Abstract
Aims and objectives
To explore the value of using Karl Jaspers’ lived experience concept of ‘grasping’ in remediating the reported dauntingness of formulation.
Conclusions
Formulation can be construed as both the process and explication of understanding why a patient is presenting in a particular way. In an automatic process of abduction, ‘feeling into’ the mind of the other, hypotheses are posted to consciousness with little mental effort as meaningful connections are grasped. Subsequent more deliberative reasoning is synthesised continuously and with surprisingly little mental effort into the best explanation(s). Karl Jaspers’ introduction to Psychiatry of the concepts involved, empathy and understanding, and his aim of making their use more scientific established the ongoing, often fierce debate about the ontology of Psychiatry; empirical versus interpretive. Trainees must resolve this for themselves in explicating a formulation, risking exposure of their prejudices. Jaspers’ emphasis on the lived experience of empathic understanding that psychiatrists bring to their work found him often using the term ‘grasp’ rather than ‘empathise’. ‘Grasping’ seems to convey more vividly and meaningfully the role that empathy plays in the initial ascertainment of mood and the subsequent hypothesis discovery, testing and synthesis.
The need for formulation, answering the question, ‘Why is this person presenting in this way at this time?’,1,2 emerged as a corollary of the application of modernist humanist concepts to Psychiatry by Karl Jaspers and others at the turn of the 19th century. 3 Promoting the subjective concepts of empathy and understanding challenged Emil Kraepelin’s promissory materialist paradigm, firmly establishing the ongoing debate about the ontology of Psychiatry; that of empiricism versus interpretation and explanation versus understanding. 4
Jaspers 5 aimed at achieving a broader ‘scientific psychology’ within the eco-sociological paradigm of holism promoted by systems theorists. He argued that the vague understanding of another person reached only in a personal and subjective way through the special attitudes and aptitudes of the particular observer is insufficient for a scientific psychology. This application of a folk psychology paradigm is seen when clinicians declare sympathy for the patient’s suffering and uncritically reassure them of being understood6,p97. Jaspers acknowledged the importance of the affective ‘declarative’ aspect but focussed on refining the more cognitive aspects; the detection of meaningful connections of mental experiences as the basis of understanding. The search for a fully conscious understanding of such mental processes is unresolved, 7 arguably contributing to the dauntingness experienced by clinicians otherwise sympathetic to the importance of subjective phenomena.8,1,2
The divergent emphasis on affective and cognitive aspects of empathy reflects its conceptual history. 9 The cognitive focus comes from 19th century German philosophers’ concept of Einfühlung; grasping automatically, with little mental effort, the liveliness of texts and minds, particularly in social interaction. 9 It was developed in Phenomenology as hermeneutics, the art of interpretation. 9 Hermeneutics reflects Jaspers’ holistic approach. It describes how hypothesis discovery about particulars must be explored and integrated in a circular process of integration towards best and most meaningful explanations.9,7 Contemporaneously with Jaspers, the American pragmatist philosopher, Charles Peirce, addressed the cognitive grasping aspect. 10 He emphasised the role of the ‘guessing instinct’ in the phase of abduction; hypothesis discovery. Hypotheses grasped are tested in the deliberative inferential phase of deduction and induction, leading to more valid explanations. 10 Peirce and Jaspers thus revived the debate about the status of subjective data that began after Homer described Odysseus’ use of nous, the ‘eye of the soul’ as Plato called it, to comprehend immediately what was going on. 1
The affective stream of empathy, of grasping the emotional state of the other, was also first apparent in Homer’s Odyssey, as ‘pity’. In the century of Enlightenment, the closely linked terms of compassion, sympathy and fellow-feeling were used by thinkers such as Adam Smith in a blended model of affective empathy similar to that of the 20th century folk psychology concept. 6
Grasping
Jaspers used the everyday language metaphor of ‘grasping’ often in writing about understanding. ‘Grasping’, in my experience, seems a less daunting concept to trainees, for whom it is at play in their daily life. We say that something has dawned upon us; the ‘aha’ experience. In most encounters, we grasp quickly how the other is. As they speak, we may find ourselves listening for meaningful connections that would help us understand how they come to be this way, and how they might be helped to feel understood, ‘recognised’ in the parlance of Critical Theory. The concept of grasping appears in literature familiar to trainees, that of Clinical Reasoning, where it is described as Type 1 processing.11,12,2
An Oxford English Dictionary (OED) definition of ‘grasp’; ‘To lay hold of with the mind; to become completely cognizant of or acquainted with; to comprehend’ 13 conveys the certainty of a comprehensive grasping. The epistemology of grasping is dealt with under the rubric of empathy and intuition in the extensive literature on those topics. Two overlapping and self-explanatory strands of conceptualisation are seen; ‘Theory Theory’ and ‘Simulation Theory’. 14 The overarching concept, as Peirce implied, is that of ‘synthesis’. 15
Jaspers’ concept of grasping
Jaspers identified grasping when he defined subjective symptoms as those that ‘cannot be perceived by the sense-organs, but have to be grasped by transferring oneself, so to say, into the other individual’s psyche; that is, by empathy. They can only become an inner reality for the observer by his participating in the other person’s experiences, not by any intellectual effort’5,p1313. Jaspers emphasised that grasping is done by a lived body, a key premise of later phenomenological philosophers including Merleau-Ponty. 16
Jaspers further refined the ontology of grasping when differentiating types of understanding. Grasping immediately from objective clues, such as facial expression, the emotional state of the patient is part of ‘phenomenological analysis’5,p1317 producing ‘static understanding’5,p1322. Jaspers describes how, as the clinical encounter proceeds, ‘static understanding’ is complemented by ‘genetic understanding’5,p1322. This begins with ‘empathic understanding’5,p1317; grasping of meaningful connections, captured by an OED definition of understanding; ‘To grasp the meaning or purport of the words (or signs) used by (a person)’. 17 Jaspers described this cognitive phase as reflective. He noted the more deliberative blending of ‘empathic’ and ‘intellectual’ understanding5,p1313 in what Reasoning Theory refers to as Type 2 processing. 12 Evans 12 provides a nuanced discussion of the debate about the difficulty of explicating what goes on in the thinker’s mind during this reflective stage.
Application of concepts
Jaspers emphasised the need for various approaches to examining subjective data. Jaspers provided incisive principles of interviewing, epitomised by the instruction to pay attention to the ‘first impression’, which is ‘unrepeatable, immediate, unique and sometimes gives a feeling of something that is only confirmed a good deal later on’18,p826, and to the stimulus exerted on the clinician by the patient and the presenting phenomena18,p825. Jaspers argued that the state of our own mental representations of lived experience, including those of culture and education, determines our ability to feel into another’s psyche5,18,pp53-57. Nevertheless, the concept of Complementary Cognition would predict that some people would have limited capacity for such empathy; in Psychiatry there will be some for whom their mental structure makes this so. 8
Jaspers argued that reliability of what is grasped is established in the same way as in the natural sciences; by comparison, repetition and verification5,p1317. Drawing on emerging systems theories1,pp140-143, he pointed out that there is uncertainty in both fields; the difference is in degree.
Adolf Meyer (1866–1950), the influential German-trained USA psychiatrist, also described working with patients to establish causal relationships, as he sought a single theoretical framework to unify the human and natural sciences in his ‘Commonsense Psychiatry’. 19 Meyer broadened Kraepelin’s descriptive psychiatry interview into the biopsychosocial one that we use today, a derivative form largely established through Meyer’s training of early Maudsley Hospital staff. 19 George Engel’s case histories of application of the biopsychosocial model follow Meyer’s influence in finding meaningful connections1,pp130-133.
Grasping and formulation
Formulation is a process of abductive reasoning that begins at the moment of first encounter. 2 The clinician grasps immediately, with little mental effort and from objective clues, an idea about how the patient ‘is’, particularly their mood. This Type 1 processing continues throughout the encounter, underpinning and shaping the Type 2 process of deliberative seeking of data, theory, deduction and reflection that lead to the best explanation(s). Type 1 processes post to consciousness automatically and convincingly the meaningful connections of psychic experiences grasped. The clinician comes to a synthesised understanding of why this person is presenting in this way at this time. It is a judgement that began with little mental effort and emerged as hypotheses that require testing but are often right. Trainees seem to find daunting the challenge of how to capture this process as a product; a spoken and written account, the ‘formulation’. Encouraging trainees to reflect on the encounter from the moment of first contact helps, as George Engel demonstrated. The patient and carer have been using the same processes, drawing on their lived experience. The clinician is better at it, but acknowledgement of the shared processes helps facilitates their involvement.
Footnotes
Acknowledgements
Discussions with Tra-ill Dowie and Jocelyn Dunphy-Blomfield are much appreciated.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical approval
Approval not needed because of the study type or article type. This article does not contain any studies with human or animal participants. There are no human participants in this article and informed consent is not applicable.
