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Year: 2022

More phenomenology in psychiatry? Applied ontology as a method towards

integration

Larsen, Rasmus R ; Maschião, Luca F ; Piedade, Valter L ; Messas, Guilherme ; Hastings, Janna

Abstract: There have been renewed calls to use phenomenology in psychiatry to improve knowledge about cau-
sation, diagnostics, and treatment of mental health conditions. A phenomenological approach aims to elucidate
the subjective experiences of mental health, which its advocates claim have been largely neglected by current
diagnostic frameworks in psychiatry (eg, DSM-5). The consequence of neglecting rich phenomenological in-
formation is a comparatively more constrained approach to theory development, empirical research, and care
programmes. Although calls for more phenomenology in psychiatry have been met with enthusiasm, there is
still relatively little information on how to practically facilitate this integration. In this Personal View, we argue
that phenomenological approaches need a shared semantic framework to drive their innovative potential, thus
enabling consistent data capture, exchange, and interoperability with current mental health data and informatics
approaches (eg, the Research Domain Criteria project). We show how an applied ontology of phenomenological
psychopathology offers a suitable method to address these challenges.

DOI: https://doi.org/10.1016/s2215-0366(22)00156-0

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ZORA URL: https://doi.org/10.5167/uzh-224970
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Originally published at:

Larsen, Rasmus R; Maschião, Luca F; Piedade, Valter L; Messas, Guilherme; Hastings, Janna (2022). More phe-
nomenology in psychiatry? Applied ontology as a method towards integration. The Lancet Psychiatry, 9(9):751-
758.
DOI: https://doi.org/10.1016/s2215-0366(22)00156-0
 Authors’ Manuscript | Please Cite Published Version

More Phenomenology in Psychiatry?

Applied Ontology as a Method Towards Integration

Rasmus Rosenberg Larsen1*, Luca F. Maschião2, Valter L. Piedade2, Guilherme Messas2, and Janna
Hastings3

1Department of Philosophy, and Forensic Science Program, University of Toronto Mississauga, Canada.
2Mental Health Department, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil.
3Clinical, Educational and Health Psychology, University College London, UK, and Institute for Intelligent

Interacting Systems, Otto-von-Guericke University Magdeburg, Germany.

1. Introduction accommodate the “addition of a phenomenological

dimension” into their research efforts.22 p. 169
Phenomenology is a methodology to describe and
analyse the content, structures, and preconditions However, one question naturally emerges from The
of subjective experiences.1–3 The method has been Lancet Psychiatry editorial, namely:
adopted by many different disciplines to study a
diverse range of topics.4,5 Since its adoption by How can a phenomenological dimension be
psychiatrists in the early 20th century, practically added to, or integrated with
phenomenology has been used to inform our mainstream psychiatric research, training, and
understanding of mental health, an approach that care programs?
today makes up a small, yet growing subfield known
as phenomenological psychopathology.6,7 It would be naïve to expect that phenomenology can
be straightforwardly added in the same way as, for
A central focus in phenomenological example, one might add a new statistical method to
psychopathology is the analysis of the direct analyse data. In practice, phenomenological
experiences of mental health conditions.8,9 The core psychopathology requires in-depth training to
assumption of this approach is that a detailed apply. A seemingly more realistic path forward
description of first- and second-person experiences could be to include trained phenomenologists more
has the potential to catalyse improvements to broadly throughout psychiatric programs. However,
research and care programs.10,11 The approach is phenomenologists are at present a comparatively
often contrasted with the known limitations of scarce resource. Thus, even on the assumption that
widely used third-person descriptive accounts of phenomenology can bring benefits to psychiatric
mental health (e.g., DSM-5, ICD-11), which, research and clinical work, the reality is that salient
according to advocates of phenomenological practical hurdles may hinder achievement of this
psychopathology, fail to do justice to the full vision (see also23–29).
complexity of mental health problems.8–10,12–15
In this contribution, we outline a practical tool that
While phenomenological psychopathology has aims to advance integration of phenomenology with
historically remained peripheral to mainstream mainstream psychiatric research and practice,
psychiatry,13,16,17 there has recently been renewed namely, a so-called ‘applied ontology’ for
enthusiasm and fresh calls to actively harness the phenomenological psychopathology, which can
insights of phenomenology in psychiatry. 18–21 For enable consistent data capturing and
example, a recent editorial in The Lancet interoperability with current mental health data and
Psychiatry22 detailed the potential value of a informatics resources (e.g., DSM-5, ICD-11, the
phenomenological approach to diagnosis and care, Research Domain Criteria [RDoC], etc.) and
calling on the broader research community to mitigate challenges associated with integration.

*Corresponding author: Rasmus Rosenberg Larsen | [email protected] 1

 Authors’ Manuscript | Please Cite Published Version

because they are experienced as disrupting self-

2. Phenomenological Psychopathology and awareness and the fundamental sense of reality.18 p.
its Potential to Advance Psychiatry 239

The call in The Lancet Psychiatry for adding a It is perhaps tempting to conclude that there is
phenomenological dimension to psychiatric nothing unique about the phenomenological
research begs the question what exactly this analyses reviewed in Fayaerts et al.,18 that these
dimension amounts to, that is, what exactly is it that observations could have been made by any astute
needs to be added? We approach this question by scientist or clinician (for a criticism along these
briefly surveying what kind of information about lines, see30). However, as pointed out in Nelson et
mental health appears to be strictly unique to al.,19 phenomenological analyses are not simple
phenomenological psychopathology, which we take observations, but rely on a range of underlying
to be a good indication of what needs to be added to assumptions about the universal, basic structures of
mainstream psychiatry (for detailed accounts of human subjective experience as identified in the
what distinguishes phenomenological phenomenological tradition. As such,
psychopathology, see the anthology by Stanghellini phenomenologists navigate their observational
et al.7). focus onto disruptions of these basic structures,
which in turn drives their analysis. Some of these
A recent review article by Fayaerts et al. 18 basic structures are cursorily defined in Nelson et
demonstrates how phenomenological analyses have al.19 such as:
yielded definitions of delusion that deviate
markedly from the definition found in other Selfhood: Includes the tacit sense of ownership
research paradigms. In the latter, delusions are and agency of one’s experience and behaviour, and
typically defined as extreme instances of false the narrative construction of a social identity.
beliefs (i.e., they are extreme because they are held
with certainty and not subject to revision). Intersubjectivity: Includes the capacity to
However, according to phenomenologists, perceive and engage with other human beings as
delusions are not mere false beliefs, but can be expressive subjects, rather than as mere objects.
distinguished from such by their correlation with
peculiar alterations to self-awareness, as well as Embodiment: Includes the capacity to shift
global changes to how reality itself is experienced. between experiences of one’s body as a power of
For example, where false beliefs are characterised as engaging with the world (Leib) and as a material
an error of reasoning (of which the person holding object (Körper).
the belief is themselves unaware), according to
some phenomenologists delusions do not hinge on Spatiality: Includes one’s capacity to appreciate
faulty reasoning, but are usually experienced as and operate within different normative spaces, such
strange epiphanies that a person, upon self- as the space of the home, the theatre, and the
reflection, cannot integrate with their general belief classroom.
system.18 p. 243 Further, where false beliefs are
convictions about factually wrong ideas, (Adapted from Nelson et al.19; see also5,31)
phenomenological analyses suggest that delusions
are different insofar that people often experience The way the semantics of these basic structures
them as arising from a quasi-real background, inform a phenomenological analysis of delusion is
recognizing their delusions as belonging to a that they orient phenomenologists towards
different realm of reality.18 p. 239 Comparatively, identifying disruptions/disturbances/alterations of
where people normally behave according to their these structures, rather than merely exploring the
false beliefs (albeit, relative to the degree they are content of the delusion (e.g., the nature of the false
unaware these are false), phenomenologists claim belief), thus leading to the observation that
that delusions rarely drive behaviours, presumably delusions are often accompanied with a disruption

*Corresponding author: Rasmus Rosenberg Larsen | [email protected] 1

 Authors’ Manuscript | Please Cite Published Version

of selfhood and self-awareness, which makes a To collect data, researchers commonly use
delusional episode qualitatively different from a resources such as standardised definitions of
mere false belief (see also20). disorders and accompanying clinical guidelines for
how to delineate these in practice, as well as
The benefits that follow from phenomenological structured tools and instruments for reliably
analyses and assessment are potentially many. 7,9,32– assessing symptoms, histories, and contextual
36 For instance, Nelson et al. 19 emphasises its factors.40,41 Therefore, in order to integrate
potential to meaningfully inform phenotypic studies phenomenological psychopathology with
of mental health conditions, as it enhances or mainstream psychiatric research, the semantic
heightens the granular resolution about particular framework of phenomenological psychopathology
clinical cases, which universal phenotype must first be explicitly defined in a user-friendly
definitions are usually based on (see also 15,37,38). A format for such data capture purposes. And we may
similar point is also stressed by Fayaerts et al.18 who further note that not only must the semantic
further emphasises that this higher resolution may framework be explicitly defined, but it must ideally
inform the development of treatment and care be organised in such a way that it is interoperable
strategies (see also14,21,36,39). with current data and informatics resources in
psychiatry.40,42,43
In summary, what is unique about
phenomenological analyses is the semantics of Here we encounter a fundamental hurdle: there is
phenomenological psychopathology. It is through a currently no single broadly accepted, standardised
distinct conceptualisation and associated semantic framework in phenomenological
methodological approach that phenomenologists psychopathology. When contributions such as
are capable of orienting, systematically assessing, Nelson et al.19 highlights a list of basic semantic
and articulating the nuanced disruptions of the entities, a closer inspection reveals that: (1) this list
basic structures of subjectivity that show in mental is not exhaustive; (2) the exact definition of these
health conditions. And it is this unique entities is not based on broad consensus; and (3)
conceptualisation that needs to be added to and there has not yet been a coordinated attempt in the
integrated with psychiatric research and practice. field of phenomenological psychopathology to
logically relate these entities with the semantics in
3. How to Add Phenomenological mainstream psychiatry.44–48 Indeed, while the field
Psychopathology to Psychiatry of phenomenological psychopathology has
produced some contributions that explicitly aim to
A substantial difficulty with the integration of clarify the semantics of phenomenology,31,32,49
phenomenological approaches into psychiatry including innovating current psychiatric
relates to the need to develop effective strategies for operational constructs15,37,50,51 and development of
phenomenologically-aware data annotation and structured clinical assessment tools,33-35,52 these
capture, thereby allowing researchers to reliably contributions are substantially outnumbered by
and validly capture information about the entities work from differing traditions, perspectives, and
that phenomenologists are referring to when they approaches within phenomenological
use terms such as selfhood, intersubjectivity, psychopathology,6,7,21,53 for which the semantic
embodiment, spatiality, and so on. In a very cross-integration has not yet been made clear.
practical way, there is a concrete need for
psychiatric researchers and practitioners to reliably As an example of semantic incongruities, consider
and validly capture, for example, a characterisation the definition of spatiality offered by Nelson et al.19
of delusion as involving a disruption of self- as a capacity to operate within “different normative
awareness and sense of reality, in clinical data, such spaces” (as quoted above). Although Nelson et al. 19
that this information is available for subsequent did not intend for this short definition to do full
scientific investigations. justice to the concept, it can be noted that some
phenomenologists understand the term spatiality as

*Corresponding author: Rasmus Rosenberg Larsen | [email protected] 2

 Authors’ Manuscript | Please Cite Published Version

denoting a much more general aspect of human and Biomedical Ontology foundry,66 encompassing
perception and experience,5 namely, how relations a library of ontologies covering the full range of life
to spatial dimensions pre-reflectively shape the science domains.
meaning of all human experience, including
fundamental experiential structures such as What makes ontology an especially appealing
distance-proximity, centrality-peripherality, strategy in the process of integrating
horizontality-verticality, etc. (see also,54–56). phenomenological psychopathology with
psychiatric research is the way ontologies can (a)
Therefore, one crucial step that will be needed to facilitate the explicit representation of
enable integration between phenomenological phenomenological entities and their relations
psychopathology and mainstream psychiatry, we alongside interoperability with existing mental
suggest, is a methodological initiative that can solve health semantic frameworks,62,66,67 and (b) serve as
the challenge of developing a harmonised and a hub for community-wide terminological
unified semantic framework for phenomenological discussions aimed at building a wider consensus
psychopathology in such a way that it is around how to define each entity in the domain of
interoperable and integrable with current clinical phenomenological psychopathology, their
and psychiatric data. In the remainder, we will taxonomic position, and the relations between
outline how an applied ontology can address this them.59,66
need and mitigate the accompanying challenges.
Note that this process of community-based
4. Applied Ontology of Phenomenological semantic explication does not involve mandating a
Psychopathology narrow understanding of phenomenological
psychopathology or any of its rich repertoire of
In the field of data and information science, the entities. To the contrary, it involves cataloguing,
term ontology refers broadly to a method for elucidating, and clarifying the differences in
semantic enrichment by adding structure and definitions for all the various entities across the
meaning to data.57,58 More technically, an ontology diverging traditions that makes up the field of
is a representational artefact that describes entities phenomenological psychopathology, and
in a domain and the relations between them (see showcasing how these can be classified and
Figure 1). Ontologies contain a taxonomy, unique interrelated into a larger and nuanced whole.
identifiers, definitions, names, synonyms, and other Working to elaborate the entities, their distinctions,
useful metadata about a domain,58,59 and are built in and interrelations will lead to a complex,
standardised computational formats such as the comprehensive, unified, and disambiguated
Web Ontology Language – a Semantic Web60 semantic framework (with the crucial
standard. computational qualities of ontologies58).

The use of ontologies is common practice in many An ontology grows through establishing
scientific fields, where they are broadly recognised community-wide consensus and semantic
for their applications in capturing complex data in a clarification, rather than being imposed and
standardised way, and supporting automated dictated by a few researchers in a top-down fashion.
reasoning over such data.61–63 In the biological and Ontologies operate at the interface between
biomedical fields, two of the most prominent technical and infrastructural standards that allow
examples of ontologies are the Gene Ontology,64 widespread dissemination and community-based
which provides a terminology for the functions of practises, which in turn support knowledge and
genes across species, and the Systematized theory convergence. The standardisation that is
Nomenclature of Medicine–Clinical Terms,65 which aspired to is that of a coordinated consensus-driven
provides a vocabulary for all aspects of clinical data. process, subject to ongoing revision and editorial
Other notable examples can be found in the work.66,68
collection of ontologies from the Open Biological

*Corresponding author: Rasmus Rosenberg Larsen | [email protected] 3

 Authors’ Manuscript | Please Cite Published Version

Figure 1: Entities in an ontology are taxonomically classified (to the right), and each term is annotated with a definition,
unique identifier, synonyms, and other metadata (to the left). In the taxonomy, the boxes (‘nodes’) represent entities; the
black lines (‘edges’) represent an ‘is_a’ or taxonomic relation; the dotted lines are other relations that hold between
entities. The example is from the Mental Functioning Ontology, 72 which can be accessed via the BioPortal88 online
ontology repository.

To achieve this objective, it is important that the basic structures of subjective experiences (initial
development be open to all potential contributors, adoption from outline provided by Messas et al.,31
that its editorial decisions be transparent, that it be which was also briefly discussed in Nelson et al.19)
developed according to explicit guidelines, that it These entities were classified (taxonomically)
involves a wide range of stakeholders in its beneath ‘higher order consciousness’, defined in the
development, and that it be released under an open Mental Functioning Ontology as “Consciousness of
licence (for more details on how to optimise one’s own mental states, a self-reflexive
ontology development, see58,69,70). consciousness of the experience of being conscious,
of having mental processes ongoing”.72 So, for
Conformant with these best practises in ontology example, the phenomenological entity
development, we have initiated a project to build an ‘embodiment’ is classified in the Mental
applied ontology of entities in phenomenological Functioning Ontology as a subtype of ‘higher order
psychopathology, which we named the Ontology of consciousness’ and defined as: “The subjective
Phenomenological Psychopathology (OPheP; access experience of being an embodied entity”. 72
to the open-source repository:
https://github.com/jannahastings/ophep – for While OPheP is being developed beneath or in
more details, see71). The OPheP is connected to the parallel to the Mental Functioning Ontology, the
wider context of biomedical ontologies, being semantic scope of OPheP is different in the sense
developed ‘beneath’, that is, in accordance with the that it only includes entities that are understood to
Mental Functioning Ontology,72 an Open Biological be, or be related to, disruptions of the basic
and Biomedical Ontology foundry library ontology. structures of conscious experience. Here, the OPheP
Further, all the foundry’s library ontologies – is built on an understanding of disruption as when
including the Mental Functioning Ontology – are a phenomenological entity (e.g., embodiment,
developed using Basic Formal Ontology,58 an selfhood, etc.) is subjectively experienced in a non-
international standard top-level ontology (ISO/IEC canonical or non-ordinary fashion (like many
21838-2), which provides an explicit metaphysical phenomenologists, we use the terms disruption,
backbone and design guidelines for developers. disturbance, and alteration synonymously). This
understanding of disruption is partially inspired by
In our previous work,71 we have outlined the Eugène Minkowski’s concept of “generative
foundation for OPheP by extending the Mental disturbance”,56 which delineates
Functioning Ontology with the core entities from disturbances/disruptions as pertaining to an
the domain of phenomenology that represent the alteration of the basic, pre-reflective level of

*Corresponding author: Rasmus Rosenberg Larsen | [email protected] 4

 Authors’ Manuscript | Please Cite Published Version

consciousness that constrains and determines first- phenomenological psychopathology. The examples
person experiences (see also37,73,74). currently included in OPheP are therefore to be
understood as preliminary, subject to community-
To exemplify how disrupted phenomenological driven approval and/or revision.
entities are defined and included in OPheP,
consider the definition of disruption of embodiment 5. Concluding Remarks
as: “Disruption of the subjective experience of being
an embodied entity”. That is, human beings The recent calls18–22 for integrating phenomenology
canonically or ordinarily experience themselves as with mainstream psychiatry must be understood in
embodied, and when this basic structure of their proper context, namely, that innovation in
consciousness is disrupted, the person’s subjective mental health research and practice has stagnated
experience is then fundamentally altered in a in the past decades.76–79 Facing this,
reflexively noticeable and persistent way. According phenomenologists have been vocal in their advocacy
to phenomenologists, there are various subtypes of for reforming psychiatry’s reliance on third-person
disruption of embodiment,75 which have yet to be descriptive accounts, aiming instead at a
added to OPheP. comparatively richer vocabulary for first- and
second-person descriptions of subjective
By following this approach, OPheP has been initially experiences. The goal is that such reform will
populated with a number of entities relating to enhance the granular resolution of how we describe
disruptions of conscious experience that have been mental health experiences, and thereby lead to
identified by phenomenologists as manifesting in innovations in research, as well as improved
schizophrenia and related conditions, and which knowledge about aetiology (causation), diagnostics,
will be recognisable to most phenomenologists. and care.9,47,71,80
Here we list three illustrative examples from the
current version of OPheP (note that the ontology However, as we have argued, achieving the
itself includes further details, which can be accessed promised benefit of phenomenological
via the repository): psychopathology is contingent on our practical
ability to integrate entities and conceptualisations
Hyperreflexivity is a disruption in from this domain with mainstream psychiatry.
‘consciousness of self’: Definition= An exaggerated More specifically, the promises of
self-consciousness in which one experiences phenomenological psychopathology depend on
oneself as a kind of external object. It is a developing strategies and methods to accurately
consequence of an inability to experience a and consistently capture data about the type of
subjective sense of oneself with a sense of self- entities highlighted by phenomenologists. If it is not
sameness or ‘ipseity’. possible to consistently capture data about
phenomenological entities (such as embodiment,
Alienation is a disruption in ‘intersubjectivity’:
intersubjectivity, selfhood, etc.), and the
Definition= A sense of being outside the usual
disruptions thereof, it is then also not possible to
customs and concerns of the shared social world.
sufficiently integrate phenomenological
Delusions of Control is a disruption in psychopathology with scientific studies of mental
‘consciousness of self’: Definition= Delusions health. From such a perspective, the development of
arising from experiences of losing agency over (a the OPheP resource may be understood as an effort
sense of the ability to act upon) one’s own body, to mitigate this fundamental challenge related to
thoughts and actions, due to a lost sense of the data, information, and knowledge capture and
boundaries between the self and the world. integration.62,71

The further development of OPheP will depend on Towards this end, it should be stressed that an
broad community-wide participation to enhance applied ontology such as we have proposed here
clarification and definition of entities in cannot stand alone as the sole means or primary

*Corresponding author: Rasmus Rosenberg Larsen | [email protected] 5

 Authors’ Manuscript | Please Cite Published Version

solution to the integration challenge. Arguably, programs, as well the inclusion of all stakeholders in
there are salient hurdles ahead that may not be cross-disciplinary debates about the overall status
strictly related to, or resolved by developing and purpose of these methods. However, as
semantic uniformity and interoperability (as we exemplified by successful ontology projects, 63,64,66
have discussed in previous work62,63,71). For the OPheP resource has the potential to play a
example, while consistent semantic framework is crucial role by acting as a hub for the broader
likely to ease the effort of data capturing, we should research and clinical community, facilitating a more
not forget or ignore that the data we aim to capture direct link between an evolving research-driven
is about other persons’ subjective experiences. And knowledge base and clinical decision-making, and
while phenomenologists might be able to develop a also adding transparency to the field of
detailed semantic framework that is theoretically phenomenological psychopathology by tracking the
adequate for describing all the complex ways in entire process from theory development to
which individuals experience mental health empirical research to clinical care.
conditions, this will not guarantee that individuals
that come into labs or clinics are also equally ◼
capable of articulating their experiences in such a
way that they clearly map onto the semantic Acknowledgements: We would like to thank the three
framework of OPheP, nor will a semantic anonymous reviewers for providing helpful comments on
framework guarantee that clinicians can sufficiently an earlier version of this manuscript.
attend to such first-person experiences. Thus,
Authors’ Contributions: Topic conceptualisation was
before these semantics can translate into the sort of
completed by RL, JH, LM, VP, and GM. The initial
‘phenomenologically enriched’ data we aim for, screening for phenomenological psychopathology terms
there will also need to be a parallel innovation in in original literature was executed by LM and VP. JH
interviewing methods advancing reliability and reviewed, revised, and imported candidate terms into
validity in data capturing (for such proposals, existing ontologies. Manuscript text was initially drafted
see37,49,81,82). by RL and JH, and reviewed and edited by LM, VP, and
GM. All authors contributed to the article and approved
Another challenge relates to the practice of using the submitted version.
phenomenology to inform clinical decisions, a
Conflict of Interest Statement: The authors declared
subject that continues to attract ongoing
no conflicts of interest.
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