good in the world and that all the bad is because of me somehow.”
- “[When depressed] I hate myself. The reason my life is so awful at these times is because I am a terrible, wicked, failure of a person. I’m not a proper human being. I am a failed human being. Everything that goes wrong in my life is directly my fault; I caused it by not doing things I should have done, or doing things I shouldn’t have done. I am a waste of a human life. No-one knows just what a horrible useless nothing of a person I really am, because I hide it from people – if they ever find out the truth, they will all hate me and I will never have a single friend in the world ever again.”
- “Deep despair, hate myself, feel like I can’t do anything right, everyone would be better off if I wasn’t here to fuck their lives up, feel useless, why was I even born, I shouldn’t be here, I don’t belong here, just want to go to sleep and never wake up.”
- “Feel hopeless, like I shouldn’t exist and it would be better for family and friends if I wasn’t here. Just feel dark, worried, impending feeling of doom.”
- “When I’m depressed I find it very hard to perform routine tasks. Motivation is a big problem, though I find if forced then once I get going I’m generally fine.”
- “I feel too scared to move, like I have to sit in one place and not move and I’ll be ok then.”
- “The world seems a bleak, cold and threatening place. What I would normally see as a challenge seems like an insurmountable problem. My whole perspective becomes negative, and I am unable to see the good and potential in anything.”
- “Everything seems 10 times harder. I had to do everything in such tiny steps. Just the simple task of getting out of bed or leaving a building would be a huge deal. I would have to tell myself ‘first get into a sitting position. Then we’ll worry about the rest of it afterwards.’ I would see everything as such an ordeal, all these little things bundled into one huge thing. I just felt like there was this massive problem and I had no idea what to do about it. […] Things seem almost impossible. Just getting out of bed is difficult […] It was an effort to do things like have a shower and get dressed. Everything was so difficult. It would take a lot of encouragement for me to begin to do anything.”
- “It’s a struggle to get out of bed and make a drink. I can only usually get a glass of squash, it’s too much effort to stand there and wait for the kettle to boil to make tea. […] your whole body struggles to move and […] moving it is like pushing your way through treacle.”
- “It goes very, very slowly. Like I remember lying awake at about 4am in my uni room and it was going so slowly, all I had to go was get through to the morning so I could get some help and it seemed almost impossible just to get through those few hours because it was taking so long.”
- “Things seem much slower, time drags”.
- “Time seems to drag. A day feels like a year.”
- “Time goes so slowly when I’m feeling really bad.”
- “When I am depressed I feel like time goes slowly, yet at the same time I feel like I – or anyone else – has hardly any time to live at all. It feels as if time is running out.”
- “When depressed, time seems to slow down, and to a certain point can become irrelevant. It is easy to lose track of days without realising it.”
- “Yes, days go past slower and more boring feeling like everything’s going to drag on. On the other hand can feel like life going too fast and the years are flying by and start getting depressed thinking not long to live now etc.”
- “I just felt very detached from time, it simply didn’t matter”.
- “When I am depressed I don’t seem to notice time, it just doesn’t matter to me, it all seems to blend into a mass of nothing. […] Time loses significance.”
- “I have no concept of time when I am depressed.”
- “Time becomes insignificant. It passes and that’s all that matters.”
- “The world appears to be a frightening place full of people who are bad and threatening.”
- “I can feel very paranoid and unsafe, like I’m on the verge of being attacked, mocked, the subject of any kind of negative attention.”
- “When I’m depressed I feel like my relationships are less stable and I trust others a lot less. I try to avoid people, as they seem angry and irritated at me, and like they don’t want me around. I feel like a burden to others and don’t want to cause anyone unnecessary distress.”
- “I withdraw from people when I’m ill and feel an outcast but even when I’m better I feel an outcast because it’s always there and find it hard to trust people enough to let my guard down.”
- “I find it extremely difficult to trust anyone; it feels like they have all ‘guessed’ there is something wrong with me and now they are all conspiring to get me ‘sorted out’ i.e. remove me from normal society so that I don’t affect everyone around me with my awful, scary madness”.
- “When I’m depressed, strangers scare me, I trust no one.”
- “I feel very separate from people, fearing that if I talk about how I’m feeling they’ll reject or disapprove of me. And yet, on the flipside of that, I can become very clingy and over-reliant on people, particularly my boyfriend, and fear that without him I’ll somehow disappear. Seeing people becomes a huge chore, so I avoid friends, but then get upset when I’m not invited to things, feeling rejected and left out.”
The Essential Features of Depression
Professor Ratcliffe emphasises that there are particular phenomena involved in most cases of severe depression, and these are strongly linked to or inextricable from each other:
- Changes in the practical significance of things: they no longer offer up the usual possibilities for activity.
- A sense of impossibility: possibilities sometimes present themselves as ‘there but impossible to actualise’.
- A sense of estrangement: possibilities that are inaccessible to the self can appear as ‘accessible to others with little effort’. Other people continue to offer possibilities for the emotional and communicative relatedness but these possibilities at the same time appear as ‘impossible for me to take up’.
- Irrevocable isolation
- A diminishment and change in the usual sense of reality: things no longer strike one as potentially available; they seem strangely distant, not quite there anymore.
- An altered sense of self: cut off from a world that offers no possibility of communion, one is an impoverished spectator who lacks a fully rich sense of being there, of being part of things, of belonging to a world. Experience of self cannot be separated from a sense of belonging to the world or from the possibility of standing in various kinds of relation to other people. So the estranged self is a diminished self.
- Changed bodily feeling: the existential shift is also an unpleasant way of experiencing one’s own body, akin to a form of pain.
- Heightening of certain kinds of possibility: a world that no longer offers up invitation to act can at the same time be an all-encompassing and imminent threat, before which one is passive, helpless and utterly alone.