Between phenomenological and community psychiatry: the Comprehending Anthropology of Jürg Zutt

Introduction

The name of Jürg Zutt (1893–1980) is associated with anthropological psychiatry, which comprises phenomenological and existential philosophy approaches to mental illness (Berrios, 1992: 309). Since the 1950s, these concepts have had great influence on psychiatric research and theory in European psychiatry (Tellenbach, 1979). Important contributions to the field were made by authors such as Ludwig Binswanger (1881–1966), Victor von Gebsattel (1883–1976), Erwin Straus (1891–1975) and Wolfgang Blankenburg (1928–2002), and also by Zutt when he was Professor of Psychiatry at University Hospital Frankfurt from 1950 to 1963. However, little is known about the effects that anthropological psychiatry may have had on psychiatric care and services, and especially what impact it may have had upon the reform movement of German psychiatry and public health services during the 1960s.

The present paper is the first systematic investigation of Zutt in the recent history of German psychiatry. Interestingly, his work on what he termed ‘Comprehending Anthropology’ was published only a decade before the reform movement of psychiatric services in Germany. Based on this observation, the association between anthropological psychiatry and the reform movement of German psychiatry during the 1960s will be examined. Since both anthropological psychiatry and social psychiatry are based on a person-centred approach, it was hypothesized that common roots are to be detected in what is called humanistic psychology. However, while the anthropological psychiatry derived from the philosophical concept of phenomenology in the tradition of Husserl, social psychiatry was closely related to the social and political changes in Western post-war Germany. Therefore, it was assumed that anthropological psychiatry and social psychiatry may share common features, but had distinct conceptual and historical origins.

Roots in neurology and psychology

Zutt was born in Karlsruhe on 28 June 1893, the son of the lawyer Adolf Zutt and his wife Ida (Schönknecht, 1999). He passed his baccalaureate in 1911 and in the same year he went to the Medical School in Freiburg im Breisgau. However, Zutt had to interrupt his studies during World War I when he served as a lieutenant in the reserve. When the war was over he continued Medical School, passing his final examination in 1920. Some months later, he graduated as a medical doctor. After his first appointment as junior registrar in medicine at St Urban Hospital Berlin, Zutt became an assistant to Karl Bonhoeffer (1868–1948), Professor of Psychiatry and head of the University Hospital for Nervous Disorders at the Charité in Berlin. ¹ During this time, 1920–37, Bonhoeffer was the teacher and scientist who had most influence on Zutt as a doctor and lecturer. Zutt later wrote, in the preface of his collected papers:

It is difficult to consider all I have to thank [Professor] Bonhoeffer for. Certainly, he provided the important elements of my early psychiatric and neurological experience which are the basis of my clinical knowledge. Surely, he inspired the opinion of what clinical science can be: the non-dogmatic liberty of asking and the requirement that every scientific hypothesis has to be proved in practice and against its critics. (Zutt, 1963b: iv) ²

The clinical practice of the hospital was characterized by Bonhoeffer’s guiding manner of dealing with patients who required respectful and dignified care. This applied both to scientific considerations and clinical decisions in which the patient had to be regarded as an individual rather than a clinical case (Scheller, 1960). Caspar Kulenkampff (1921–2002), stepson of Zutt, ³ emphasized that Bonhoeffer might have influenced Zutt in his way of dealing with patients more than in other areas. ⁴ There are no hints that Bonhoeffer initiated or contributed to any issue in the field of anthropological psychiatry. Nevertheless, his clinical and theoretical frameworks were certainly compatible with the ideas Zutt developed in his later work.

One of Zutt’s first scientific publications was the paper ‘The question of an association between homosexuality and body build’, published with Mair in 1922 (Zutt and Mair, 1922). In this study, undertaken at the University Hospital at the Charité, the authors disproved a study by Weil (1921) who had argued that the specific constitution of homosexuals is expressed in their body shape. In addition to his employment as a registrar, Zutt was trained in psychoanalytic therapy with Karl Abraham (1877–1925) who was the head of the Berlin Psychoanalytic Society. ⁵ From 1922 to 1923 Zutt worked in Zürich as an unpaid assistant (Volontärassistent) to Eugen Bleuler (1857–1939) at the Zürich University Hospital for Nervous Disorders. While in Zürich, Zutt published ‘Remarks on the amount of sediment rate of red blood cells in the mentally ill, especially in schizophrenia’ (Zutt and Glaus, 1923), which showed that the sediment rate is higher in catatonia and organic psychosis than in other schizophrenic disorders. By this time, Zutt had already come to the view that schizophrenia comprises different syndromes rather than a single entity.

When he returned to Berlin, Zutt became a lecturer at the University Hospital. The atmosphere at the Charité supported neurological-psychological concerns since psychiatrists such as Erwin Straus and Victor von Gebsattel contributed equally to progress in psychiatry and neurology (Gebsattel, 1954; Straus, 1935). A conference in Danzig in 1928 included a session entitled ‘Affectivity, emotion and inner perspective’, a psychological theme that would be a central issue of Comprehending Anthropology. According to Zutt the term ‘inner perspective’ (innere Haltung) reflects the mental representation of voluntary actions and corresponds to a modern-day notion of intersubjectivity. The introduction of the concept of inner perspective to psychopathology coincided with a review of the psychological term of affectivity which until then had not differentiated between emotion and inner perspective. Zutt (1929) published a major paper concerning this topic entitled ‘The inner perspective: a psychological investigation and its impact on psychopathology especially in schizophrenic disorders’. Although this paper was based on a dualistic theory of a body-mind differentiation which did not correspond to phenomenology, the notion of inner perspective is an important element of later work on Comprehending Anthropology.

In 1928 Erwin Straus, Willy Mayer-Gross (1889–1961), Karl Hansen (1893–1962), Kurt Beringer (1893–1949) and Zutt founded Der Nervenarzt, a monthly journal for all fields of psychiatric and neurological practice, including psychosomatic interactions. To this day, Nervenarzt has remained the leading German-language neurological-psychiatric journal and is the official organ of the German Society for Psychiatry and Psychotherapy (DGPPN). In 1931 Zutt presented his post-doctoral qualification on ‘Right-left-disorder, constructive apraxia, and pure agraphia’ to the medical faculty of the Friedrich Wilhelm University in Berlin (Zutt, 1932). ⁶ This work focused on the differentiation between constructive praxis and automatism during body movement. Zutt hypothesized that each perception requires an active mental state which is not similar to the perception itself. Another paper, published with Karl Bonhoeffer in 1934 and noted for its potential political impact, was the court report ‘On the mental state of the Reichstag arsonist, Marinus van der Lubbe’ (Bonhoeffer and Zutt, 1934). This report characterizes van der Lubbe with subsyndromal personality traits which did not reach manifest personality disorder.

In October 1934, Zutt became a senior registrar and, finally, in 1936 he received an appointment as a senior lecturer at the Charité. Clearly, in the 1930s Zutt was already aware of the importance of psychological and social factors in the aetiology of psychiatric disorders, not just biological causes. This was during the most difficult period for German psychiatry under the Nazi regime. An example of Zutt’s thinking was his talk at the Second Congress on Hereditary Biology, when he considered the question of heredity in alcoholism. Zutt took the position that alcoholism is due to a broad spectrum of risk factors which may range from endogenous causes to social surroundings (Zutt, 1936). He emphasized that assumptions about the hereditary load of individuals have to be set against the influence of personal and living circumstances. With this, Zutt argued against the prevailing opinion that psychiatric symptoms may in most cases be due to genetic aberrations.

At the end of the 1930s, Zutt could look back on a successful lectureship and a considerable number of publications in the field of psychiatry and neurology. Accordingly, he might have been appointed to a chair, but the political situation in Germany at this time prevented this final step in his career. He commented later: ‘There was no chance of any appointment appropriate to the level of my qualifications because I decided not to join the NSDAP, ⁷ the government party of the German Nazis, but party membership would have been necessary to receive any appointment.’ ⁸ Zutt had been considered for the chairs at the universities of Königsberg and Prague, but was rejected for this reason. Finally, on the recommendation of Bonhoeffer, Zutt was appointed head of the Kuranstalten Westend, a private Berlin hospital.

In October 1939, Zutt was nominated as Honorary Professor; however, there was increasing resistance in the medical faculty. The political situation at Friedrich Wilhelm University Berlin is documented in a letter from the rector to the Minister for Science, Culture and Education which refers to the controversial nomination of Zutt. The rector wrote:

Please find enclosed the application of the medical faculty from 26.7.1939 for nomination of Prof. Dr. Georg Zutt as Honorary Professor. Since a rather formal transmission from senior lecturership to Honorary Professor is considered, I disregard any comments on the application of Professor Zutt which would have been negative following the remarks of the dean and the head of lecturers. ⁹

During World War II, Zutt could not avoid military service, and from 1936 to 1939 he was a surgeon-major in the reserve; at the beginning of the war in 1939, he was called up to the army. However, after only a few months serving in Berlin, he succeeded in being discharged to become Head of the Outpatients Department at the Charité. ¹⁰ From 1939 to 1945 he divided his time between the Kuranstalten Westend and the Charité.

At the end of the war, Zutt was appointed as temporary head of the Psychiatric and Neurological University Hospital at the Charité in Berlin, but he resigned in 1946. In a letter dated 17 Jan. 1946 to the dean of the medical faculty he explained that he had withdrawn because the schedule for his post included only five hours a week of academic time. However, Zutt had already applied for the chair at the University of Würzburg. The former head of the University Hospital, Werner Heyde (1902–64), had been dismissed after the war because of his involvement in the euthanasia of mentally ill patients during the Nazi regime. ¹¹ The head of the medical faculty in Würzburg, Heinrich Boening (1895–1960) was first nominated for the post, but he was withdrawn from consideration because he was also politically involved with the Nazis. ¹² Zutt was the second choice and in October 1946, he was appointed to the chair of Psychiatry and Neurology at the University of Würzburg. Zutt accepted the appointment, and completed his work as head of the Kurstanstalten Westend in late 1946. In the same year, he was also offered, but declined, an appointment to the University of Hamburg. At that time, each civil servant was investigated for evidence of previous support for or political involvement in the Nazi party, but Zutt was found to be clear of these taints (Spruchkammerentscheid). ¹³

During the Würzburg years, Zutt focused on psychotherapy and psychosomatics as disciplines of medical sciences, and he published a paper on the psychology of addiction. In this period he did not produce a systematic analysis of philosophical or sociological issues in psychiatry, but he used his broad experience in neurology and psychoanalysis to consider principles of impaired intersubjectivity in psychosis and to keep abreast of recent developments in phenomenology.

Comprehending Anthropology: between science and humanities

In 1950 Zutt was appointed to the chair of Psychiatry and Neurology at the University of Frankfurt am Main. His predecessor, Karl Kleist (1879–1960), had established a modern clinic characterized by a variety of innovative therapies including occupational therapy. ¹⁴ But when Zutt arrived in Frankfurt, there was an opportunity for a further renewal of the department. He negotiated with the city of Frankfurt, the hosts of the university, three specialist training posts, support for the development of a neurosurgery department including a chair of Neurosurgery, and a six-room apartment as his living quarters. ¹⁵ It is noteworthy that Zutt made it a condition of his own appointment that a Professor of Neurosurgery should be appointed to his department, which indicates that he was concerned with developments in neuroscience.

Zutt himself characterized his talk at the 1953 meeting of the Society of German Neurologists and Psychiatrists in Munich as a turning point. He criticized the guidelines of clinical psychiatry at the time, in contrast to anthropological considerations (Zutt, 1954a: 342). He also referred to the clinical impact of phenomena such as trust, distrust, safety, and anxiety (Zutt, 1954b). As a representative of German post-war psychiatry, Zutt became well known among neurologists and psychiatrists when he was elected as the president of the German Society of Psychiatrists and Neurologists (the successor to the German Association for Psychiatry) in 1954.

In the 1950s, German psychiatry was much influenced by what might be called the South-West German phenomenological-anthropological tradition (südwestdeutsche phänomenologisch-anthropologische Schule) (Seidel, 1990); as well as Zutt, lecturers and professors such as Hans Ruffin (1902–79) in Freiburg im Breisgau and Walter Ritter von Baeyer (1904–87) were important (Janzarik, Viviani and Berrios, 1998). However, this tradition and the term ‘anthropological psychiatry’ go back much earlier to what was known as the ‘Wengener Kreis’, founded by Binswanger, von Gebsattel, Straus and Minkowski (Passie, 1995). In summary, German psychiatry at this time was influenced by various humanistic approaches to mental illness ranging from psychoanalysis to daseinsanalysis or existential philosophy (Binswanger, 1946; Blankenburg, 1978; Heidegger, 1954; Kulenkampff, 1955).

The work Zutt published in the 1950s and 1960s contains the major expositions of his Comprehending Anthropology (Zutt, 1953). After his ‘turning point’, he adopted an anthropological perspective on clinical psychiatry and psychology. At the 70th meeting of the Association of Neurologists and Psychiatrists for South-West Germany in Baden-Baden in 1955, Zutt presented a lecture entitled ‘The life-course (Lebensweg) as metaphor of a person’s history: comments on life-crises’, which emphasized the personal history of patients as a major category in anthropological psychiatry. In 1955, during the congress of Bavarian psychiatrists which took place in Würzburg, he challenged Gruhle (1880–1958) who argued that psychiatry has to refer to empirical data whereas humanities are based on ethics. Zutt took the position that any research required a theory before empirical data might be considered. In his view, Gruhle’s differentiation between empirical science and non-empirical humanities was simply a non-empirical and rather antiquated assumption.

Another important contribution to anthropological psychiatry was made during the symposium ‘The paranoid syndrome from an anthropological perspective’, chaired by Zutt and Kulenkampff at the 2nd International Congress for Psychiatry in Zurich in 1957. Being aware of the potential misinterpretation of the term ‘anthropological psychiatry’, ¹⁶ Zutt explained:

It is something relatively new in psychiatry. One may assume that we consider psychosis as psychogenic disorders, and that we do not consider anatomical and physiological causation. This is a misunderstanding … Anatomy and physiology remain two major basics of psychiatry. But we think that the phenomena traditional psychiatry cannot understand in logical terms have to be considered by using other approaches. (Zutt and Kulenkampff, 1958: 1)

During this time, Zutt produced several publications focusing on an anthropological interpretation of clinical phenomena. His paper ‘On the bearing body’ (Zutt, 1958) identified two basic ways of being that are associated with the appearance and the ‘being-born’ (tragende Leib) nature of man. In ‘On the anthropology of the vegetative’ (Zutt, 1960), the existence of circadian rhythms and affective constitution in man indicate his basic attachment to nature and biology.

In 1961 Zutt was again elected President of the Association of German Psychiatrists and Neurologists. In October 1961, Zutt officially retired as Professor of Psychiatry and Neurology but acted in this position until his successor was appointed to the chair in March 1964. Zutt died, aged 87, on 13 Nov. 1980. His grave is in Fischbachtal-Niedernhausen in the Odenwald where he had spent holidays during his lifetime.

Understanding psychosis – the concept of Comprehending Anthropology

The basic principles of what Zutt referred to as Comprehending Anthropology are summarized in the publication ‘On Comprehending Anthropology: efforts to ground psychiatric experience in anthropology’ (Zutt, 1963a). Moreover, the collected papers, ‘Towards an anthropological psychiatry’ (Zutt, 1963b), comprise an elaborated conclusion of the anthropological characteristics of mental disorders. Before demonstrating the major assumptions of his theory and its implications for clinical psychiatry, we should reflect on the historical background against which Zutt developed his ideas. On the one hand, biological psychiatry had progressed with respect to pharmacotherapy as an effective treatment option and, on the other, social sciences questioned psychiatry as a medical discipline. Alongside these competing approaches, integrative concepts such as the biopsychosocial model of vulnerability arose (Zubin and Spring, 1977). Although anthropological psychiatry was inspired by phenomenology as a philosophical concept, it shared with the biopsychosocial model several common features of humanistic psychology. In my view, both concepts tried to characterize the individual modification of mental diseases such as psychosis after the illness has emerged. Both concepts are compatible with the biological basis of psychosis and regard most cases of psychosis as arising from a combination of biological vulnerability exposed by psychosocial stressors.

However, there are differences between the psychiatry of Comprehending Anthropology and the biopsychosocial model, which arise from their conceptual basis. While the vulnerability concept describes various different influences on an emerging psychosis ranging from biological vulnerability to social stressors, Comprehending Anthropology provides a psychological perspective of the psychotic experience during each stage.

Zutt’s Comprehending Anthropology is based on the assumption that even in a pre-reflective condition, man is able to perceive his own appearance and the relation of this appearance to others (Zutt, 1963a). In this description, Comprehending Anthropology is concerned with intersubjectivity and its disturbances in schizophrenia as revisited in the recent past (Parnas, Bovet and Zahavi, 2002). According to Zutt, pre-reflective living includes two basic states of being. On the one hand, there is the being of the voluntarily movable, apparent body and, on the other hand, the being of the involuntarily movable, bearing body. The being of the voluntarily movable, apparent body reveals the aesthetic scope of experience, meaning a scope of appearances; while the being of the involuntarily movable, bearing body opens to the affective-vegetative scope of emotions and feelings (Zutt, 1963a).

Moreover, man is referred to the aesthetic scope of experience by something that Zutt called the ‘horizontal stand’ (horizontaler Stand) (Zutt, 1955). A horizontal stand goes with order and security. In contrast, within the affective-vegetative scope of experience, man achieves a ‘vertical stand’ that underlies the involuntary motions, the rhythm of emotions and feelings and vegetative processes. Zutt argues that a disintegration of the horizontal stand is associated with psychopathological changes, such as those described in schizophrenic psychosis (Zutt, 1963a). Thus, a delusion reveals a loss of standing that involves a characteristic change in appearances in the sense of losing one’s borders and becoming overwhelmed. With the loss of horizontal stand, a person’s sense of order and their sense of safety in terms of distance from external perceptions or threats are destabilized. In contrast, a loss of vertical stand leads to a drying-up of feelings and emotions as described in affective psychosis.

Comprehending Anthropology exemplifies the anthropological approach, because it draws attention to the specific relationship between the subject and his or her experience, for example in the context of psychotic disorders. In Comprehending Anthropology, this relationship is elaborated by the notion of ‘stand’, which expresses the simultaneity of experiencing and of demarcation of experience (Zutt, 1963a). The clinical relevance of a ‘loss of stand’ refers to the uncontrolled penetration of strange and alien appearances leading to experiences which are described psychopathologically as delusions (Zutt and Straus, 1963).

Therapeutic concerns about the loss of trust are highly relevant in paranoid psychosis. Specific experiences may have a profound influence on the therapeutic alliance, as a result of structural changes within the patient’s experiences and mental state. Zutt argues that in paranoid schizophrenia the loss of horizontal stand is associated with a loss of trust, because the patient cannot be sure of order and security in view of what appears to him as his body, and in view of the distortions in the appearance of others. Alienation seems to penetrate the scope of experience and to dominate the schizophrenic patient. Zutt considered that the acceptance and empathy shown to the patient by the therapist will enable him to experience confidence again in time. Zutt emphasizes that first the therapist trusts in the patient, then the patient gets an impression of very intense social contact that he has not experienced for a long time; finally he learns to trust again as he is taught to have control in situations where order and safety are provided. With the confidence acquired by this, delusions should be limited. It should be noted that in Comprehending Anthropology the building of confidence is not discussed in ethical terms, but reflects an adaptation process, in which giving confidence could result in a structural alteration of experiencing.

The therapeutic concerns of Comprehending Anthropology derive not only from the phenomenon of loss of trust but also reflect an experience-dependent alteration of mental structure. Biological evidence of the effects of non-pharmacological intervention was not available in Zutt’s time. But in recent years, the findings of neurobiological studies have demonstrated a dialectic relationship between experience and cognition. Zutt would have regarded symptoms such as delusions, thought extraction or thought insertion not solely as malfunctions of thinking, but more as a specific way of experiencing and self-perception.

However, this anthropological view has come under pressure from studies that have employed a formal analysis of thinking, influenced by transcendental philosophy. For example, Spitzer (1988) showed how transcendental philosophy can be applied as a conceptual framework to make sense of the patient’s disturbed self-experience, disturbed capacity to differentiate between me and not-me, and his experience of fragmented identity. Spitzer (1988) suggested that the term ‘transcendental’, which derives from the work of Kant, ‘refers to something to which one has to refer to before experience takes place, something dealing with the possibility of any experience’. Thus it has something to do with conditions of the possibility of any kind of experience (emphasis added). Experience is always an experience of something; there is normally a unity of experience, and also an experience of time, so identity of experiencing a subject throughout their different experiences is a transcendental feature relevant to psychopathology. However, this feature may be altered in schizophrenia. If there is such a fundamental disturbance of a condition of the possibility of experience, then something that we call ‘experience’ will no longer be possible. Symptoms such as thought extraction and thought insertion are good examples of this disturbance of experiencing. When schizophrenic patients speak about what they experience, their description often consists of metaphors that may be misleading. But these patients do not have a referential framework to describe the changed way of experiencing without using metaphors in their attempts to do so. Similarly, if clinicians do not use such a theory, they will not be able to see that what patients report are metaphors. Finally, this kind of analysis demonstrates that schizophrenic symptoms need to be understood on the basis of some kind of theory that considers, first, what has happened to the formal structure of experiencing, and second, what is this experiencing like. If the structure of experiencing has changed, this has obvious implications for communicating with the patient. However, in a formal analysis, and often in clinical practice too, this second point is not taken into consideration sufficiently. In contrast to this, phenomenological (and anthropological) psychiatry tries to understand symptoms and reflects on what kind of communication is most appropriate.

Comprehending Anthropology and the reform of mental health services

In the 1950s, Zutt considered more and more the relevance of Comprehending Anthropology for clinical practice. When Zutt wanted to establish close links between the psychiatric departments and the local general hospital, he often emphasized the advantages of university hospitals in providing specialist treatment for the mentally ill among other medical specialties. Likewise, Zutt hoped that the reintegration of psychiatric patients might be accelerated by the University Hospital, which would always be located within the community: ‘… do not found new asylums or even enlarge the asylums we have but … establish modern psychiatric-neurological services in the general hospitals’ (Zutt, 1956).

Zutt emphasized that these aspects are not antagonistic to biological psychiatry but instead they help to complete the spectrum of mental health. He provided the guidelines of anthropological psychiatry, which began to demonstrate the need for a change of psychiatric services throughout Germany. In the 1950s, Zutt wrote on practical requirements for services that should conform with anthropological knowledge. By doing this, he started to demonstrate a kind of theoretical framework of what modern psychiatry could be. One of his major concerns was the reintegration of the mentally ill who had been treated in asylums outside local communities. Instead, social and medical services should contact patients from the first episode onwards, though a range of treatment options would be needed depending on the severity of the condition. Since the daycare services were not sufficiently adapted to the patient’s requirements, Zutt (1962) supported day and night clinics and complete outpatient services as an alternative.

As head of the University Hospital of Psychiatry and Neurology in Frankfurt am Main, Zutt had the chance to realize some of his ambitious ideas. He made changes in his department so that it became one of the most modern neurological-psychiatric units in Germany at the time. More relevant for the history of contemporary psychiatry is the fact that Zutt founded the first psychiatric day hospital in Germany in 1959. This ward started when Kulenkampff established an outpatient department where the patients stayed overnight but were at work during the day. Over the next few years, he enlarged the ward up to 20 beds in 1962, and later he established a combined day and night hospital with 36 places. Since he could not adopt modern structures of mental health services from practice in Germany, Kulenkampff adapted the model of day and night hospitals from a regional social psychiatric service in Paris.

Kulenkampff was a senior lecturer in Frankfurt when he headed the Section for Social Psychiatry under Zutt. He initiated not only the first day-hospital service mentioned above but also set up a political reform of German mental health (Kulenkampff and Picard, 1989). In 1967 he left Frankfurt and took the chair of Psychiatry at the University of Düsseldorf. In contrast to Frankfurt, there was no attempt to reform in Düsseldorf at that time, so from his academic position Kulenkampff was unable to realize his idea of a complete reform of mental health services. In contrast to Zutt, who did not renounce his clinical and academic career, Kulenkampff quickly left his chair to concentrate on political work. As a member of the German social-democratic party (SPD) he became deputy for psychiatry in the Rhineland. His position allowed him to initiate structural changes in the mental health services. His appointment as director of the commission of inquiry by the lower house of the Federal Parliament was probably the challenge Kulenkampff had sought since the early 1960s. This commission really initiated the reform of mental health services in Germany. In his political role, Kulenkampff referred to his medical and scientific experience to combine theoretical knowledge and practical issues of modern psychiatry (Kulenkampff, 1962). There were many conflicting positions in the debate between academic psychiatric services and local asylums, and the different methods in psychotherapy. However, Kulenkampff achieved an agreement on the new structure of psychiatric services, which comprised local community-centred out-patient clinics rather than asylums in remote locations. He retired in 1988 but his colleagues and collaborators continued his work in Frankfurt am Main.

Despite his connection to Zutt, it cannot however be concluded that the reform of psychiatric services by Kulenkampff was solely inspired by anthropological psychiatry. Although there are some papers by Zutt on how psychiatric services and therapies should change in order to give better provision for the patient’s needs, it was the engagement of many others, including Kulenkampff, that made the reform of psychiatric services in Germany possible. Nevertheless, it was Zutt who supported Kulenkampff in opening the first psychiatric day hospital in the country. Since both anthropological psychiatry and social psychiatry are based on a person-centred approach, common roots are to be detected in what is called humanistic psychology. However, while Comprehending Anthropology derived from the philosophical concept of phenomenology in the tradition of Husserl, social psychiatry was closely related to the sociological and political issues in Western post-war Germany.

Interestingly, although social theories did not rely on the concept of Comprehending Anthropology, medical psychology and cognitive neuroscience have tried to understand the symptoms of mental illness. Thus they have gone beyond social or political considerations towards meeting Zutt’s intention. One example of these approaches is ecological psychotherapy, which is based on the philosophy of encounter (Willi, Toygar-Zurmühle and Frei, 1999). It proceeds from the assumption that man cannot develop by himself but is always in need of his relationships to others that then challenge his personality. In ecological psychotherapy, the relationship of a person to his environment is simultaneously the result and the starting-point of his later life. Ecological psychotherapy applies to man the thesis of behavioural ecology: that organisms are engaged in developing relationships to their surroundings and in using them efficiently. To describe the active self-experienced creation of one’s environment, the term ‘replied functioning’ is used. Self-esteem and identity, and the whole personality development, are closely related to replied functioning. Also borrowed from behavioural ecology is the notion of a ‘personal niche’, which represents the whole of a person’s relationships.

Another recent example of how we understand the actions of others is that of mirror neuron system activation. Cognitive neuroscience has revealed a growing body of evidence that mirror neurons allow us to develop intersubjectivity (Rizzolatti and Craighero, 2004). This way that we respond to the actions of others is something that was fundamental to the ideas of Comprehending Anthropology.

Conclusion

Wolfgang Blankenburg (1980) argued that the search for an approach adequate to the mentally ill is representative of any anthropological psychiatry. Most anthropological theories arise from philosophical assumptions about the human being and the nature of mental illness (Langenbach, 1995). Unlike descriptive psychopathology, anthropological psychiatry went further and attempted to understand what a symptom represents in the patient’s experience (Walker, 1993). To this concern, notions such as Daseinsverlust, loss of stand and debordering gave an impression of what experiences psychotic patients are living with, which could not be provided by a sociological theory (Baeyer, 1963). Recent neurobiological research has started to identify the mechanisms underlying the experiences of the subjects and their neural correlates. As a result, clinical psychiatry today is concerned with biological, psychological and philosophical aspects of mental illness.

As a major finding, the present paper reveals a strong relationship between the concept of Comprehending Anthropology and the biopsychosocial model upon which social psychiatry is based. However, it cannot be concluded from my findings that the reform of psychiatric services in Germany resulted directly from the anthropological approach. The reform was, instead, a result of practical issues within psychiatric services and was driven by the need for humane medical treatment by an enlightened public after World War II in Germany. Nevertheless, we may conclude that anthropological psychiatry and social psychiatry share common features in their approach to mental health but must be distinguished by their conceptual and historical origins.