Martti Siirala and Gaetano Benedetti – Friends in the dialogical and psychotherapeutic sharing of burdens

Abstract

This article explores the dialogical collaboration and friendship between Martti Siirala and Gaetano Benedetti, particularly in the development of the psychotherapy of schizophrenia and the human psychotherapeutic attitude toward carrying and sharing burdens. Siirala and Benedetti outlined a psychotherapy that considers existential and philosophical dimensions alongside the clinical aspects of illness, without being bound by schools of thought, authorities, or doctrinal systems. The main material in the article is based on documents from the Martti Siirala archive, the most important of which is the German-language correspondence between Siirala and Benedetti after Siirala moved back to Finland from Switzerland at the end of 1957. Benedetti’s activities in Basel are also illuminated by descriptions sent to Siirala by nurse Aino Kärkkäinen of her experiences in Switzerland in the late 1950s.

Keywords:

• Burghölzli
• conception of illness
• existential psychotherapy
• Friedmatt
• psychotherapeutic practice
• psychotherapy of schizophrenia

Martti Siirala (1922–2008) started familiarizing himself with psychoanalysis in the early 1950s, but never committed to the orthodox Freudian thought and movement. He became interested in existentially orientated psychoanalysis, anthropological medicine as developed by Viktor von Weizsäcker, and the existential-phenomenological philosophy signposted by Martin Heidegger and Edmund Husserl. Siirala and his family lived in Zurich from 1952 to 1957. After Siirala, the then neuro-psychiatrist and subsequent psychiatrist-psychoanalyst, had settled in Zurich in December 1952, he began working as an assistant in the treatment of schizophrenic patients at the Burghölzli Hospital under Manfred Bleuler in January 1953. Despite Manfred Bleuler’s preference for the natural sciences, and endocrinological psychiatry in particular, he, like his father Eugen, allowed and supported at Burghölzli the development of the intense psychotherapy of schizophrenia and new forms of applying psychoanalytic and psychodynamic theories to psychiatric practice.

Siirala’s supervisor was Gaetano Benedetti (1920–2013), who had arrived at the same hospital in 1947 as a volunteer assistant, and who was to become Siirala’s close colleague and friend. Benedetti was born in Catania, Sicily, on June 26, 1920, the eldest of three sons of a surgeon father and a religious mother. The family was wealthy and the children were privately educated at home until the age of 14. Gaetano Benedetti studied medicine at the University of Catania, where it was not possible to specialize in psychiatry, as psychiatry was integrated into neurology throughout Italy (for Benedetti’s background, see Conci, 2008; Conci, Koehler, & Peciccia, 2014).

Psychotherapy of schizophrenia in Switzerland

Benedetti’s move to Switzerland paved the way for psychiatry and schizophrenia psychotherapy (Benedetti, 1994). At the instigation of Manfred Bleuler, Benedetti had spent nine months in the USA between 1950 and 1951 on a study trip, during which time he had become familiar with intersubjective and neo-psychoanalytic views on schizophrenia psychotherapy (Harry Stack Sullivan, Frieda Fromm-Reichmann, Harold Searles, and Otto Will) and with the “direct analysis” of John Rosen (1953). Benedetti was appointed research assistant under Bleuler in 1952 and began to develop schizophrenia treatments, initially based on Rosen but soon moving away from this toward a more human and intensive psychotherapy of schizophrenia, in which the psychotherapist’s sensitive and optimistic attitude and partial identification with the patient were essential. Benedetti wrote his doctoral dissertation on alcohol hallucinations in 1952 and was appointed docent of psychiatry at the University of Zurich.

Manfred Bleuler has recalled Benedetti was appreciated at Burghölzli as a “highly esteemed member of our staff” that was “more and more moved by his dedication to schizophrenic patients and his skill to understand their psychodynamic life” (quoted by Koehler, 2002, p. 4). Benedetti’s empathy toward his patients was, in Manfred Bleuler’s (1987) view, reminiscent of the attitude of his father, Eugen Bleuler. Benedetti and Siirala had the same International Psychoanalytical Association (IPA) training analyst in Zurich, Gustav Bally (1893–1966), who favored open cooperation with non-IPA members and held, with Medard Boss, seminars that Siirala and Benedetti attended, among others.

Manfred Bleuler had invited Boss and Bally to teach psychoanalysis at Burghölzli in 1948–1949. Although Bally and Boss were originally members of the Swiss Psychoanalytic Society under the IPA, they did not follow the IPA training instructions. For one thing, they supervised their analysands. Their teaching focused mainly on a psychoanalytic training circle, which Manfred Bleuler had already started in 1941 and incorporated into the university training at Burghölzli in 1950. From 1955 onward, this training was officially linked to the Institut für ärztliche Psychotherapie, the bastion of Bally’s and Boss’s teaching, where Siirala also received his psychotherapist’s diploma.

Bally adhered more closely than Boss to Freudianism, who continued to develop Daseinsanalyse inspired by Heidegger. Boss had undergone a six-month psychoanalysis with Sigmund Freud in 1925 and became Carl Gustav Jung’s disciple (1938–1947) but distanced himself from Freud’s metapsychology and Jung’s analytic psychology. He became acquainted with Heidegger in 1946 (the correspondence started in 1947), and began to formulate his Daseinsanalyse, which he turned into a phenomenological-hermeneutic psychotherapeutic method.

At the same time, Bally was more eclectic than Boss. He had recommended that psychotherapeutic training in Switzerland should be attached to university clinics or to specialist training units in mental hospitals. He deplored the situation in which private psychotherapeutic or psychoanalytic institutes in different areas were too school-devout, too one-sided, and tied to a certain orientation, be it Freudian, Jungian, Adlerian, Binswangerian, Horneyan, or Rosenian. Bally was in favor of closer collaboration between Freudians, existentially oriented analysts, and Jungians. He held Freud in high esteem, without succumbing to Freudian orthodoxy. On Freud’s meaning for medicine, Bally (1959) stated: “Until Freud, the language of medicine had served solely as a means to reporting and communicating. Only he has given it back its consciousness of the fact that language is dialogical, that is dialogue between others and ourselves.” (emphasis in the original)

The open and inspiring psychotherapeutic training atmosphere in Switzerland was also reflected in Zurich at the end of the 1950s. The Institut für ärztliche Psychotherapie was active, as was the IPA-related psychoanalytic seminary and the C.G. Jung Institute. From this Swiss background, Martti Siirala had drawn a philosophical-existential-phenomenological-anthropological and sociopathologically tinged reinterpretation of psychoanalysis. To this amalgam were added the new conceptions of illness, such as the one expressed by von Weizsäcker (1951) in Fälle und Probleme. He saw illness as something “produced,” as a solution devised by an individual but also societally and therapeutically applicable. It was one of the ways in which people could relate to encounters with each other.

Siirala’s close ties with, for instance, Gaetano Benedetti, Norman Elrod, Fritz Meerwein, and Christian Müller stem from his years in Switzerland. He also stayed in contact with Wilhelm Kütemeyer, Wolfgang Jacob, and Heinrich Huebschmann, who continued von Weizsäcker’s work at the University of Heidelberg. Siirala wrote a remarkable number of letters to colleagues and friends, both near and far, written in Finnish, Swedish, German, and English. In this article, I have quoted some of his (in German) letters to Benedetti and other colleagues, as well as some letters sent to him by Benedetti (also in German) and other colleagues. All the letters come from Martti Siirala’s archive. The translations are mine.

Benedetti remained a member of the IPA until the end of his life, while Siirala shunned IPA activities and Rosen’s patient-centered attitude and advocated “open psychoanalysis” (Ihanus, 2002). In addition to Bally and Boss, Benedetti collaborated with Marguerite Sechehaye and Christian Müller.

Benedetti and Müller founded the International Symposium for the Psychotherapy of Schizophrenia, which became the basis for the ISPS (International Society for the Psychotherapy of Schizophrenia; now the International Society for Psychological and Social Approaches to Psychosis). Benedetti, Müller, Siirala, Fritz Meerwein, and Norman Elrod had together arranged many preliminary discussions on the design of the symposium (Herner, 1957). The first symposium was held in Lausanne at the Cery Hospital in October 1956, with Finnish psychiatrists Siirala, Kauko Kaila, and Allan Johansson among the 70 or so participants (Siirala, 1957a, 1957b).

Benedetti actively participated in many subsequent symposia, which also brought Finnish psychiatrists into contact with the field (e.g., Siirala, 1960). Also of significance are the thorough reports on schizophrenia research prepared by Benedetti and his colleagues from the early 1950s to the 1970s (Benedetti, 1957; Benedetti & Rauchfleisch, 1975; Benedetti, Kind, & Johansson, 1962a, 1962b; Benedetti, Kind, Johansson, & Wenger, 1969; Benedetti, Kind, & Mielke, 1957).

When reminiscing about and assessing the early days of schizophrenia psychotherapy, Benedetti (2006, pp. 33–34) remarked that although Freud, Jung, Eugen Bleuler, and Ludwig Binswanger had approached schizophrenia psychologically, they had not focused on the relationship toward the patient in the same manner as that adopted in the 1950s. This change of attitude, “a new wind,” was characterized by Benedetti (2006, p. 34) by using the terms “symbolic realization,” “relatedness,” “basic trust,” and “the constancy and reliability of the relationship.” In the psychoanalytically oriented psychotherapy of schizophrenia, there emerged, in the 1950s, a gradual transition from verbal interpretation to nonverbal interpretive expression, “the symbolic game, the psychodrama, the gesture, the so-called ‘latent therapeutic response’ “ (Benedetti, 2006, p. 40).

The initially collegial relationship between Benedetti and Siirala in Zurich gradually developed into a close, dialogically open, and mutually enriching friendship that continued until Siirala’s death. Siirala also began to use Benedetti’s nickname, “Dedo.” For Siirala, the relationship with Benedetti was the most important in terms of psychotherapeutic practice, the associated “co-humanity” attitude (Benedetti, 1973), and the sharing of human experience. Benedetti’s (1952) doctoral thesis on alcohol hallucinations had been completed at Burghölzli, and with the merit it bestowed, he was appointed docent of psychiatry at the University of Zurich in 1953.

Benedetti’s early contacts with Finland

Benedetti also visited Finland several times to lecture and provide training. The earliest visit to Finland, together with Siirala, dates back to April 1955. The Association for the Promotion of Psychoanalysis, which had been founded in 1952, had invited Benedetti to hold a seminar on the psychotherapy of schizophrenia in German with Martti Siirala in Helsinki from April 25 to 28, 1955. That seminar was attended not only by members of the association, but also by several other people with a professional interest in the subject. Benedetti also gave a lecture on the psychotherapeutic treatment of schizophrenia at the Lapinlahti Psychiatric Clinic on 25 April.

Benedetti’s program in Finland continued from April 29 to 30, 1955, during the consultation days held by doctors and priests. After World War II, these annual consultation days in Finland served as an early public arena for discussing psychotherapy and psychoanalysis. In addition, psychoanalysis had already been discussed at the meetings of the Finnish Christian Medical Association (founded in 1923) in the 1930s and again after the war in the 1940s and 50s.

Benedetti was the main speaker at the consultation days. He lectured on both days on the topics “Die Spaltung des Gewissens” (The splitting of conscience) and “Die Schizophrene Vereinsamung als Vorenthaltung mitmenschlicher Gemeinschaft” (Schizophrenic loneliness as the pre-exclusion from human community). Other lectures included Martti Siirala’s “What kind of questions and tasks does the confrontation with mental illness pose to us?” and Martti Kaila’s “The state of mental healthcare in our country.” Benedetti and schizophrenia psychotherapy attracted the attention of the press and articles on his visit were published in several newspapers.

Benedetti also took part in the discussions on the status of patients, treatment, and mental health work, as well as on the plans for a diaconal institution designed to serve as a psychiatric clinic, providing psychotherapy and psychotherapeutic training for priests and promoting research in the field. The plan did not materialize as such, but it was one of the spurs for the creation of the independent Therapeia Foundation. Benedetti had suggested to Martti Siirala that the Therapeia Foundation should be set up on an international basis, so that he himself could participate in its activities. However, Siirala was not in favor of this idea, as he thought that international contacts would make the management of the Foundation’s affairs too complicated (letter from Martti Siirala to Aarne Siirala, November 2, 1956).

Benedetti’s contacts with Finland had already resumed at the end of 1955 when, on December 28–29, he gave a series of lectures on modern psychotherapy methods at the invitation of the “Adam’s Guild” of the priests’ brotherhood. His special topic was the “demons” imagined and internalized by patients. According to Benedetti’s interpretation, such demons were expressions of an unsatisfied “love hunger” derived from childhood. In total, about 80 people attended Benedetti’s lectures, including psychiatrists, priests, theologians, psychologists, and others interested in the subject.

In 1955 and 1956, Siirala had nursed the idea of bringing Benedetti to Finland. In a letter (August 24, 1955) to his medical colleague Allan Johansson, Siirala says:

For my part, I have decided to try everything I can to get Benedetti to come to Finland permanently. It shouldn’t be totally impossible. We would first get him a visiting docentship, at the same time as he would be working in our planned psychotherapeutic institute for treating psychoses. Perhaps then, one day, we could set up a chair of psychotherapy at the university—Benedetti having that chair.

Benedetti himself was interested in these plans although not committed to them.

Benedetti in Basel

Plans to bring Benedetti permanently to Finland did not go ahead, however, as Benedetti was invited, in 1956, to succeed the physician-psychoanalyst Heinrich Meng as an associate professor of psychohygiene and psychotherapy at the University of Basel. At the same time, he was also granted the right to private practice. In a letter to his brother Aarne (July 29, 1956), Martti Siirala explained that Benedetti was about to move to Basel with his family and start his new job at the beginning of the semester in October.

The Friedmatt Asylum, located outside Basel, was opened in 1886. It took until 1954 before its surrounding walls were removed. The presence of the Swiss pharmaceutical industry was felt at Friedmatt, where, under the direction of psychiatry professor and chief physician John E. Staehelin, the therapeutic effects of chlorpromazine, among others, were studied as early as 1953. Psychopharmacological treatment began at Friedmatt in 1956 (Bangen, 1992). In the 1960s, the Friedmatt Asylum was renamed the Psychiatrische Universitätsklinik (Psychiatric University Clinic). In 1923, the Psychiatric University Polyclinic (Psychiatrische Universitäts-Poliklinik) was opened in the center of Basel, which was under Friedmatt administratively, and under the Basel Cantonal Hospital from 1977.

Benedetti’s psychoanalytically and psychodynamically oriented psychotherapy for schizophrenia took on a different, experimental, and marginal role from the mainstream psychiatric treatment in Basel. As early as 1958, in a letter to Siirala (dated March 23), Benedetti deplored the fact that opposition to his psychotherapy work at the Basel clinic had increased to such an extent that he felt it necessary to advertise for others to take his place:

The resistance at the clinic has become so strong that I finally considered it necessary to quit my post at Friedmatt by the end of June. This experience as well as those at Burghölzli will be a lesson for us for the future. This work must be better prepared in the future and begun only when certain preconditions exist.

In a letter dated October 12, 1958, Siirala commented on Benedetti’s difficulties at Friedmatt and expressed support for his efforts at reform and the formation of a permanent working group. Siirala (in the same letter) maintained that the basic difficulty lay in separating two human groups. The “proper” society was inhabited by the group of “normal” and “high-grade” people, while the other group consisted of the “abnormal” and “low-grade” people who were not really seen as parts of society – unless they were “normalized” through therapy or otherwise. Fundamentally, the solidarity needed in the struggle with psychosis was often missed and it was a very complicated and time-consuming process to raise the awareness of such solidarity among “normal” people (including those working “normally” in therapeutic organizations).

Benedetti had to fight for his own concepts of treatment and, at the most difficult stage, was even prepared to leave Basel altogether and return to Zurich to take up the post of chief physician at Burghölzli under his lifelong supporter Manfred Bleuler (letter to Siirala of August 30, 1959). Under Professor Paul Kielholz at Friedmatt (1959–1985), Benedetti was nevertheless able, despite opposition, to lead, as a respected pioneer, the small psychotherapeutic and psychohygienic institute at the University of Basel. He also worked at the University Psychiatric Polyclinic in Basel in therapeutic, training, supervision, and research work until his retirement in 1985.

Benedetti had been invited to the University of Frankfurt am Main in 1960. That same year, Siirala drew up a proposal, signed by several people and addressed to the Finnish Neuro-Psychiatric Association, to further propose to the University of Helsinki Faculty of Medicine that Benedetti be invited as a visiting professor for the spring semester of 1961 (letter to Benedetti of October 8, 1960). In the proposal (dated October 14, sent October 17, 1960), Benedetti is described as “a therapist with rare ability to empathize with the difficulties of another human being, and with an exceptionally interpretative intuition, as well as a person who has a profound respect for and understanding about the distressed human being in his patient.” Benedetti is also described as a “critically screening researcher” and “an excellent teacher.” The association proposed an invitation, but Benedetti’s health prevented him from accepting an invitation from the University of Frankfurt am Main or the University of Helsinki.

Benedetti had suffered from an acoustic neuroma, a brain tumor of the auditory vestibular nerve, which had caused him to lose the hearing in his right ear and vision in his right eye, from complications in the facial nerves. A surgical operation in late 1961, followed by a second operation, succeeded, however, in restoring Benedetti’s ability to work after about a year (letters from Benedetti to Siirala dated March 12 and November 10, 1962). He had visited Finland before his illness, and on August 25, 1960 gave a lecture on “The problem of guilt and psychotherapy” at the annual meeting of the directors of the European evangelical academies and lay institutes.

Intermezzo: Aino Kärkkäinen’s experiences of everyday life as a nurse

In Basel, Dr. Allan Johansson from Finland was a volunteer assistant at the institute led by Benedetti, and under Benedetti’s analysis from 1957 to 1961. Under Benedetti's guidance, another Finn, nurse Aino Kärkkäinen, also studied psychotherapy for psychoses in Basel. Kärkkäinen had gone there to learn about the new European treatments for psychosis. By chance, in the summer of 1955, she had in London met Finnish psychiatrist Martti Paloheimo, who told Siirala in a letter (September 23, 1955) that he had advised her to turn to Siirala because he had got the impression that she was “comparatively talented, at least she has shown a tendency for independent thinking: a Savonian merchant’s daughter, travelling around Europe without help or advice and looking for better learning opportunities.”

In 1956, Kärkkäinen had already spent six months in Zurich, where she first met Siirala, Benedetti, and Manfred Bleuler. In July of the same year, she returned to Finland and, under the auspices of psychiatrist Oscar Parland, tried to create a new atmosphere of care in his ward in Nikkilä Hospital. She was met with resistance from traditional psychiatry. For example, in one of her letters, she mentioned that psychiatrist Elmi Harlahti, a proponent of shock treatments, was “constantly on my back in Nikkilä Hospital because ‘Benedetti is not her prophet, so let’s not spread that religion in the house’ “ (Aino Kärkkäinen’s letter to Siirala dated October 4, 1956). Kärkkäinen did not receive any support from nurses either. Only from the Association for the Promotion of Psychoanalysis did Kärkkäinen gain some interesting insights and she even gave a lecture there with Oscar Parland. At the end of 1956, Kärkkäinen returned to Basel and was able to continue her psychotherapy work there under Benedetti.

In her letters to Martti Siirala, who returned to Finland from Switzerland in December 1957, Aino Kärkkäinen, whose nickname was “the Fly,” reported her news about Benedetti and her experiences as a ward nurse at Friedmatt. For example, in a letter dated January 27, 1958 from Basel, she gave Siirala an eyewitness description of the clinic, while also explaining her personal situation and professional ambitions:

I think it is best to confess that last week has been a very critical one. Prof. B[enedetti]. and myself were close to a breaking point. I’m smiling a bit now, but it was far from a joke. The situation here at the clinic has been – as you know – sozusagen miserabel [so to say, miserable]. It got to the point where a couple of members of the staff + Prof. [John E.] Staehelin suggested that Prof. B. should set up his own department under the auspices of Friedmatt. A fine suggestion as such. The matter has now progressed so far that Prof. S proposes taking it up further in administrative circles. The department will be small, only 4 places for patients. Still, that’s a step forward!

Prof. B. quickly seized upon the idea and started arranging things at a Catania pace. Dr. A[llan]. Johansson would be associate doctor and Ms. A[aino] K[ärkkäi]nen department nurse + teacher … I declined the honor; I had tried to present my arguments years ago. It just so happened that the very posts I had escaped from came my way again, as if to order. I was shaking like an aspen leaf when I realized that Herr Professor only saw the positive sides (of which there were many) and not the situation of the person in question. And then the Prof. gave me an ultimatum: “You should make up your mind, either say yes or look for a job elsewhere.” – And that was when I cried for the first time … 

It’s almost unbelievable that things can turn out this way. For 2½ years I've been ‘wrapped around the professor’s little finger,’ reacting when called, but now for the first time I had to say ‘no way.’ Now I’ve reached the point where I can continue my so-called therapies. I can also have a group (colors, clay, etc. in the context of work therapy) and I have a library at the Institute. And I’ll have a local woman here as a part-time nurse.

This makes me look ungrateful toward the Professor. Still there were too many weighty reasons why I couldn’t do anything else. The biggest and most important is probably my personal situation. Everyone else in this field has at least one person close to them, relatives – there’s more to life than work. Analysis must also play its part. I’ve lacked both. I’ve had wonderful support from Prof. B., but he no longer has the time, and his enthusiasm has waned considerably in these circumstances. – So, my position now is that I’m trying to ‘stay afloat’ until I finally get into analysis. The candle has been burned and long burned at both ends, and now there’s not much left to do. I fervently hope that a solution will appear from somewhere … Prof. B. has not yet been able to fathom my stubbornness. Nevertheless, I guess he saw my hopelessness!

Struggling with professional and financial worries, Aino Kärkkäinen gradually decided to break away from the Friedmatt Hospital and Benedetti. While on holiday in Rome, she sent a letter, dated April 10, 1958, to Siirala, announcing that she had begun her analysis with psychiatrist Fritz Meerwein. Finally, she told Siirala from Basel (letter of October 22, 1958) that she had made up her mind and drummed up the courage to say to Benedetti: “Now I’m leaving you, hah!” In her own words, Kärkkäinen had been treated with disdain by the “gentlemen” of the clinic. Benedetti had smiled and interpreted “the whole thing as a neurotic symptom, with all the best possible explanations”: “We had difficult hours in the obscurity of this institute,” as Kärkkäinen put it to Siirala (letter of October 22, 1958). Later, however, the discussions with Benedetti went better, “like in the old days in Zurich when we were very good friends” (the same letter).

Kärkkäinen had gone to Zurich to seek advice from Manfred Bleuler, who had initially suggested that Kärkkäinen should study medicine and then work as an assistant at the Burghölzli Hospital, but he had also been prepared to employ her directly as a nurse at Burghölzli, with separate funds. Kärkkäinen, however, decided to take a part-time job as an occupational therapist at the Zurich University Hospital for Surgery, run by Alfred Brunner, at the beginning of 1959, while studying at the Institute for Applied Psychology, listening to lectures at the University of Zurich and continuing her own analysis, which lasted two and a half years. In 1960, Kärkkäinen also worked as a group therapist at Burghölzli.

Aino Kärkkäinen’s experiences reflect the difficulties that a woman seeking professional and personal development had to face in a male-dominated clinical community. Kärkkäinen heard in the hospital colloquium how her own analysis was belittled: “You are unable to accept your own motherhood” (letter to Siirala, October 22, 1958). She was skeptical about “using science to turn people into specialists, men with brains and women who are allowed to nurse patients and play Santa Claus” (the same letter). The lack of a university entrance qualification and the lack of specialized studies distanced Kärkkäinen from the male “brain club” and created “a little bitterness toward those gentlemen, as it really seems that a woman’s duties in the field should include nothing more than bathing and feeding” (the same letter). Nurses were not usually accepted to psychoanalytic training. As Paul Federn’s assistant in 1935–1938, and through Grete Bibring’s and Anna Freud’s control analysis, Gertrud Schwing from Zurich had been the first nurse who was accepted to the Vienna Psychoanalytic Society (Weiss, 1966).

Siirala, who followed Kärkkäinen’s experiences from Finland, supported her by recommending scholarships, encouraging her to continue her own analysis and later to return to Finland to work on intensive psychotherapy. Siirala considered Kärkkäinen to be very talented, but in a letter to Allan Johansson (November 8, 1958), Siirala commented that he did not fully understand what kind of “demon” was driving her. In the same letter, he gave his own “diagnosis” of her:

Aino has ‘placed’ in men (specifically in her superiors or in authority figures in general) on the one hand the image of great helpers for whom nothing is impossible, and on the other hand the image of those who specifically do not want her to get ahead and strive and compete with them … There must have been something in Benedetti that fed this image of those superiors … .

After many difficult phases, Aino Kärkkäinen, then a single mother of a daughter, was appointed clinical therapist at a private clinic in Münchenbuchsee (Privatklinik Wyss) in 1963. Documents relating to later phases of her life have thus far not been found.

Dialogical relationship and “one’s own way”

Siirala, in reflecting on the development of Benedetti’s conception and therapy of schizophrenia, considered that it was based not only on Benedetti’s extensive experience, but also on Boss’s Daseinsanalysis, Bally’s sociological-philosophical orientation, and the dialogue with Siirala (Siirala’s letter to Richard Eeg-Olofsson of February 26, 1960). To these can also be added the stimuli provided by Eugen and Manfred Bleuler, Jung, and American intersubjective perspectives. Schizophrenia was defined by Benedetti as a split between isolated and symbiotic self-states and lack of symbolic function in maintaining interaction (Benedetti & Peciccia, 1994).

In a letter to his brother Aarne (July 29, 1956), Martti Siirala confidentially mentions that Benedetti was apprehensive about publishing a schizophrenia work together with Siirala, “because in my opus I explicitly confess Christ, which he cannot do for the time being. Personally, I am not quite sure whether that explicit confession could be left out of my opus or not.” Siirala’s (1961) schizophrenia work Die Schizophrenie des Einzelnen und der Allgemeinheit (Schizophrenia of an individual and community) included only Benedetti’s previously published article (1955), and the religious overtones remained in the work although references to Christ in Siirala’s later production were reduced.

Benedetti, in his letter to Siirala (December 13, 1959), talks about his reading experience regarding the manuscript of Siirala’s work Die Schizophrenie des Einzelnen und der Allgemeinheit and delivers friendly, albeit direct, criticism. Benedetti had initially considered co-authoring the work, but came to another conclusion:

I sense in your basic conception what is, for me, a disquieting readiness to call strongly into question everything connected with tradition, language heritage, societal norms, and the authority of institutions, and to become increasingly isolated. Is that necessary, dear Martti? Is there no possibility of being in step with other people, being faithful to their language, and always being ready to listen to what they say to us? A ‘way of writing that looks artificial’ remains disjointed even when it tries to express something honest and profound … 

I have also doubted whether it is wise to write a piece on one’s own life history in the preface to the book … an unprepared reader can … certainly get a one-sided and incorrect impression that the writer’s strong problems have engendered a certain religious thematization of the phenomena stemming from mental illness … 

For when you also say that everyone should take responsibility for his own part, and when you as well mention that there was “of course no unanimity of views” in the circle, too little has been said about the fact that you have, in an essential area, gone your own way strongly (and of course necessarily) opposing other opinions, including mine.

Dear Martti, I now very much hope that you won’t take this the wrong way, and that you will understand that this criticism of mine, which in friendship must always feel bad, is delivered to support our friendship.

Siirala and Benedetti were not always in agreement in their dialogue. Benedetti’s starting points were more academic and conciliatory, while Siirala’s comments sometimes had a more critical and challenging tone (see also Ihanus & Siltala, 2011, pp. 119–120). Siirala clarified his position and the nature of his personal opposition in his letter to Benedetti (December 25, 1959):

For me, questioning societal norms, the authority of institutions or even language heritage does not absolutely mean isolation – as it seems to mean for you … 

Yes, Dedo, I’m fully aware that in a sense I have “gone my own way” and continue to do so. This is the fate of every more or less independent human being (incidentally, so do you – albeit in a different dimension from me). It only becomes particularly apparent to people who cherish systematic thinking … 

The fact that we are honest with each other does not, in my opinion, in any way endanger our friendship – you needn’t worry about that. I believe that we – you and I – have essentially met and are close to each other. Of course, the ‘sword also slashes’ through our hearts, and the demonic seductions threaten our friendship. However, if we remain vigilant, we’ll always find a way, won’t we?

This kind of independence from authorities and schools of thought was expressed by Siirala in several other contexts as well. Thus, he did not elevate Binswanger, Boss, or Bally as grand masters, nor did he see any possibility of engaging with any psychoanalytic, Daseinsanalytic, or Jungian current, or any doctrine, be it psychotherapeutic, philosophical, or theological. In his close contact with Benedetti, Siirala tried to secure and foster openness in the psychotherapeutic encounter and experience, and to pave the way for previously unknown development potential – in patients and psychotherapists alike. For Siirala, the already-known was an indication of the all too widespread depressive and defeatist (insensitive) sense of lifelessness.

From transfer to transference and self-realization

In his schizophrenia work, Siirala (1961) coined the concepts of the “first reception” and the “reception world,” referring to everyone’s childhood history in which the developmental course of early experiences is routed and rooted, forming the vicissitudes of hope and despair. In his later works, Medicine in metamorphosis (1969) and From transfer to transference (1983), Siirala evolved the concept of “second reception” (already introduced in Siirala, 1961). The reception of earlier vicissitudes in the current therapeutic situation is the core of the second reception, meaning for Siirala (1969, 1972a, 1972b, 1983, 1993) a shift from transfer to transference, from an anonymous, vicarious placing of burdens to an increasingly shared fate in dialogue, taking the specific individual transitional form of transference. The therapeutic process outlined by Siirala proceeds from listening to and talking about psychological and organic symptoms, namely the message of illness, to sharing the burdens and gradually unpacking the “transfer package” in and through transference. Transference takes the place of projection (Benedetti, 1964a), when projection “is allowed to move from the vacuum space of ‘objective givenness’ to sharing” (Siirala, 1972a, p. 134).

Ultimately, disengagement from the transferred burden can free the burden-bearers to creatively realize the potentialities that have been lost. Shifts of collective burdens onto individuals resulted, in Siirala’s view, in a community denying its responsibility and leading its individual members to illness and distress, affecting both their personalities and their body and its organs. In a community, the transfers of and substitutions for illness, defined as objective and legitimate, aim to prevent a shift away from the static and repetitive world of the first reception toward the living dialogue of the second reception, and further toward the individual’s (family’s or group’s) responsibility, a unique reception of the world and existence, a third reception without a therapist. This “third transfer” implies a “new integration” (Siirala 1969, p. 127) in which the absoluteness of the first (burden) transfer has undergone a profound and liberating transformation.

In psychotherapy, sharing the burdens becomes the primary task of the therapist (or peace negotiators in collective conflict resolution). Ultimately, Siirala saw sharing as affecting the whole of humanity, with transgenerational transferences continuing “throughout the bloodstream of the community, without stopping at the therapists” (Siirala 1972b, p. 318). Transference must extend to “all dimensions of trust and hope, distrust and despair” (p. 318). At the same time, Siirala also warned against the dominance of any single theoretical model or perspective, and against therapy theories becoming dogmas of faith and salvation unless they are critically analyzed.

For his part, Benedetti (e.g., 1964a) tried to get rid of the specific schools and currents of psychotherapy and to reinvent it as a “science of encounter” in which the therapist relentlessly “carries” their patient and preserves an unbroken human contact even through the most difficult moments. For Benedetti, psychotherapy was more of an “attitude” than a “method of treatment.” Through this attitude, the developmental resources of the patients are given free rein to emerge in unforeseen connections. One should be careful about using such words as “healing” and a “change of personality.” Both Benedetti and Siirala basically thought that no pre-established scheme or norm can guarantee the meaningfulness of interpretation in therapy or make the therapeutic situation receptive to unknown possibilities or to silenced voices. Benedetti (1964a) stated that the patient may get better with the help of any theory (or despite any theory) if they are given, in the frame of that conceptual thinking, something that they need. This can be given in the language of words and deeds.

In Benedetti’s thought, Siirala also found something that he had to reconsider. This concerned human corporeality, the foundation of both individual and communal existence. After having read Benedetti’s manuscript for Klinische Psychotherapie (1964a), Siirala praised the work (letter to Benedetti, June 6, 1963) as a “historically meaningful, ‘epoch-making’ step in the whole of psychotherapy,” a “real treasure trove,” its style being “wonderfully clear, precise and at the same time nuanced and deep,” its “perspective always open” and its tone “very sympathetic.” However, in Benedetti’s text, Siirala missed discussion about “the embodied form of existence of the human individual and community,” as well as about “the relatives, staff, the therapeutic team and society in general,” as the basic (“third”) psychotherapeutic perspective on both somatic and mental disorders. The communal-societal dimensions of illness-being were, according to Siirala (1986, p. 21), best considered by von Weizsäcker and his followers, whereas in Daseinsanalysis (à la Boss) such dimensions were “very meager.”

Benedetti’s manuscript for Klinische Psychotherapie reminded Siirala of their many dialogues in Zurich and their mutual understanding that in psychotherapy one should not stick to pointing out how the patient had failed in their existence, but rather support the patient in seeking how to realize their existence. Thus, the therapist “carries” the patient through even the most difficult moments toward the reciprocally hidden resources and possibilities of self-realization. Siirala (letter to Benedetti dated June 6, 1963) confessed to Benedetti: “You have always opened your heart and ears to this [self-realization]. We returned to this issue again and again, while I was painfully aware that I am always inclined to the first attitude [thinking how the patient has failed].”

Concern for humanity

In his early writing, Siirala (1954, p. 50) had stated, already in complex terms, that existential philosophy is:

sighing of humanity under the strong chains of rationalism – striving from being under the curse inflicted by the use of the word ‘is’ and its terrible shallowness back to the sources of lost richness and differentiation, away from idealism stranded in a cul-de-sac and away from empty formalism.

In existential philosophy, as well as in different -isms, science, and religion, the young Siirala saw a human being in the self-appointed position of “the master of the message of one’s existence” (1954, p. 49).

Benedetti’s visits to Finland continued from the 1970s onward. In August 1971, he participated in the ISPS symposium on schizophrenia in Turku, followed by a lecture in Helsinki. In September 1978, he gave a public lecture in Helsinki on “Der Geisteskranke als Mitmensch” (The mentally ill person as a fellow human being) and delivered a lecture at a weekend seminar organized by the Therapeia Foundation. He participated in the Therapeia Foundation’s psychoanalytic and interdisciplinary “Violence” conference in Haiko in August 1980 and in the Therapeia Training Seminar in June 1984. As an honorary member of the Therapeia Association, Benedetti gave a keynote speech in Helsinki on November 19, 1993 on the 35th anniversary of the Therapeia Foundation. Benedetti was also invited to become an honorary member of the Finnish Psychiatric Association in 1979.

In his unpublished autobiographical notes (1974), Siirala summarized in English his understanding about Benedetti’s personality and activities:

In the rapid assimilation of Swiss-German culture he [Benedetti] had neither lost his Sicilian accent, the gesticulation nor the fire combined with Latin precision. At the same time, he seemed to me to have a too unrestricted veneration for the German ways of thematizing and institutionalizing. Science and university he seemed to take as basically unambiguous in their trends and practices. For him, they simply represented essentially benign forces in themselves. Their own self-interpretation he also was inclined to take for full currency. However, he did not prove quite unreceptive to my suggestions that schizophrenia-like patterns were also present and perceptible in them. Benedetti supervised my treatments with schizophrenic patients in the connection of which he told me about his own ongoing therapies. An intense dialogue gradually evolved between us two. Benedetti just was there – equally with his own patients and with the ones I told him about. I never had the feeling that he would have interpreted anything in this or that particular way; he just seemed to be present, listening and answering in the most natural way provided by an immediate contact with the core of the patients’ schizophrenic communications. This stirred up in me a correlated passion to voice the insights emerging out of his experiencing and of mine, and potentiated by the accompanying intense dialogue – in as universal a language as possible. This finally led me to write a book … (Die Schizophrenie des Einzelnen und der Allgemeinheit) the manuscript of which I finished in my home-made German in 1957.

Psychotherapy as a human encounter and “attitude” rather than a strictly limited method or technique of treatment, independent of fixed theories, doctrines, and schools, was Benedetti’s (1964a, 1964b, 1975) aim, which was also supported by Siirala in his emphasis on non-attachment to authorities and dogmatic systems. Benedetti had extensive clinical therapeutic experience and an ethos that stressed the value of scientific research, while Siirala focused more on philosophical issues, particularly the role of faith, knowledge, and power in psychotherapy and its co-responsible encounter with the message and appeal of illness. Siirala was skeptical about the power and specific terminology of the medical tradition, which could lead to “anonymous determination” and “primary thematization” and displace individual and communal efforts to free oneself from “self-alienation” (Siirala, 1972a, pp. 134–136).

Both Benedetti and Siirala shared an interest in the existential dimensions of illness, especially schizophrenia. Siirala, however, considered that human existence included not only ethical elements, but also the elements of “sacredness” and “religiosity,” linked to “trust, hope, solidarity,” and not to the “stifling dogmatisms” of theories, philosophies, or religions (Siirala, 1972a, p. 153). For example, in the treatment of schizophrenia, Siirala considered it necessary to develop an empathic understanding about both individual and collective delusions and divisive phenomena. Like the “psychiatry of peoples” outlined by Harry Stack Sullivan in 1948 (Sullivan, 1953), Siirala (1972a) saw the possibility of extending this understanding to include relations between religions, science, cultures and ideologies, and social, ethnic and language groups.

In his writings (e.g., Benedetti, 1994, 2006; Benedetti & Peciccia, 1994), Benedetti summarized three key dimensions of psychosis psychotherapy that have links to his dialogue with Siirala. First, the therapist seeks a creative and multilayered “understanding” concerning the patient’s difficulties and possibilities. Second, the “affective closeness” with the patient involves the therapist’s partial identification with the patient. Third, however, the therapist maintains the “positive distance” that allows for self-reflection and a perspective of change without the intertwining of the therapist’s and the patient’s problems.

In his letter to Siirala (December 7, 1969), Benedetti mentions with appreciation Siirala’s work Medicine in metamorphosis. Speech, presence, and integration (Siirala, 1969), from which he says he learned much, and which brought back some memories of their former times together. The dialogue between Siirala and Benedetti was not interrupted during Siirala’s lifetime although the correspondence between them remained sparse. They were not eager to write letters to each other, but longed for a direct and immediate face-to-face conversation, of the type they had engaged in during their shared years in Zurich.

In some letters, there is a palpable nostalgia and at the same time a persistent desire to further develop a dialogical psychotherapeutic and human understanding, even though encounters had become less frequent. Consequently, Siirala (letter to Benedetti, December 17, 1969) expressed his trust in continuing mutual discussions: “In fact, I either do not have the feeling that our dialogue has been silenced, but that it is just waiting somewhere to be continued.” In his letter to Siirala dated October 13, 1977, Benedetti paid tribute to Siirala’s

concern for humanity, which is often indiscernible in so many psychoanalysts or Marxists. It is so good that there are people who, like you, keep calling to mind such thoughts. Sometimes it seems as if we are being destroyed by an evil fate; but the fact that we never give up is the healing secret … 

Benedetti recalled Siirala’s reflections on the nature of love in therapy, defined by different ideals. Siirala thought that love does not “flow” from the therapist to the patient but is manifest in the therapist’s loyal and reliable presence in the therapeutic situation with the patient. Benedetti (2006, p. 36) quoted Siirala:

All of our ideas about love fall apart again and again and we experience something completely different than we expect, and we discover that in the occurrences between the patient and ourselves, hatred and bitterness horn their way in over and over again.

Among friends, the many faces of love were also part of the dialogue.

Acknowledgement

I am grateful to Ann-Helen Siirala-Forsberg for allowing me to quote all the manuscript material from the Martti Siirala Archive.

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Notes on contributors

Juhani Ihanus

Juhani Ihanus, PhD, is associate professor of cultural psychology at the University of Helsinki and Associate Professor of the history of science and ideas at the University of Oulu, Finland. He has published books and articles on the history of psychology and psychoanalysis, psychoanalytic theory, psychohistory, cultural and clinical psychology, the psychology of literature and art, and biblio/poetry therapy.