“The Case of Ellen West” (Der Fall Ellen West – Eine anthropologisch-klinische Studie) was published in 1944–1945 by the Swiss psychiatrist, Ludwig Binswanger.Footnote ¹ The case-history describes the life and illness of a young woman who lived at the beginning of the twentieth century and suffered from what would probably be diagnosed today as a combination of an eating disorder and a borderline-personality disorder. The patient's identity and several personal details were withheld; Ellen West is a pseudonym.

Ludwig Binswanger (1881–1966) was heir to a psychiatric dynasty and head of Bellevue, a private sanatorium established by his grandfather in 1857 in Kreuzlingen, near Lake Konstanz. Patients came to Bellevue from various European nations and most of them were wealthy and well-educated. They resided in private bedrooms, sometimes accompanied by family members, dined with the doctors in the plush hall, and enjoyed a rich recreational program. Ellen West came to Bellevue in the winter of 1921 after having endured several failed treatments, including two psychoanalyses. Three months later she was diagnosed as schizophrenic. After repeated suicidal threats, her husband was asked either to admit Ellen to the closed ward or to leave the institution with her. He chose the latter option; several days later she killed herself. More than twenty years after the event, Binswanger returned to his archives, chose the case-record of Ellen West, and composed what has come to be his most famous case-history.

In hindsight, “The Case of Ellen West” is considered to be the seminal text of Daseinsanalyse, Binswanger's attempt at synthesizing existential philosophy and psychotherapeutic practice. Trained as a psychiatrist under Eugen Bleuler at the Bürgholzli clinic in Zurich, Binswanger was an avid autodidact, communicating with many philosophers, such as Edmund Husserl, Ernst Cassirer, and Martin Buber, and incorporating their thought into his own psychotherapeutic theory.

Binswanger's Daseinsanalyse was part of a broader “phenomenological-existential” psychotherapeutic orientation that developed in central Europe during the first half of the twentieth century in response to dissatisfaction with the theoretical frameworks of psychiatry and psychoanalysis. The members of this movement – among them Medard Boss, Eugène Minkowski, Erwin Straus, and Roland Kuhn – questioned the possibility of capturing human existence by means of an objective-descriptive scientific theory. Moreover, such a theory was perceived as an impediment to the real holistic and intersubjective encounter that formed the basis of the therapeutic framework.

While Binswanger's earlier work was phenomenologically-oriented, Martin Heidegger's Sein und Zeit (1927) had a profound impact on the development of his Daseinsanalayse, which was most fully expressed in Grundformen und Erkenntnis menschlichen Daseins (Reference Binswanger, Max and Hans-Jürg1942). Thereafter, Binswanger turned to writing case-histories to demonstrate his theory, “The Case of Ellen West” being the first in a series of five cases that were eventually collected in Schizophrenie (Reference Boss and Lefebre1957).

The first part of the case-history (approximately a fourth of the entire essay) is a detailed depiction of Ellen West's life and the manifestation of her illness, while the rest of the text is devoted to an existential analysis of the case, as well as a discussion of general theoretical issues. Binswanger's main argument is that Ellen West's suicide was an authentic choice, in fact, that it was the only possible end of her existence. In addition, Binswanger strives to legitimize his diagnosis, and employs the case to demonstrate the theoretical framework of Daseinsanalyse, differentiating it from psychopathology and psychoanalysis.

The case-study uses Ellen West's diary excerpts, poems, and letters, which reveal her as an intelligent, educated, and insightful woman who was keenly aware of her conflictual existence and capable of expressing it lyrically. The texts span the time from her early childhood to her suicide at thirty-four, and illustrate her transformation from an ambitious adolescent to a frustrated and weary woman.

“The Case of Ellen West” has evoked strong emotional reactions from readers: grief for Ellen West and her anguish; anger at her therapists and family members who did not succeed in abating her misery or preventing her suicide; and condemnation of the socio-historical conditions that impeded women like Ellen West from leading self-fulfilling lives. These reactions may be found in the secondary literature, which tends to be charged with emotion to a degree that is extraordinary compared with other academic texts. Almost all the secondary literature challenges and seeks to undermine Binswanger's interpretative argument – his diagnosis of schizophrenia and his description of Ellen West's suicide as an authentic action. Rejecting Binswanger's interpretation, most of the literature depicts Ellen West as a victim. Thus, some authors place the responsibility for her suicide on Binswanger and the therapeutically-impotent psychiatry of the time. Others blame the dominant male figures in Ellen's life, particularly her father and husband, for imposing their own will, while constraining her independent aspirations. Even more generally, some accuse patriarchal society of oppressing Ellen West as a woman – an oppression manifested in the “pathology” that she developed.Footnote ²

This sometimes vehement criticism, however, is often accompanied by uneasiness, deriving from the fact that Binswanger's interpretation is repudiated despite the absence of raw data concerning Ellen West. In fact, some of the writers openly lament the lack of immediate information regarding the patient and the structure of the case-history that – with its emphasis on the theory of Daseinsanalyse – presents a fragmentary and edited version of the past, which hinders the proposal of alternative interpretations (see for example Lester Reference Lester1971, 251).

Indeed Binswanger's narrative of Ellen West's life, illness, and treatment includes many omissions, particularly when compared to the standard model for a case-history that usually includes (among other things) an account of the doctor-patient relationship and the therapeutic interventions undertaken. Naturally, some details were eliminated to preserve the anonymity of the patient, and the particulars that Binswanger chose from the wealth of available data were those that were pertinent to his thesis concerning the life and death of Ellen West. Paradoxically, it is precisely the richness of the case-history and the unusual abundance of resources upon which it relies that render the lacunae in Binswanger's narrative and his occasional silences more striking. Thus, the reader's curiosity may be aroused in the face of laconic descriptions or obvious omissions, particularly regarding Ellen West's stay in Binswanger's sanatorium in Kreuzlingen. How did the treatment proceed? What kind of therapeutic relationship did Binswanger and Ellen West develop? Moreover, Binswanger's abundant use of the patient's autobiographical material – copiously quoting from her diaries and letters – intensifies the reader's awareness that knowledge of Ellen West and her creative corpus is necessarily mediated by Binswanger's editorial choices.

Until recently, no outlet was readily available for these frustrations, as Ellen West's personal file from the Bellevue sanatorium is surprisingly and disappointingly insubstantial, containing neither Binswanger's notes regarding the patient's three-month treatment, nor Ellen West's autobiographical material that figures so prominently in the case-history. Fortunately, recently donated archival material compensates for this dearth.Footnote ³ The new archival material is extraordinarily rich, both quantitatively and qualitatively, granting immediate access to Ellen West's point of view, while shedding light and filling the voids in Binswanger's narrative.Footnote ⁴ The treatment in the Bellevue sanatorium is described from the vantage point of the patient (and her husband), and may be compared to the descriptions of her therapists. Indeed, there are other case-study texts that also document psychotherapeutic treatment from the viewpoint of the patient; however, these were usually written in retrospect, and in many cases, describe an (at least partially) successful treatment. Parallel documentation – of both doctor and patient – is extremely rare, particularly in the instance of a treatment that failed to cure the patient, and yet contributed to the development of the therapist's theory, and was deemed worthy of publication.

It is now possible to address (if not necessarily to answer in a straightforward manner) the question: “If we were able to know the complete circumstances surrounding Ellen West's life, what would our interpretation of the case be?” Indeed, the new archival sources reveal important data regarding Ellen West's life, illness, and treatment and resolve some of the enigmas posed by Binswanger's case-history. Moreover, the wealth and the historiographical characteristics of the material – i.e., the availability of different types of documents, written by different people, for different purposes – introduce new problematics and raise methodological questions about the potentialities and limitations of historical representation and interpretation.

In this paper, I will present some of the data that the new sources reveal concerning Ellen West's treatment in Kreuzlingen. This presentation will serve as a starting point to explore how Binswanger formulated the case-history using the various textual sources he had at his disposal. Thus, I will attempt to deconstruct and problematize the case-history, exposing it as a complex and heterogeneous artifact, made of interwoven stories, composed by multiple authors with varying intentions. Drawing out the different narrative strands, I will elucidate the way these strands interact to form the case-history. I do not claim that “the historical truth” resides in any one of these narrative strands, but rather that it is embodied in the textual interaction itself. Hence, I will not try to give an answer as to what “really happened” in Kreuzlingen, nor will I try to depict the authentic subjectivity or experience of Ellen West herself. Instead, I will focus on the different textual strands that constitute (sometimes conflicting) representations of this subjectivity and of the events that led up to her tragic death.

More generally, I will illuminate the constraints and limitations of attempts to represent a psychiatric patient – her life and death, her illness and therapy – and to bridge the theory and practice of psychotherapy via the genre of the case-history. “The Case of Ellen West” serves as a particularly pregnant example for elucidating broader methodological and epistemological concerns regarding the historical study of case-histories and the theoretical formulations of mental illness. My reading of this case-history represents an attempt to incorporate theoretical frameworks and conceptual structures that stress the inter-subjective or relational aspects of both the therapeutic encounter and the writing of history, and the assumption that both psychotherapist and historian are professional story-tellers. The characteristics of the story told by the therapist or historian, however, have been fiercely debated in both professions since the 1960s. What kind of a narrative is it? Is it created or discovered? Who are its author and audience? What is the narrative's purpose: to unveil a hidden truth about the past or to prepare the ground for future action? And what is its value: epistemological, ontological, or aesthetic?Footnote ⁵

* * * * * *

Ellen West arrived at the Bellevue sanatorium on January 14, 1921, to begin her treatment with Binswanger. Her first impressions were positive, and initially she expressed careful hopes for recovery. On January 18, she wrote to her parents:

Letters written to relatives indicate that Binswanger's treatment of Ellen West was spare, certainly less intensive than the two previous psychoanalyses. Binswanger's initial diagnosis was of melancholia, and his prognosis optimistic. Binswanger explained to Ellen that while psychoanalysis was sometimes valuable, he found that in cases of melancholia this method was useless, even harmful (Letters from 29 January 1920 and 11 February 1921, UAT 702/13, 500, 510). Instead, he prescribed a moderate combination of rest, baths, and strolls, and – estimating that treatment could go on for several months – warned Ellen West to remain patient. The rest of Binswanger's treatment amounted to two brief daily visits – thirty minutes long at most. In a letter to her parents from 16 February 1921, Ellen described to these visits. She wrote:

Thus, the treatment in Bellevue seems to have been limited temporally, distanced emotionally, and constituted of an eclectic mixture of psychiatric techniques. Moreover, there does not appear to be anything particularly existential about this therapeutic praxis.

In comparison to the rather cool therapeutic relationship described in Ellen's letters, a very warm relationship developed between Binswanger and Ellen's husband, Karl. In a letter to her mother-in-law, Ellen reported that Binswanger and Karl frequently played chamber music in Binswanger's private quarters; the husband playing the cello, Binswanger the piano. In the first letter sent to the husband after Ellen West's suicide, Binswanger referred to their musical interaction, noting that: “the first chapter of Beethoven's sonata, op. 5 no. 1, has gained a special meaning for me” (Letter from 12 April 1921, UAT 702/11,2). This correspondence was not unique; on the contrary – the two men continued to have an active written dialogue until 1961, that is, many years after the patient herself had died. The husband even visited Binswanger and his wife in Reference Binswanger and Max1935.

This extraordinarily warm relationship was made possible, in part, because Karl resided in the sanatorium during his wife's three-month hospitalization. This was unusual in the course of Ellen's illness, for both the first and the second psychoanalysts viewed the husband's presence as complicating, perhaps even hindering the treatment, and requested that he leave her for a certain time-period. Binswanger, on the other hand, not only assented to the husband's presence, but perceived it as enhancing the patient's condition.Footnote ⁹

The husband's eagerness to play an active role in the treatment administered to his wife (apparently not against her will) may be traced consistently throughout the decade of her illness. Thus, the husband wrote letters to doctors on behalf of his wife, functioning, as it were, as her legal guardian. He also requested that the attending physicians formulate a summary report upon her release, to be sent to him. However, Binswanger was the only doctor that actively encouraged this behavior. In fact, from the beginning of the treatment, the husband was present at almost all of Binswanger's daily visits. Moreover, from their initial encounter onwards, Binswanger met with Karl alone after seeing Ellen to discuss (or in his own words, “think aloud”) diagnostic, prognostic, and therapeutic possibilities, treating him as a colleague or a collaborator (Husband's diary entry from 18 January 1921, UAT 702/10,4).Footnote ¹⁰ This practice ensued throughout treatment, Binswanger being forthright, even blunt, with the husband, while ambiguous in his interactions with the patient herself. It is therefore the husband's detailed diaries that supply most of the information about Binswanger's clinical thoughts and actions. Indeed, in his first conversation with the husband, Binswanger was less resolute than he had appeared to Ellen West regarding diagnosis and prognosis:

In an attempt to finalize a diagnosis, Binswanger asked the patient and her husband to compose an anamnesis; i.e., an initial case-history. While according to Binswanger, working on her case-history visibly calmed Ellen West, her letters and diaries continued to express melancholic frustration, and she exhibited frequent mood-swings and severe suicidal intentions. In his diary, Karl described a non-atypical day:

As the danger of suicide became more acute, Binswanger continually warned the husband of the need to keep careful watch of Ellen. The option of commitment to the closed ward was considered, but in mid-February still deemed unnecessary (Husband's diary entries from 15 and 16 February 1921, UAT 702/10,5). However, as treatment continued to stall, and Karl informed Binswanger that his leave of absence was about to expire (which would make it necessary to leave Ellen in the sanatorium on her own), Binswanger pronounced the closed-ward compulsory, yet added pessimistically that “in case that Ellen should deteriorate, it would make no difference [gehupft wie gesprungen] whether [the husband] stayed” (Husband's diary entry from 27 February 1921, UAT 702/10,6).Footnote ¹¹

Interestingly, neither the case-record nor Ellen West's autobiographical material contains any indication of her wish to be admitted to the closed ward (as reported by Binswanger in the case-history), her mid-March visit there, or her impressions thereof. According to Binswanger's account: “Her visit to the locked wards has had a rather unfavorable effect. ‘I would want to smash in the solid panes immediately’” (Binswanger CEW, 264; Binswanger FEW, 101). However, there is no evidence of this statement in the archival material. In fact, her diary remains prominently silent between March 2 and March 17, so that the only details of the treatment proceedings are the ones provided by the husband's diary and Binswanger's case-history. From the former, it becomes clear that in this period, Binswanger began to experience doubts regarding his initial diagnosis and relatively hopeful prognosis. Already in the beginning of February, he had noted Ellen West's “dissociation,” and at the end of the month, admitted the lack of improvement in her condition. But it was only in mid-March that he pronounced a new diagnosis, telling the husband:

The following days Binswanger reiterated and even aggravated the diagnosis, saying on March 10 that “Ellen has been suffering for 4–5 years from an acute mental illness [. . .] of the paranoid type (his uncleFootnote ¹³ would say: psychosis of a degenerative basis)” (Husband's diary entry from 11 March 1921, UAT 702/10,6; emphasis in original). The next day he discussed at greater length three possible diagnostic categories with the husband. The first – manic-depression, which had been adopted by Ellen West's previous therapists – he resolutely rejected. The second – paranoia – he suggested tentatively, noting that while Ellen certainly manifested paranoid trends it was not a case of pure paranoia, “since behind paranoia lies the entire personality, whereas in this case there exists a splitting of the personality.” With that he came to the third diagnosis, which he presented as most plausible – schizophrenia (Husband's diary entry from 12 March 1921, UAT 702/10,7).

In order to ascertain his alternative diagnosis, Binswanger invited two colleagues – Eugen Bleuler and Alfred Hoche – for a consultation.Footnote ¹⁴ Bleuler was Binswanger's former teacher and the highest authority at the time with regard to schizophrenia, a fairly obvious choice. Why, however, did Binswanger choose Alfred Hoche, a psychiatry professor at Freiburg im Breisgau, who was not mentioned by name in the case-history, but merely designated as a “foreign psychiatrist”?

A possible answer might be found in the content of a text that Hoche published shortly before the consultation. In 1920, together with the jurist Karl Binding, Hoche published a short booklet, entitled “The permission to annihilate lives unworthy-of-being-lived” (Die Freigabe der Vernichtung lebensunwerten Leben), which advocated the euthanasia of terminally ill, but also of mentally disabled and mentally ill patients. To justify the annihilation of those they called “mentally dead” (geistig Tote), “empty human-shells” (leeren Menschenhülsen), or of “burdensome existence” (Ballastexistenz), Hoche and Binding appealed to cost-benefit reasoning, as well as to eugenic motivations (Binding and Hoche 1920, 51, 55). In hindsight, this booklet has frequently been seen as the theoretical and ethical text that prefigured and supported the Nazi mass-exterminations of the mentally retarded and ill, beginning in 1939 (Shorter Reference Shorter1997, 99).

It is highly probable that Ellen West and even more probably, her husband – who was a legal professional – were aware of Hoche's infamous ideology, as his text was widely-read. Especially relevant in this context is Hoche's comment that in the case of suicidal patients it is particularly tempting to “let fate take its course” (Binding and Hoche Reference Binding and Alfred1920, 49). Possible confirmation of the above hypothesis may be found in the fact that already in the week prior to the consultation, there appeared new tropes in Ellen West's writing, echoing Hoche's eugenic jargon. Thus, she wrote in the following (and last) diary entry:

In fact, it seems that even before the arrival of the doctors, the husband and Binswanger had come to view self-induced death as Ellen West's necessary fate. Thus as early as mid-February, the husband pondered his duty in preventing his wife's suicide, noting in his diary: “One tells me that this is a disease. Could be; but I can no longer stand her anguish and the unrelenting suffering. Do I have the right to hinder her, when I truly love her? The need to seriously confront myself with this question is terrible. Her suffering is immeasurable . . .” (Diary entry from 14 February 1921, UAT 702/10,5). Binswanger's response to this dilemma was very ambivalent, as he frequently relayed to the husband mixed or contrasting signals in the very same conversation.Footnote ¹⁵ In addition, there was Binswanger's stance regarding euthanasia, to which he did not seem (according to the husband) “to be opposed [. . .] in principle.”Footnote ¹⁶

Indeed, it seems that by mid-March a decision had been made, as the husband informed Binswanger that he and Ellen had “faithfully and mutually promised to help each other, when it can no longer go on,” and told him – apropos the upcoming consultation – that for “[his] soul a psychiatrist was no longer needed, only for [his] reason [Verstand]” (Husband's diary entries from 14 and 16 March 1921, UAT 702/10,7). Binswanger seemed to have accepted this decision. On March 21 the husband noted that Binswanger “is completely different [. . .] hardly opposes Ellen's [suicidal] assertions (discusses with me methods of death! Where should I bury her?).” The next day Binswanger told Ellen West herself that “this was not a life worth living,” and conceded that she was suffering “more than ever before” (Husband's diary entries from 21 and 22 March 1921, UAT 702/10,8). The husband's report of Ellen's remark – “she feels as someone who has been condemned to death; only it is she who has condemned herself to death, because she can no longer live like this” – may sound, in view of the involvement of others in this decision making process, rather ironic.Footnote ¹⁷

This was the premise of the consultation, and its result is known: Bleuler and Hoche concurred with Binswanger's prognosis, doubted “any therapeutic usefulness of commitment even more emphatically” than Binswanger, rejected any possibility of a “definitely reliable” therapy (sicher wirksame Behandlung), and implicitly assented to Ellen West's release from the sanatorium (Binswanger CEW, 266; Binswanger FEW, 104). All three agreed that it was not a case of obsessional neurosis or of manic-depressive psychosis, but of a more severe untreatable illness. After the doctors had pronounced their judgment of non-remediable madness Ellen West and her husband left the sanatorium for their home. Three days later, she took a lethal dose of poison, and died. She left several documents, which shed light on her last thoughts and on the circumstances of the suicide.Footnote ¹⁸ In her farewell letter to her husband, she described the suicide as “redemption” and instructed him with regard to burial arrangements and clothes, jewelry, pictures, and memorabilia that were to be distributed to family members and friends. Amongst her various doctors, she mentioned only Gebsattel, requesting that he be given something; no other doctor was mentioned in this context.

Gebsattel seems to have been the only therapist with whom Ellen achieved a real therapeutic alliance; however, the treatment, upon which the new archival material sheds much light, terminated in a traumatic manner. While beginning hopefully, the stalling of treatment frustrated Ellen and the inexperienced Gebattel, until both patient and therapist were on the brink of despair. In a letter to her husband, she described the unfolding drama: “Gebsattel himself is undergoing emotional things that may make the continuation of the analysis impossible. He has not lost faith in the [idea of] analysis, but has realized that it cannot be the final end, the final solution. PRECISELY THROUGH THE WORK WITH ME, it has become clear to him that there must be a way beyond analysis, which would bring us nearer to the primeval truth” (Letter from 8 April 1920, UAT 702/8; italics emphasis in original; my emphasis in upper case). Thus, the first psychoanalysis did not simply end “for external reasons” – as in Binswanger's laconic account – but in rather catastrophic circumstances: Ellen West had to come to terms with Gebsattel's assertion that it was precisely her case that made him lose faith in the therapeutic effectiveness of psychoanalysis.

Three days after the suicide, the husband wrote Binswanger a letter, which formed the basis for the latter's account in the case-history of the patient's action. The letter repeated the characterization of Ellen West as incapable of living, and quite openly depicted the husband as fully conscious and aware of his wife's suicidal intentions and actions:

* * * * * *

By now, it should be clear that the new archival sources reveal important data that broaden the hermeneutic horizon and enhance the reader's ability to construct alternative interpretations regarding Ellen West's life, illness, and treatment.Footnote ¹⁹ Moreover, the richness and the historiographical characteristics of these sources also elucidate the methodological problematics involved in the assessment of psychotherapeutic treatment and its ensuing textual representation: the case-history. In what follows, I will elaborate these difficulties by exposing the case-history as a textual remnant of complex multi-subject interactions. I will tease out the text's interwoven narrative strands, showing how each strand bears the different motivation of its author.Footnote ²⁰

As I will demonstrate below, the analysis of both the therapeutic interaction and its textual representation cannot be confined merely to the dyadic patient-doctor framework, but must be grounded in an inter-personal matrix of greater breadth. The need to widen the scope of analysis is brought to the fore when carefully investigating the historiographical characteristics of the archival materials, and the way in which Binswanger used these sources in constructing “The Case of Ellen West”: How was it composed? What resources were available to Binswanger when writing up the case? What were the underlying motivations of these sources?

Phenomenological Psychology

In the “Case of Ellen West” and in other more theoretically-oriented texts, Binswanger identified the methodology that guided Daseinsanalyse – both his therapeutic practice and his epistemological endeavors – as phenomenological (see, for example, Binswanger [Reference Binswanger and Max1923] Reference Binswanger and Alice1994). As defined by Edmund Husserl, phenomenology abstains from explaining perceived phenomena. Rather, it allows these phenomena to “express themselves” and appear immediately to the investigator, who attempts to intuitively comprehend and interpret them as such (Binswanger [Reference Binswanger and Max1946] 1994, 232–234).

What does it mean, however, to utilize the phenomenological method in the practice of psychotherapy? According to Binswanger, grounding the therapeutic framework in this methodology allows the psychiatrist to investigate and understand the patient's personal experience of his or her subjective world, without resorting to “theoretical preconceptions” or prior meaning-frameworks. Adopting a non-judgmental attitude, the analyst investigates the patient's immanent experience, as described by him or her, without clinically reducing its phenomenal expressions into “symptoms” (Binswanger [Reference Binswanger and Max1923] 1994, 57).Footnote ²¹

In addition to his theoretical texts, Binswanger addressed methodological issues in “The Case of Ellen West” itself. Thus, preceding his analysis of the patient's existence, Binswanger posited a distinction between the phenomenological and the medico-historical methods, according to the way in which each addresses the patient's life-history, writing:

Later on, Binswanger differentiated between the ways in which phenomenology and psychoanalysis analyze the patient's life-history and warned against the latter method, in which:

At this point two questions need to be asked with regard to Binswanger's proclaimed psycho-phenomenological method: is it philosophically viable? And (if so) did Binswanger actually live up to these lofty ideals when treating Ellen West and writing her case-history?

While I will not address the first question, which deserves a lengthy discussion that would exceed the scope of this paper, I believe that there are some fundamental difficulties in the application of the phenomenological methodology to psychotherapy.Footnote ²² But, even if we were to accept this methodology without disputing its underlying presuppositions and basic principles, the specific details which characterized Binswanger's treatment of Ellen West and the writing of her case-history, as revealed in the archival material, prove that the phenomenological approach did not correspond to the reality of “The Case of Ellen West.”

The Stories of Sources

Binswanger constructed the case-study and presented Ellen West's diaries and letters in a way that seemed to imply that he had immediate access to these rich textual sources. Moreover, in a later essay, where he referred to the case-history, Binswanger boasted the alleged abundance of sources at his disposal, writing:

However, as I will show below, in actuality Binswanger most probably did not have direct and non-mediated access to the original autobiographical material. Rather, he merely had at his disposal excerpts that Ellen West's husband had gleaned from the raw materials and subsequently compiled into two different versions, each bearing a distinct character.Footnote ²³

The first version was composed during the stay in Bellevue. As recounted in the case-history, in the initial phase of treatment Binswanger asked the patient and her husband to “work out an exact anamnesis” – i.e., an initial case-history – as an aid in arriving at “our definitive diagnosis” (Binswanger CEW, 262–263; Binswanger FEW, 100). The result was a type-written report, approximately fifty pages long, composed by the husband and written in the third person. The report describes Ellen West's life from her childhood till her arrival in Bellevue, elaborates the development of her disease, and includes many excerpts from her diaries and letters. Many paragraphs in Binswanger's published case-history are direct quotations from this account by the husband (UAT 702/12).

The second “autobiographical” source for Binswanger's case-history was another product of the husband. In 1922, after Ellen had committed suicide, Karl collected excerpts from diaries, letters, and poems that she had written in different periods in her life, and bound them as a book, in an attempt to formulate a type of “biography” (UAT 702/13). Although this lengthy book, encompassing more than five hundred pages, was compiled after the conclusion of treatment and the suicide of the patient, one of the few copies that were made was loaned to Binswanger for several months in 1923. If he took notes, Binswanger could have used this book as an additional resource, when writing the case-history.

While both of the husband's compilations make use of texts written by Ellen, and while there is a certain overlap in the excerpts chosen, the basic motivations underlying the composition of each work were different. Hence, each compilation presents a different (hi)story of Ellen West's life and illness.

The first text was written, in accordance with Binswanger's explicit request, as an attempt to trace the development of the patient's illness. The focus of the text is therefore the pathology; it is an illness-narrative, punctuated with selections from the autobiographical materials that illustrate the different phases of the disease. The husband's explicit account, as well as his implicit narrative (expressed through the selection of particular excerpts) presents Ellen's illness as the result of a purely internal conflict, irrespective of her interactions with others in her milieu (family members and therapists). Thus, the pathology is limited to Ellen West's own subjectivity, without accounting for the influence that these (sometimes conflictual and coercive) interpersonal relationships exerted on the development of the illness.

The underlying motivations for the composition of the second text, on the other hand, are more complex. Compiled after the suicide and entitled “Ellen West – letters, diary-leaves [Tagebuchblätter], poems,” the book was construed as a type of non-narrative “biography.” It was intended as a collection of texts written by Ellen West, from which one could conjure her person.Footnote ²⁴ Indeed, the book is composed of 445 numbered excerpts, and lacks an explicit narrative connecting them. However, the text does contain an implicit narrative, designed to draw a non-pathological life-history and to eliminate the illness, as much as possible, from the story being told. Thus, before sending the book to Binswanger, the husband wrote:

Despite their distinct characters, the two texts had one thing in common: they were both compiled by Ellen's husband. Other than the texts provided by the husband, Binswanger apparently had no direct access to Ellen West's original autobiographical material. Therefore, his only means of investigating her innermost thoughts and anxieties, some of which she shared with others in letters, was via the abbreviated and edited version supplied by the husband, who was indubitably not a neutral observer (if such an adjective is appropriate for a “historian” in any case). In the biography's preface the husband even addressed his “censoring” explicitly, writing that he was obliged to “leave out” the “all too personal” – though valuable – details. It is quite understandable that the husband chose to withhold some of the data to protect his or others' privacy. However, the fact that he edited Ellen's autobiographical material necessarily constituted an interposing element that distorted Binswanger's perception and interpretation of the data. In fact, even in the sanatorium Karl acted as Binswanger's accomplice and mediator, writing down Ellen's dreams and handing the notes over to Binswanger. These were later used by Binswanger to recount the dreams in the case-history, although he did not analyze them with the patient herself.

Hence, an analysis of the archival material makes clear that Binswanger could not have carried out the phenomenological ideal that he proclaimed in “The Case of Ellen West.” In reality, Ellen West's personal experience and subjective world were conveyed through an additional agent, whose actions of editing, censoring, and veiling constituted yet another level of representation; therefore, Binswanger was necessarily incapable of immediately intuiting his patient's subjectivity.

Writing the Case of Ellen West

I have shown, then, that even the interpersonal relationships between the different actors and the therapeutic interaction, which took place in the sanatorium, were mediated by written documents – formulated by various authors, each motivated by different aims, and each voicing his or her own narrative. I will now turn to Binswanger's narrative, which subsumed those of the other players, by weaving their various narrative strands into the final textual fabric known as “The Case of Ellen West.”

My analysis draws on Kathryn Montgomery Hunter's conceptualization of the therapeutic interaction as “fundamentally narrative,” and her differentiation between the patient's and the doctor's narratives, which are frequently at odds. The doctor interrogates the patient's story of the subjective experience of disease and transmutes it into medical information and diagnosis, “an interpretive retelling that points toward the story's ending.” This “objectified” narrative directs the doctor's care of the patient and may later be abstracted into medical knowledge. Particularly potent is Hunter's description of the conflict between doctor and patient over the authorship of the illness narrative, which derives from the fundamental incommensurability of versions: “A silent tug-of-war over the possession of the story of illness is frequently at the heart of the tension between doctors and patients, for that tension is in part a struggle over who is to be its author and in what language, a struggle for the interpretation of life (and death) events” (Hunter Reference Hunter1991, 13).Footnote ²⁵

The textual artifact constructed by Binswanger is simultaneously historical – recounting the life and illness of Ellen West, and disciplinary-theoretical – employing the specifics of her case to formulate more general arguments and to introduce Binswanger's new theory of Daseinsanalyse. As author of this text, Binswanger encompasses several professional identities: practitioner and theoretician, therapist and historian. The final narrative therefore represents the result of his attempt at reconciling these entities and negotiating their different (and sometimes incompatible) motivations. Was the case-history an extension of the treatment of Ellen West as an individual – an attempt to recount and interpret the history of her illness and the therapeutic interventions? Or was the aim to introduce a new philosophically-oriented therapy, for which this patient functioned as a convenient illustration? Was the author committed to the historical truth of his encounter with his former patient, or to the future of the therapeutic profession and its potential patients?

Indeed, “The Case of Ellen West” – like other case-histories – is plagued by an internal tension, deriving from the attempt to straddle the realms of clinical practice and inductive hermeneutics. As in other instances of clinical casuistry, Binswanger's case-study exemplified poignantly (if unwittingly) the strain resulting in an attempt to overcome the disparity between the idiographic and the nomothetic, stating:

Ellen West, then, was abstracted by Binswanger into a generic reference of the specific polarized existential structure that she embodied, in an attempt to make the case-history pertinent for other members of the clinical or therapeutic discipline.Footnote ²⁶ The disciplinary community targeted by Binswanger was that of Daseinsanalyse, which was just beginning to establish itself in this period. In fact, Binswanger published “The Case of Ellen West” during a seminal phase in the theoretical development and professional consolidation of existential psychology. The case-history thus functioned simultaneously as means of demonstrating and of constituting the theory and praxis that were coming into being. But was the case of Ellen West a well-chosen example? Could it be seen as a persuasive and effective demonstration of Daseinsanalyse? Or should we view the case not merely as a manifestation of a new discipline, but also as the introduction of a new narrative genre?

From a literary perspective Binswanger's analysis is quite aesthetically-gratifying, as his well-constructed narrative employs Ellen West's autobiographical material very effectively. However, the case does not seem to provide an especially good professional model for existential psychotherapy. Indeed, it is likely that therapists reading the case-history in order to understand how to conduct Daseinsanalyse, or those treating it as a replicable example, will be frustrated. Rollo May, the American psychotherapist who edited the volume that included the English translation of “The Case of Ellen West,” expressed this consternation in writing: “When editing this volume [. . .] we had difficulty piecing together information about what an existential therapist would actually do in given situation in therapy” (May Reference May and Rollo1958, 76–77; emphasis in the original).

In the case of Ellen West, this perplexity derives first and foremost from Binswanger's argument that no therapeutic means could have saved Ellen West from death: his claim that since her existence was inherently tragic, her fate was sealed.Footnote ²⁷ Thus, Binswanger paradoxically undermined the case-history's traditional generic role: a medium of knowledge dissemination, and a means of teaching technique to other therapists.

It should be noted that for a case-history to fulfill its prescribed role, it is not necessary that the treatment be successful, that is, that the patient be cured; in fact, most of Freud's case-studies are of treatments that ended prematurely and may be seen, in hindsight, as therapeutic failures. The reason, then, that “The Case of Ellen West” – which presents itself (at least partly) as a therapeutic taleFootnote ²⁸ – does not satisfy our expectations as a case-history is not the lack of a happy ending. Rather, it is the want of any discussion of the therapeutic interventions that were undertaken or that should have been undertaken, and the employment of the concept “tragedy,” which would appear to have no place within any therapeutic discourse.Footnote ²⁹

Arguably, Binswanger was engaged in a different project altogether – more philosophical or anthropologic than therapeutic – which necessitated a new genre of discourse, more descriptive or interpretative than prescriptive (Lanzoni Reference Lanzoni2004, Reference Lanzoni2005). Granting that this was Binswanger's intention, one may still critically examine the ensuing “disciplinary hybrid” and wonder whether the internal tensions or contradictions underlying this synthesis, particularly as manifested in “The Case of Ellen West,” were not fatal.Footnote ³⁰

While I find Binswanger's critique of the reductive inquiry-methods and discourse-modes of psychiatry and psychoanalysis persuasive, and his attempt to provide an alternative admirable, the solution he offered in its stead – as represented in his case-studies – is wanting. Binswanger's case-histories differed from the structure and format of the standard medical-study mainly in the presentation of an extended philosophically-informed analysis of his patients' mode of existence. My claim is not that such generic deviation – i.e. a turn towards a more “literary” or philosophical style of medical writings – is problematic per se, or that it renders the resulting work less “clinical.” In fact Freud, whose case-histories famously read like “short stories,” as well as A. R. Luria (and following him Oliver Sacks) were engaged in similar endeavors.

If anything, I would argue that Binswanger did not go “far enough” in his project. Thus, although he was quite critical of the medical methods of investigation and frameworks of theoretical conceptualization, Binswanger did not specifically challenge (so far as I can find) the medical case-history as a genre of representation. And indeed he retained one crucial element of this genre – the elimination of the author from the narrative. Thus, whereas Freud's case-histories were self-dramatizing discourses, and whereas both Luria and Sacks (who promoted a type of “romantic science”) appear as characters in the narratives they spin, Binswanger all but disappears from the case of Ellen West, remaining in the relatively safe position of the omniscient yet invisible author.Footnote ³¹ He thereby manifested an ambivalence vis-à-vis his own version of “romantic science,” not realizing that unveiling the enigma of the patient's subjectivity necessitated an (at least partial) exposure of therapist's own in a truly intersubjective encounter.Footnote ³²

Returning to the specifics of “The Case of Ellen West,” it is important to recall that Binswanger published the case-history more than twenty years after the therapeutic interaction took place. At the time of publication, Heidegger's Daseinsanalytik served as Binswanger's guiding therapeutic ideology; from the case-history itself, it is unclear whether that was the case at the time of Ellen West's treatment. However, this seems highly improbable, as Heidegger's Daseinsanalytik, as epitomized by Sein und Zeit, was only published in 1927. Perhaps this is the reason for Binswanger's decision to refrain from divulging important information concerning the course of treatment, which might have exposed the fact that his existential interpretation of Ellen West was only a retrospective one.

Thus, in “The Case of Ellen West,” the characteristic generic tension between the particular and the general, between the idiographic and nomothetic, was exacerbated by a significant temporal lapse between the actual therapeutic interaction and the writing of the case-history, and by the intention, which prompted the publication, of establishing a new discipline. In the process of retrospectively and teleologically shaping Ellen West's illness so as to fit the existential interpretation that he wished to promote, Binswanger thus obscured the “reality” of the treatment.

Ellen West's case-history was therefore used by Binswanger as a framework for the construction of a new discipline. But at the same time the converse process took place; the theory of Daseinsanalyse was utilized by Binswanger to justify what may be seen as the treatment's failure: the suicide of the patient.

Ellen West's tragic death must have haunted Binswanger for many years, as his letters to her husband attest. In 1923, Binswanger wrote: “It is odd [merkwürdig] how lively your wife remains in my mind's eye as well. It is enough to reread one of her lines for the entire person to reappear before me.” In 1933 he claimed: “I think very often of you and your dear first wife. One never forgets such experiences.” And even in 1961 he was still occupied with his decision to release Ellen West from the sanatorium, writing: “The decision at the time was one of the most difficult in my life. But even today and with more experience, I consider it the right decision” (Letters from 11 April 1923, 14 August 1933 and 10 May 1961, UAT 702/11,2).

I believe that in writing “The Case of Ellen West” Binswanger attempted, intellectually and emotionally, to come to terms with the “unfinished business” that this therapeutic interaction constituted for him. Thus, he wrote in the case-history: “What we psychiatrists judge as and label from the outside as a striking, bizarre, morbid ‘act of a schizophrenic’ can be understood existential-analytically as an often last attempt of the existence to come to itself!” (Binswanger CEW, 311; Binswanger FEW, 150). Binswanger's interpretation of Ellen West's suicide as her final attempt to achieve an authentic existence seems to be his attempt to endow with meaning this almost inconceivable action – one that is irrevocable, and in hindsight also inevitable – and to work through the helplessness, guilt, and anger, which he must have felt in the face of this deed.

It should be mentioned, at this point, that Ellen West's suicide was not the only one that Binswanger experienced in the course of his life. Binswanger's eldest son, Robert, who was destined – following the familial tradition – to inherit his father's role as head of the Bellevue sanatorium, killed himself when he was twenty years old. In his diary, Binswanger described the day of the suicide, 6 April 1929, as the most difficult day in his life.Footnote ³³ And in his letter to Freud, sent at the end of that year, Binswanger expressed his intention of utilizing scientific research as a site for working through his grief, writing:

It was with this son that Binswanger had, a year earlier, read Heidegger's Sein und Zeit (Diary entry, quoted in Freud and Binswanger 1992, xxiii). Indeed, he later described the filial suicide in terms that resonate with existential philosophy, writing: “On vacation, I felt yet again, that the statement, that I have not overcome my fate with my son, is foolish, for fate is just there for man to remain in it, and from it be molded and formed” (Letter from 19 October 1936, in Freud and Binswanger 1992, 238).

However, in his attempt to reform the medical profession and its obligations – Daseinsanalyse being, as it were, the phoenix of an expanded “medical” vision, rising from the ashes of two key suicides he experienced – Binswanger created a Janus-faced disciplinary hybrid. For when arguing that in the case of Ellen West no therapeutic means could have intervened in the patient's existentially-authentic trajectory towards death, and in designating this case as the paradigmatic example for his new methodology, Binswanger posited an inherent contradiction, or at least a jarring disjunction, between the theory and praxis of Daseinsanalyse.Footnote ³⁴ In challenging that one basic notion which characterized contemporary psychotherapy: that the therapist's interventions aim at a genuine modification of the patient's condition – either by changing the nature of the illness or by changing the patient's attitude towards his or her illness – the epistemology and pragmatics of Binswanger's Daseinsanalyse seemed to be inexorably at odds.Footnote ³⁵

* * * * * *

In this essay I have revealed “The Case of Ellen West” to be a complex textual construct. This clinical tale is not the simple and unitary narrative it purports to be, but is rather a conflict-laden heterogeneous mixture of stories, composed by multiple narrators, each of whom offered his or her version of the reality in which they all participated. As such, the case-history is a remnant of their interpersonal and inter-textual relationships, an intersection of multiple narratives and a variety of personal and disciplinary motivations, all interwoven into a complex whole.

The case-history is thus made up of at least three imbricate interpretative strands, which I have attempted to isolate and articulate in this paper. The first is the one that Ellen West herself composed in her diaries and letters. The second – the psychiatric interpretation that Binswanger (with the aid of the husband) pronounced during Ellen's institutionalization in the form of diagnosis: schizophrenia. The third strand is the narrative proposed by Binswanger in hindsight, more than twenty years after the conclusion of treatment and the patient's suicide. This last one is a psycho-philosophical interpretation that leads to a different kind of closure: the necessary-voluntary death of a tragic existence. To these three overt narratives one must add the husband's mostly implicit interpretative layers, which mediated – through the editing process of the autobiographical material – between the narratives of Ellen West and Binswanger. The authorial subjectivity in “The Case of Ellen West” was hence diffuse in time and space, and fragmented among at least three participants, each spinning a different narrative strand. In the course of this paper, I have attempted to unravel the medico-historical fabric into its woof and warp, to separate it into its constitutive threads of different color and strength.Footnote ³⁶

Yet I realize that while deconstructing (or untangling) the case-history, I have of course contributed an additional interpretative level to “The Case of Ellen West”: my own narrative. To conclude in a reflexive mode, I ask: what kind of historical narrative have I constructed? What was the underlying mode of emplotment, to use Hayden White's terms, of this narrative? And what is its epistemological and ontological value?

As I have presented it, “The Case of Ellen West” is a text that simulates a therapeutic narrative, but that serves Binswanger as a type of “cover story.” It supplies Binswanger, in hindsight, with a justification for his actions – the failure of treatment and non-prevention of the suicide – by employing the plot-structure and the thematics of tragedy to describe Ellen West's existence. In addition, I have depicted “The Case of Ellen West” and the process of its composition as a type of Bildungsroman, the case-history serving as a developmental-formative vehicle: emotionally for Binswanger himself, and professionally for the discipline of Daseinsanalyse.

Formulated as such, it is clear that my reading has modest epistemological aspirations. Although I have introduced many previously unavailable details regarding Ellen West's treatment and the writing of her case-history, the intention was not to unearth some hidden truth about the events of the past. Rather, I sought to illuminate the constraints and limitations of historical knowledge, particularly as it pertains to the subjectivity of psychiatric patients and the intersubjective relationship underlying the psychotherapeutic encounter. The intention of my reading was not to reach definitive conclusions, but rather to raise questions to which no simple answers may exist.