Subido por José Manuel Martínez Rodríguez

Schizophrenia embodiment and intersubjectivity

An embodied and enactive approach to psychopathology regards
mental illness not a malfunctioning process occurring in the individual
brain but a disturbed way of enacting a world, in particular, to co-constitute a shared world through adequate interaction with others. I will use
schizophrenia as a paradigm case for this approach. Whereas current
neuropsychological theories attribute the core, disturbances in schizophrenia to higher order cognitive processes such as “theory of mind” or “metarepresentation”. In contrast, phenomenological approaches locate the main
disorder in schizophrenia on a lower level, regarding it as a fundamental
disturbance of the embodied self, or a disembodiment. This includes (1) a
weakening of the basic sense of self, (2) a disruption of implicit bodily
functioning, and (3) a disconnection from the intercorporality with others.
As a result of this disembodiment, the pre-reflective, practical immersion
of the self in the world is lost. Delusions may then be described as
disturbances of the joint constitution of a shared world. This approach
offers therapeutic options that are based on re-embodiment and
And then something odd happens. My awareness (of myself, of my father,
of the room, of the physical reality around and beyond us) instantly grows
fuzzy. Or wobbly. I think I am dissolving. I feel – my mind feels – like a
sand castle with all the sand sliding away in the receding surf. …
Consciousness gradually loses its coherence. One’s center gives way. The
center cannot hold. The 'me' becomes a haze, and the solid centre from
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which one experiences reality breaks up like a bad radio signal. There is no
longer a sturdy vantage point from which to look out, take things in, and
assess what’s happening. No core holds things together, provides the lens
through which to see the world … (Saks 2007, 12f.).
This report from a patient about her first experiences of schizophrenia
in her 7th year of life shows how this illness may affect the self in its very
core. Of course, phenomena of alienation or depersonalization are not
restricted to schizophrenia. Rather, they are so pervasive in mental
disorders that in French psychiatry the term “alienation” even signifies
mental illness in general. But only schizophrenia may call the mineness of
one’s own sensations, thoughts and actions into question and threatens the
person with a loss of self. In order to understand this illness in its essence,
a philosophically founded psychopathology is therefore indispensable.
Conversely, the disorders of the self in schizophrenia should be of crucial
interest for any philosophy of subjectivity in order to test its concepts of
self-awareness, personhood and intersubjectivity by reference to empirical
The phenomena of self-alienation and self-disorders gained particular
attention for the first time in German and French psychopathology around
1900. Kraepelin (1913, p. 668) characterized schizophrenia as a "peculiar
destruction of the inner coherence of the personality" and as a
"fragmentation of consciousness" ("orchestra without conductor"). Bleuler
(1911) saw the basic disturbances in schizophrenia in “a splitting of
thought, feeling, will and the subjective sense of personality”. A bit later,
Berze (1914) assumed a “basic alteration of self-awareness” and a
“hypotonia of consciousness” to be the hallmark of schizophrenia. Finally,
Jaspers summarized the basic disorders as put forward by different authors
by the terms of “incoherence, dissociation, fragmenting of consciousness,
... weakness of apperception, insufficiency of psychic activity and
disturbance of association” (Jaspers 1968, 581), and added the experiences
of something being “made” which affects the thoughts, perceptions and
actions of the patient. Schneider (1959) later termed these peculiar
experiences of made thoughts, made feelings or made actions “egodisorders”, characterized by a loss of the boundaries between ego and
other; in Anglo-American psychiatry the term “passivity experiences” has
established itself.
In the last decades, phenomenological psychopathology has extended
these early concepts by subtle analyses of the basic pre-reflective self- and
world-experience which is fundamentally altered in schizophrenia often
many years before the onset of acute psychosis (Blankenburg 1971; Sass
and Parnas 2003; Stanghellini 2004; Fuchs 2000, 2005). From this point of
Schizophrenia, Embodiment and Intersubjectivity
view, it is not the so-called productive symptoms of the acute phase (i.e.
delusions and hallucinations) which are crucial for understanding the
illness, but rather the insidious erosion of bodily self-awareness,
perception and action which may often date back even to the patients’
childhood. In order to describe this alteration of experience adequately, a
differentiation of the concept of the self is primarily required that is
capable to particularly grasp the pre-reflective strata of experience. In
what follows, I will first outline such a distinction, then go on to analyse
the disorders of the self in schizophrenia on this basis.
Self and Self-awareness
Referring to the concepts currently discussed in phenomenology,
developmental psychology and cognitive neuroscience, we may distinguish
the basic, pre-reflective or core self from the extended, reflective or
personal self (Damasio 1999; Gallagher 2000; Rochat 2004; Zahavi 2005).
Basic or bodily self
(1) The basic self is characterized by an implicit, pre-reflective selfawareness that is present in every experience without requiring
introspection. Thus, any sensation, any perception or action directed
towards an object implies a tacit self-awareness; it is given immediately,
non-inferentially as mine. This first-personal givenness of all experience
may be regarded as a general medium in which specific modes of
experience are articulated. As the most basic form of selfhood, it may also
be called ‘mineness’ or ipseity (from the Latin ipse = ‘self’ or ‘himself’;
Henry 1973; Zahavi 1999). Ipseity is even preserved when autobiographical
memory is lost, as in amnesia or dementia, or when a long-term sense for
the future is missing, as in certain frontal brain damages.
On the other hand, the basic self should not be conceived as an
abstract, disengaged ego, but as involving the dimensions of self-affection,
embodiment and intercorporeality. Ipseity or ‘mineness’ is bound to the
background feeling of the body, mediated by proprioceptive and
kinaesthetic awareness, and implies a basic auto-affection which could
also be called the background feeling of being alive. Moreover, it involves
the sensory-motor relation to the world mediated through the body with its
particular constitution and its habitual background capacities. By being
embodied and thus structurally coupled with a complementary
environment, the basic self becomes an “ecological self” (Neisser 1988). It
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is embedded into its lived space and lived world which presents itself as a
field of possibilities, affordances, barriers or obstacles (Fuchs 2007).
Looking at the developmental aspect, these dimensions of embodied
self-awareness date back very early in life, even to the prenatal period.
From the 3rd month of pregnancy on, the fetus has reached sensorimotor
contact with its environment, discernible in more and more coherent
movement patterns and reactions to tactile or acoustic stimuli. By growing
integration of proprioceptive, kinaesthetic and sensory modalities, the
body schema is formed as a sensorimotor self-coherence.
As the ecological self is formed in the early interactions with the
environment in general, a basic intercorporeal or social self develops in
the interactions with others in the first months after birth. From the first
days on, babies are able to imitate facial expressions of others, that means
their intermodal body schema couples with the other’s body such that the
movements perceived in his face may be transposed into the baby’s
kinaesthetically felt movements. One’s own and the other’s body are
experienced as akin from birth on. This enables a bodily resonance with
others, particularly with the mother, which soon develops further into
shared affective states, emotional attunement or interaffectivity. The infant
acquires an implicit knowledge of how to interact with others, to share
one’s joy, elicit the other’s attention, avoid overstimulation etc. Thus,
intercorporeality and self-awareness are closely connected, constituting an
additional, social dimension of the basic self.
Extended, reflective or personal self
Primary self-awareness thus not arise from self-reflection or from a
social attribution; it is always already given with any experience, dating
back into prenatal life and further developing in the first year of life.
The extended or personal self begins to shape in the second year of
life. It is based on a number of emerging capacities that are closely
- the capacity for a higher-order awareness of one’s conscious states,
i.e. introspective or reflective self-consciousness;
- the capacity to understand others as intentional agents and to take
their perspective, i.e. self-transcendence;
- the capacity to understand and issue verbal reports about one’s own or
others’ feelings, thoughts and intentions, i.e. narrativity;
- the capacity to form a conceptual and autobiographical knowledge of
oneself, i.e. a self-concept.
Schizophrenia, Embodiment and Intersubjectivity
The extended self emerges in the course of early socialisation,
depending on the acquisition of autobiographical memory, concepts and
language. Its fundamental structure is intersubjective and reciprocal: It is
constituted through the ongoing relation to others, as the ‘social self’ or
‘me’ conceived by G. H. Mead (1924), which includes seeing oneself ‘in
others’ eyes’, internalizing their attitudes toward oneself and gradually
adopting the roles offered by the community. Taking the perspective of
others implies a shift from ego-centric to allocentric space and a concept
of oneself and others as intentional agents who are responsible for their
actions. The German philosopher H. Plessner (1975) spoke of the
“eccentric position” that is characteristic of the human mind. This position
is not only a cognitive achievement, but gives rise to a number of ‘selfreflective emotions’ such as shame, embarrassment, feelings of guilt or
pride which all depend on the internalized, evaluating ‘gaze of the other’
(Seidler 2000; Fuchs 2002). Any narrative only makes sense for a real or
an implicit other as well. There is an inner witness in most of our actions
and intentions, to whom we could give an account of what we did, and
justify what we are doing. In relating to herself, the person lives immersed
in narratives, at the intersection of different stories already begun but not
yet completed.
Despite this complex and dialectical structure, the extended self always
remains based on pre-reflective self-awareness: Only a being with the
constant sense of mineness is able “to form concepts about herself,
consider her own aims, ideals, and aspirations as her own, construct stories
about herself, and plan and execute actions for which she will take
responsibility” (Gallagher & Zahavi 2005). Disturbances of basic selfawareness are therefore bound to affect the extended self as well. Both
dimensions of self-experience, however, are not present a priori, but have
to be constituted by a complex interaction of biological, psychological and
social processes. The coherence of the self is a constant achievement of
self-constitution and self-affirmation – an achievement which may be
disturbed in manifold ways.
Schizophrenia as a Disorder of the Self
On this basis, let us now turn to schizophrenia. Current neuropsychological
theories attribute the core disturbances in schizophrenia to higher order
cognitive processes such as “theory of mind” or “meta-representation”
(Frith 1992, 2004; Brüne 2005). In contrast, phenomenological approaches
locate the main disorder in schizophrenia on a lower level, regarding it as a
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fundamental disturbance of the embodied self, or a disembodiment. This
(1) a weakening of the basic, pre-reflective sense of self,
(2) a disruption of implicit bodily functioning in the dimensions of
both perception and action, and
(3) a disconnection from the intercorporality with others.
As a result of this disembodiment, the pre-reflective, practical
immersion of the self in the world is fundamentally disturbed. This basic
alteration develops gradually, often many years before the manifest acute
Disembodiment of Self
According to the concept mainly developed by Parnas and Sass (Parnas
& Sass 2001; Sass & Parnas 2003), schizophrenia involves a diminishment
of basic self-awareness or ipseity. This draws on Minkowski’s (1927)
concept of schizophrenia as implying essentially a loss of vital contact
with reality. This is experienced as a feeling of a pervasive inner void or
lack of presence; it may also be expressed in complaints about certain
opacity of consciousness (feeling like “in a fog” or “surrounded by
invisible walls”) or a general existential feeling of being alien to the world.
This disturbance of pre-reflective self-awareness permeates all areas of
I constantly have to ask myself who I actually am. It is hard to explain...
most of the time I have this very strange thing: I watch myself closely, like
how am I doing now and where are the ‘parts.’ ... I think about that so
much that I cannot do anything else. It is not easy when you change from
day to day. As if you were a totally different person all of a sudden (de
Haan and Fuchs 2010, p. 329).
It is as if I am not a part of this world; I have a strange ghostly feeling
as if I was from another planet. I am almost non-existent (Parnas et al.
2005, p. 245).
A further example of compulsive self-observation is quoted by Parnas
and Handest:
If a thought passed quickly through his brain..., he was forced to direct
back his attention and scrutinize his mind in order to know exactly what he
had been thinking. In one word, he is preoccupied by the continuity of his
thinking. He fears that he may stop thinking for a while, that there might
Schizophrenia, Embodiment and Intersubjectivity
have been “a time when my imagination had been arrested.” ... He wakes
up one night and asks himself: “Am I thinking? Since there is nothing that
can prove that I am thinking, I cannot know whether I exist.” In this
manner, he annihilated the famous aphorism of Descartes. (Parnas &
Handest 2003, p. 128).
In vain, the patient tries to banish his existential fear of losing himself
by constantly reassuring himself. This explicit turn backward does not,
however, reach the source of thinking which should imbue it with a sense
of mineness. If the intentional act is no longer embedded in selfawareness, it remains unrealized and has to be repeated emptily, resulting
in what Sass has called hyperreflexivity (Sass 2000). Disorders of basic
self-awareness have recently come to be explored in detail by means of an
extensive, phenomenologically based interview (EASE, Examination of
Anomalous Self-Experience, Parnas et al. 2005).
Disembodiment of Action and Perception:
“Pathological Explication”
The disturbance of basic self-awareness in schizophrenia is accompanied
by a loss of automatic processing, leading to an increasing fragmentation of
perceptual and motor schemas, and to a ‘pathological explication’ of the
implicit functions of the body. Thus, otherwise tacit sensory-motor
processes become available for introspection.
“Explication of the implicit” is a well-known experience to us: By
reducing a schema or gestalt to its single elements, and we do not see, as it
were, the wood for the trees any more. Thus when looking for a typing
error, we cannot attend to the meaning of the text at the same time. Or if
we repeat a familiar word several times slowly and aloud it may sound
strange to us: The implicit coupling of syllables and meaning is dissolved.
In the same way, when thematizing a part of the body, it no longer
functions as part of the tacit knowledge. If the musician concentrates on
his single fingers, he will stumble in his run, as we also will when running
down the stairs and thinking of the single steps. Explication thus disturbs
former familiarity and leads to an alienation or disintegration.
Now in schizophrenia a “pathological explication” occurs. This
concerns both bodily functioning in action and perception.
(a) Action
Schizophrenic patients often experience a disintegration of habits or
automatic performances, a “disautomation”. Instead of simply dressing,
driving, walking, etc., they have to prepare and produce each single action
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deliberately, in a way that could be called a "Cartesian" action of the mind
on the body. Thus, the units of meaningful actions are fragmented,
resulting in a pathological explication and hyperreflexive awareness of
normally tacit aspects of everyday behaviour (Sass & Parnas 2003).
If I do something like going for a drink of water, I’ve to go over each detail
– find cup, walk over, turn tap, fill cup, turn tap off, drink it (Chapman
1966, p. 239).
There were periods in which I felt extremely badly coordinated … I also
found myself to be extremely clumsy, somehow, when walking. I therefore
constantly observed my walking and my movements … Climbing the stairs
was also very extreme … I really thought each step after the other, as it
was, each movement … (de Haan & Fuchs 2010, p. 330).
No matter where, the observing was with everything I did. Even when
playing games on the computer … And the hand-eye coordination, you
observe it all. Simply everything you do everything you say (de Haan &
Fuchs 2010, p. 330).
Here the implicit couplings or sensorimotor syntheses of the body
break down and must be replaced by conscious planning and execution.
The patients no longer manage to carry out a unified arc of action or use
their body naturally for this. This leads to a loss of spontaneity, to
increasing self-observation, and to hyperreflection. Every action, however
trifling, requires targeted attention and action of the will, as it were a
“Cartesian” impact of the Ego on the body. It is not for nothing that the
patients often speak of a break between themselves and their body, feel
hollowed out or like lifeless robots.
I am like a robot which someone else can use, but not me. I know what has
to be done but cannot do it (Chapman 1966, p. 231).
The feeling of being alive consists in being an incarnated self, which
can direct itself naturally through its body to the world. I present another
example (drawn from Bürgy 2003, p. 8ff.):
The 32-year old patient reports that at the age of 16, he had become
more and more uncertain about whether his personal things really
belonged to him or had somehow been exchanged by others. When buying
books, he was not sure if the salesman had not secretly replaced the ones
he had chosen; so he had to give them away and always buy new ones.
When leaving things on his school-desk inattentively, he later began to
doubt whether they were still the same, and had to throw them away. More
Schizophrenia, Embodiment and Intersubjectivity
and more he lost the trust in his environment. At the age of 21, he also
began to doubt whether these were really his own arms that did a work or
somebody else’s. He had to carefully to observe his arms from the hands
up to the body in order to make sure that they were his own, and he
repeatedly looked behind himself in order to see if there was not
somebody else who moved them. Now he could not trust his own hands
any more, and doubted the simplest actions. He took endless time to dress,
since he had to touch the cloths several times and had to repeat his
movements again and again to make sure they were his own. He did not
know whether he held his trousers the right way and in which order to
dress. Every movement was like an arithmetical problem that had to be
pondered over with extreme concentration. So he became stuck in his
everyday performances and felt more and more desperate.
In this patient, the loss of the basic self-awareness first manifests in his
distrust in the ownership of his belongings. In vain he struggles to fight the
growing alienation of his personal surroundings. Then the tacit “mineness”
of his own movements or agency is weakened, and the units of meaningful
actions are deconstructed. In order to compensate for this disautomation,
the patient has to prepare and produce each single action deliberately, in a
way that could be called a "Cartesian" action of the mind on the body. But
even then he cannot get sure whether they are not actually performed by
somebody else. The intentional arc mediated by the tacit bodily feeling of
“I can” is broken. Schizophrenic patients often speak of a split between
their mind and their body, of feeling hollowed out, like a machine or a
robot; for the sense of animation depends on being an incarnated subject,
with integrated bodily performances at one’s disposal. The disautomation
of action may culminate in a loss of agency, rendering the patients
incapable to wilfully release an action they intend to perform.
(b) Perception
In perception, the disembodiment manifests in an impaired capacity to
recognize familiar patterns or Gestalten which in turn leads to an overload
of details. Thus e.g. the features of familiar faces may come to look odd or
distorted like masks. A schizophrenic patient of Minkowski illustrates
another example, the loss of semantic transparency: “He can no longer
read at all. He becomes attached to a word, a letter, and does not attend to
the meaning of the sentence. He examines whether all the "i’s have dots
over them, whether there are accents where needed, whether all the letters
have the same form" (Minkowski & Targowla 2007, p. 273). Here the
single elements lose their function as carriers of intentional meaning.
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I have to put things together in my head. If I look at my watch I see the
watch, watchstrap, face, hands, and so on, then I have got to put them
together to get it into one piece (Chapman 1966).
Everything I see is in bits. You put the picture up bit by bit into your head.
… If I move there’s a next picture that I have to put together again
(McGhie u. Chapman 1961).
With growing alienation of the intentional arc, the act of perceiving
itself may come to awareness; then the patient is like the spectator of the
single moments of his perceptive processes.
I become aware of my eye watching an object (Stanghellini 2004, p. 113).
I saw everything I did like a film camera (Sass 1992, p. 132).
For me it was as if my eyes were cameras, and my brain was still in my
body, but somehow as if my head were enormous, the size of a universe,
and I was in the far back and the cameras were at the very front. So
extremely far away from the cameras (de Haan and Fuchs 2010, p. 329f.).
The perceiving subject gets into a position external to the world; he
becomes a homunculus who looks on his own perceptions like pictures.
The distortion of perception is also the core of the peculiar experience
at the beginning of the manifest or acute psychosis which Jaspers (1968)
described as “delusional mood.” The alienated perception turns the objects
into mere appearances or phantoms. There is an artificial, enigmatic and
uncanny alteration of the environment, connected with a loss of the overall
meaning of the situation. At the same time, new, idiosyncratic saliencies
may emerge, i.e. expressive qualities, strange features of persons and
faces, or hypersignificant objects standing out from the background. Over
the course of time, these fragments are reorganized by emerging delusions
that provide a new but rigid coherence of the perceptual field by
sacrificing some features while preserving others.
A final stage is reached when the dissolution of the intentional arcs of
perception, thinking, and action is so far advanced that the remaining
fragments of perception, thought, or movement take on a strange, objectlike character and finally appear to be imposed on the patient from the
I could no longer think the way I wanted to. It was as if one could no
longer think oneself, as if one were prevented from thinking oneself. As if
Schizophrenia, Embodiment and Intersubjectivity
the ideas came from outside ... I began to wonder whether I am still that
person or an exchanged person (Klosterkötter 1988, p. 111).
It is not hard to see how typical ego disorders such as thought
insertions or verbal hallucinations can develop from such forms of
Disembodiment of Intercorporeality and ‘Common Sense’
Now I turn to the intersubjective dimension of schizophrenia. Here we
have to take into account that it is the lived body that conveys the practical
knowledge of how to interact with others, how to understand their
expressions and actions on the background of the common situation. Thus,
we are involved in a sphere of primary “intercorporality” (Merleau-Ponty
1960). This tacit or enacted knowledge is also the basis of ‘common
sense’: It provides a fluid, automatic and context-sensitive preunderstanding of everyday situations, thus connecting self and world
through a basic habituality and familiarity.
If this embodied involvement in the world is disturbed as in
schizophrenia, it will result in a fundamental alienation of intersubjectivity:
the basic sense of being-with-others is replaced by a sense of detachment
that may pass over into a threatening alienation. It manifests itself in a
subtle “loss of natural self-evidence”, as Blankenburg (1971) has
impressively described it. Precisely those things become a problem “which
cannot rationally be unequivocally defined, which are a matter of tact”
(Blankenburg 1971, p. 82, own transl.): which dress one wears, how one
addresses someone, how one apologizes, and so on Patients report that
they feel isolated and detached, unable to grasp the natural, everyday
meanings of the common world.
When a child, I used to watch my little cousin in order to understand when
it was the right moment to laugh or how they managed to act without
thinking of it before … It is since I was a child that I try to understand how
the others function, and I am therefore forced to play the little
anthropologist (Stanghellini 2004, p. 115).
I just observe everything I do and everything that is happening around me
very closely. I probably cannot help doing that … When I talk to other
people, I always try to consider everything twice, to do it right … When I
want to make a joke, I reconsider it … It is as if I am an outsider (de Haan
& Fuchs 2010, p. 330).
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Thus, the behaviour of others comes to be observed from a distant or
3rd person point of view instead of entering 2nd person embodied
interactions. As a result, interpersonal relationships are in constant need of
being constructed by deliberate efforts, leading to constant stress in
complex social situations and finally to autistic withdrawal.
This alienation can also be felt when interacting with the patient,
leading to what has been termed praecox feeling by the Dutch psychiatrist
Rümke (1941), derived from the former term dementia praecox for
schizophrenia. It means the sense of an interpersonal atmosphere of
unnaturalness, characterized by a lack of mutuality, responsivity, or
I felt trapped by a peculiar kind of distress, as if, in contact with my
patient, something broke within me (Minkowski 1933)
Even after a very brief mental state examination it becomes clear to the
psychiatrist that his [the patient’s] empathy is lacking … it is impossible to
establish contact with his personality as a whole (Rümke 1941)
In the intercorporal encounter, the patient’s emotional expressions and
verbal utterances do not seem to correspond to each other or to the context
(parathymia); bodily movements and expressions are not integrated to
form a harmonious whole through which the person could manifest itself.
Kraepelin spoke of a Kraepelin spoke of a “loss of grace”. As a result,
others will experience the schizophrenic patient more as an object-body
than as a lived body. This impression corresponds to the overall
disembodiment of the schizophrenic person.
Disturbances of Secondary Intersubjectivity
in Schizophrenia
The disturbance of basic self-awareness in schizophrenia does not only
affect primary intersubjectivity, but also the higher level of self-other
distinction or self-demarcation, resulting in phenomena termed
transitivism by Bleuler (1911):
When I look at somebody my own personality is in danger. I am
undergoing a transformation and my self is beginning to disappear
(Chapman 1966).
Schizophrenia, Embodiment and Intersubjectivity
“The others’ gazes get penetrating, and it is as if there was a consciousness
of my person emerging around me … they can read in me like in a book.
Then I don’t know who I am any more (Fuchs 2000, p. 172).
Such reports show that ‘being conscious of another consciousness’
may threaten the schizophrenic patient with a loss of his self. How can this
be explained? – In current neurocognitive accounts, the sense of self is
regarded as being generated by inferential self-monitoring processes.
Corresponding explanations of symptoms such as transitivism, thought
insertion, acoustic hallucinations or passivity experiences rely on the
concept of shared representations, i.e. overlapping neuronal representations
for the execution of an action and for the observation of the same action in
others (Decety and Sommerville 2003). A hypothetical failure of the
action attribution system (neuronal “who” system, Georgieff & Jeannerod
1998) then leads to self-other confusion and delusional misattribution.
However, such modular explanations miss the basic disturbance of
self-awareness that precedes the acute psychotic symptoms often by years.
From a phenomenological perspective, the self-other distinction is
automatically constituted in every experience as an aspect of nonreflective self-awareness (Parnas 2003). If this primary embodied sense of
self or ipseity is disturbed, then becoming aware of others as being aware
of oneself will become precarious. In grasping the other’s perspective, the
patients are no more able to maintain their own embodied centre. This is
illustrated by the following case description:
A young man was frequently confused in a conversation, being unable to
distinguish between himself and his interlocutor. He tended to lose the
sense of whose thoughts originated in whom, and felt ‘as if’ the
interlocutor somehow ‘invaded’ him, an experience that shattered his
identity and was intensely anxiety-provoking. When walking on the street,
he scrupulously avoided glancing at his mirror image in the windowpanes
of the shops, because he felt uncertain on which side he actually was
(Parnas 2003, p. 232).
As pointed out in the first section, the verbal interaction with others
implies a continuous oscillation between the central, embodied perspective
and the decentred perspective from which I am aware of the other as being
aware of me. It is this dialectical tension of the “eccentric position” that
the schizophrenic patient cannot maintain any more. The perspectives of
self and other are confused instead of being integrated through a self-other
metaperspective, resulting in a sense of being invaded and overpowered by
the other. The same confusion arises for the patient when perceiving
himself in the mirror. A similar case example is given by Kimura:
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When I am looking into a mirror, I do not know any more whether I am
here looking at me there in the mirror, or whether I am there in the mirror
looking at me here. (….) If I look at someone else in the mirror, I am not
able to distinguish him from myself any more. When I am feeling worse,
the distinction between me and a real other person gets lost, too. While
watching TV, I don’t know any more whether I am speaking in the TV-set
or whether I am hearing the words here. I don’t know whether the inside
turns outwards or the outside inwards. It is as if the foundation of my self
collapses. Are there perhaps two ‘I’s? (Kimura 1994, p. 194; own transl.).
Here it is precisely the virtuality of the mirror image that undermines
the embodied sense of self. While looking into the mirror, the patient
cannot maintain his own centre, thus confusing the embodied and the
virtual self. This is generalized to the perception of virtual others in the
mirror, and finally to the encounter with real others. As we can see, the
conditions of the possibility for the phenomenon of transitivism are rooted
in the dialectical structure of intersubjectivity. To recognize others as
mental agents, that means as persons, and to recognize oneself as a
separate person among others is one and the same achievement, namely
reaching and maintaining the eccentric position. However, this
achievement is threatened when the basic bodily sense of self is weakened,
finally resulting in a short-circuit of perspectives, as it were, or a melting
of self and other.
This short-circuit may also lead to the experience of thoughtbroadcasting: All the patient's thoughts are known to others; there is no
difference between his mental life and that of others any more. Thus, he is
entangled in a disembodied, self-referential and delusional view from the
outside (Fuchs 2005). It is also for this reason that the first episode of
schizophrenia frequently occurs in situations of social exposure and
emotional disclosure, that means, when the affirmation of one’s own self
against the perspective of the others is at stake: e.g. when leaving the
parents’ home, starting an intimate relationship or entering working life. In
such situations, the patient may lose his embodied perspective and start to
feel observed, persecuted and permeated from all sides. Thus we find
again what I have called a disembodiment, caused by a loss of self in the
dialectical process of intersubjective perception.
Finally, I turn to delusions as disorders of secondary intersubjectivity
or perspective-taking. At first sight, one might think of delusions as the
mere product of faulty neuronal information processing, or of “broken
Schizophrenia, Embodiment and Intersubjectivity
brains”. After all, delusions misrepresent reality, so they must be somehow
“in the head”. However, even in present-day psychiatry, this is not the
whole story, for the current definitions of delusion contain a cultural
clause: Even convictions that seem bizarre from a Western viewpoint may
well be shared with others in a corresponding cultural background and
then give no justification for a diagnosis of delusion (APA 2013, p. 103)
shows that the essence of delusion cannot be just a wrong content or
representation of reality – delusion should rather be considered an
interactive phenomenon. Instead of reifying delusion as a localizable state
in the head of the patient, an enactive approach regards it as a disturbance
of intersubjectivity, arising in a social situation that is always constituted
by two or more interaction partners.
According to the enactive approach to cognition, organisms do not
passively receive information from their environment which they then
translate into internal representations; rather, they constitute or enact the
world through their sensorimotor interactions with the environment
(Varela et al. 1991; Thompson 2005, 2007). However, for human beings
this constitution is not a solitary activity but always means an
intersubjective co-creation of meaning. We live in a shared life-world
because we continuously create and enact it through our coordinated
activities and “participatory sense-making” (De Jaegher & Di Paolo 2007).
This applies in particular to the domain of the social world, which means,
to the processes of mutual understanding, negotiation of intentions,
alignment of perspectives and reciprocal correction of perceptions.
Let us look at this more closely. In social interactions, shared meanings
are produced by circular processes of action and mutual perception
according to the following pattern (cf. schema 1): a person A makes an
utterance (superior black arrow), anticipating a certain reaction of his
partner B. Now B interprets A’s utterance, thus at least implicitly taking
A’s perspective, and then gives a corresponding reply (lower black arrow),
anticipating a certain reaction of A. Now it is A’s turn to interpret B’s
reaction, to compare it with his own anticipation, and then to make a
second, affirming, modifying or correcting utterance. B compares this with
his expectation, now in turn modifies or affirms his own reply, etc. This
yields an ongoing interactive circle which may even be better illustrated
by a spiral of interactions, leading to shared or participatory sense-making
(schema 2). One could also say that the shared meaning is generated and
constantly transformed through the interaction which implies an alignment
of perspectives or mutual perspective-taking. In successful interactions,
this spiral leads to an increasingly consensual understanding or definition
of the shared situation (as symbolized by the increasing approximation of
Chapter Fifteen
A and B) – even if there were differing viewpoints, attitudes and
prejudgments at the beginning.
Schema 15-1: Interactive Circle
Schema 15-2: Spiral of Participatory Sense-Making
Schizophrenia, Embodiment and Intersubjectivity
It is important to note that there is an implicit background or
framework to this process which consists of all the commonsensical
assumptions about how an interaction works, what kind of reactions are
adequate or inadequate, what presuppositions may be taken for granted,
including the meaning of words or phrases in certain contexts, the shared
cultural values and the overall view of the world. One most important
element of this background, however, is a basic sense of trust – the
underlying assumption to live in a world with shared values, with mutual
expectations and obligations, and with reliable rules of the social game.
This “bedrock” of unquestioned certainties (Wittgenstein 1969, Rhodes &
Gipps 2008) is a fundamental presupposition of the consensual
understanding of a situation. Following Erikson (1959) and others (Stern
1985, Trevarthen & Logotheti 1989),we may assume that a sense of basic
trust and affective attunement normally develops in the first year of life, as
a presupposition for being related to others, learning from them, and thus
being socialized into the human community.
However, if there are constraining boundary conditions to these
circular processes, then the joint negotiation of meaning will be disturbed
and mutual understanding will fail. Such is the case e.g. when one of the
partners is deaf, or does not understand the other’s language or cultural
background. It is well known that these are typical conditions which in
vulnerable persons may lead to suspicion, paranoid ideation and finally to
delusions of persecution – termed “paranoia of the hard-of-hearing”
(Cooper 1976) or “paranoia of immigrants” (Fossion et al. 2004, CantorGraae & Selten 2005; Fuchs 1999). In these cases, adequate understanding
of verbal utterances is compromised, leading to a disturbance of the circle
of social action and perception. The non-verbal and behavioural signals of
others become ambiguous, and their reactions are no more congruent with
the patient’s anticipation. More and more, the deaf person or the
immigrant gets entangled in situations in which the utterances or
expressions of others seem to be aimed at him in a sinister way, and he is
unable to neutralize these perceived self-references by subsequent
correcting interactions.
At a certain point in this process, the basic trust in others breaks down
and is replaced by a paranoid delusional framework which now converts
even the most harmless events and doings in all the more insidious
machinations and intrigues. The breakdown of the medium of trust and
attunement to others leads to a loss of the natural evidence of
commonsensical reality (Blankenburg 2001). Moreover, there is a looping
effect between the arising paranoid ideation and the reaction of the others
to the patient’s altered suspicious behaviour. Their irritated reactions
Chapter Fifteen
contribute to his sense that there is something to be suspicious about,
which in turn feeds back into their failure to make themselves understood.
With some modifications, this description applies to schizophrenic
delusions as well. For in the prodromal stages of the psychosis, the
alienation of perception and the resulting loss of familiar significances
particularly extend to the social sphere. The faces, the gazes and the
behaviour of others become highly ambiguous, and the interactive circles
with others are fundamentally disturbed. In the delusional mood arising
from this ambiguity (Jaspers 1968, Fuchs 2005), the basic trust in others
breaks down. Now the patient feels being "meant" by gazes from the
background, being spied at from out of anonymous cars, or secretly tested
in well-prepared situations. The co-constitution of a shared world fails and
is replaced by the new, idiosyncratic coherence of the delusion.
Nonetheless, delusions are not mere products of a deranged brain. For
their essence is not a faulty representation of the world, but the failure of
co-constituting the world through mutually taking and aligning one’s
This becomes manifest in particular when the patient is confronted
with doubts or objections. In most cases, he will not be able to adequately
respond to these; on the contrary, he will simply assume a consensually
perceived situation even though this is not at all the case from the other’s
point of view. The patient behaves as if others could only be of the same
opinion. He does no longer succeed in taking their perspective, in
transcending his own point of view. Again, delusions may be described as
a loss of the eccentric position. An important result of this is the exclusion
of chance (Berner 1978). Chance or coincidence normally allows us to
neutralize irrelevant elements of a situation by attributing it to a mere
contingency, not to another’s intention: “This was not meant for me” or
„not aimed at me“. For the schizophrenic patient, however, the situation is
reversed: It is precisely the normally irrelevant background elements that
adopt a meaningful, sinister and threatening character. The deluded person
does no longer acknowledge the possibility of chance, and thus refuses to
treat the shared situation as an open one. This inability to take a different
perspective on the situation in turn leads to a severe irritation and worry in
his interaction partners. They do no longer know how to comprehend his
behaviour, or where they stand with him. This experience corresponds, on
the level of verbal interaction, to the praecox-feeling on the intercorporeal
In sum, delusions may not be sufficiently described as individual false
beliefs. Rather, they correspond to an intersubjective situation deprived of
the basic trust and attunement to others that could help to restore a
Schizophrenia, Embodiment and Intersubjectivity
consensual understanding of the situation and to co-constitute a shared,
commonsensical reality. No matter what their neurobiological
presuppositions and components are – no doubt that these are of crucial
importance – delusions are not just products of individual brains but
disorders of the in-between, or of enacting a world through interaction
with others. Delusions are relational phenomena, insofar as they escape
our attempts towards understanding; they appear as a withdrawal from the
established order of sense by which we aim to grasp them.
Schizophrenia implies a disembodiment of the self in the sense of
losing one’s habitual bodily performance, and with it the pre-reflective,
questionless being-in-the-world that is mediated by the body. Thus, the
relationship of self and world is in constant need of being reconstructed by
deliberate efforts, leading to the growing perplexity and hyperreflexive
ruminations that are found in schizophrenic patients. Since the sense of
self is bound up with the sense of others, disembodiment of self and
disturbance of intercorporeality mutually influence each other. Therefore
the basic disturbance may also be regarded as a loss of “common sense”,
i.e. the tacit knowledge and familiarity guiding the relations and
interactions with others. This finally results in disturbances of intersubjectivity
on higher levels, reaching their climax in delusions.
The concept of the bodily or embodied self allows us to consider the
manifold and often heterogeneous symptoms and experiences in
schizophrenia from an integrative point of view. It may serve as a
paradigm for a psychopathology which regards the relations between the
person and the world to be mediated by the lived body on all levels. On
that condition, mental illness may no longer be localized within an inner
space, be it the psyche or the brain.
Malfunctions of the neural system, possibly due to faulty neuronal
maturation, certainly play a role in the fundamental disturbances found in
schizophrenia. But these malfunctions act only as one of the factors which
contribute to the disturbance of enacting a coherent perceptual world and
of inter-enacting a shared world. There are no brain systems that produce
schizophrenia by themselves. Mental illness is not just a brain disorder,
but an extended phenomenon, a disturbance of the patient’s lived body,
lived space and relationships with others. As the Dutch psychiatrist Jan
van der Berg (1972, p. 46) has put it: “The patient is ill means that his
world is ill”. What it means to be an embodied being in relation to the
world may perhaps be best recognized in schizophrenia where the self
Chapter Fifteen
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