CHAPTER FIFTEEN SCHIZOPHRENIA, EMBODIMENT AND INTERSUBJECTIVITY THOMAS FUCHS Abstract 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 intersubjectivity. Introduction 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 270 Chapter Fifteen 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 phenomena. 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 271 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 272 Chapter Fifteen 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 interrelated: - 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 273 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 274 Chapter Fifteen fundamental disturbance of the embodied self, or a disembodiment. This includes: (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 psychosis. 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 experience: 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 275 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 276 Chapter Fifteen 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 277 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. 278 Chapter Fifteen 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 outside: 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 279 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 experience. 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). 280 Chapter Fifteen 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 attunement: 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 Transitivism 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 281 “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: 282 Chapter Fifteen 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. Delusion 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 283 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 284 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 285 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 286 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 perspectives. 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 level. 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 287 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. Conclusion 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 288 Chapter Fifteen suffers from a disembodiment and thus loses its being-at-home in the world. References APA (American Psychiatric Association) (2013) Diagnostic and statistical manual of mental disorders. 5th Ed. Arlington, VA: American Psychiatric Publishing. Berner, P. (1978) Psychopathologische Wahnforschung und psychiatrische Hypothesenbildung. Der Nervenarzt. 49(3), p.147-152. Berze, J. (1914) Die primaere Insuffizienz der psychischen Aktivitaet: Ihr Wesen, ihre Erscheinungen und ihre Bedeutung als Grundstoerung der Dementia praecox und der Hypophrenien ueberhaupt. Leipzig: Deuticke. Blankenburg, W. (1971) Der Verlust der natürlichen Selbstverständlichkeit. Ein Beitrag zur Psychopathologie symptomarmer Schizophrenien. Enke, Stuttgart. —. (2001) First steps toward a ‘psychopathology of common sense’ (transl.: Mishara A). Philosophy, Psychiatry, & Psychology. 8. p. 303– 315 Bleuler, E. (1911) Dementia praecox oder Gruppe der Schizophrenien. Leipzig: Deuticke. Brüne, M. (2005) “Theory of Mind” in schizophrenia: A review of the literature. Schizophrenia Bulletin. 31. p. 21-42. Bürgy, M. (2003) Zur Phänomenologie der Verzweiflung bei der Schizophrenie. Zeitschrift für klinische Psychologie, Psychiatrie und Psychotherapie. 51. p. 1-16. Cantor-Graae, E., & Selten, J. P. (2005) Schizophrenia and migration: a meta-analysis and review. American Journal of Psychiatry. 162. p.1224. Chapman, J. (1966) The early symptoms of schizophrenia. British Journal of Psychiatry. 112. p. 225-251. Cooper, A. F. (1976) Deafness and psychiatric illness. British Journal of Psychiatry. 129. p. 216-226. Damasio, A. R. (1999) The feeling of what happens. San Diego, CA: Harcourt. de Haan, S., & Fuchs, T. (2010) The ghost in the machine: Disembodiment in schizophrenia. Two case studies. Psychopathology. 43. p. 327-333. Schizophrenia, Embodiment and Intersubjectivity 289 De Jaegher, H., & Di Paolo, E. (2007) Participatory sense-making: an enactive approach to social cognition. Phenomenology and the Cognitive Sciences. 6. p. 485–507. Decety, J., & Sommerville, J. A. (2003) Shared representations between self and other: a social cognitive neuroscience view. Trends in Cognitive Science. 7. p. 527-533. Erikson, E. H. (1959) Identity and the Life Cycle. New York: International Universities Press. Fossion, P., Servais, L., Rejas, M. C., Ledoux, Y., Pelc, I., & Minner, P. (2004) Psychosis, migration and social environment: an age-andgender controlled study. Eur. Psychiatry. 19. p. 338-343. Frith, C. D. (1992) The cognitive neuropsychology of schizophrenia. Hillsdale, NJ: Earlbaum. —. (2004). Schizophrenia and theory of mind. Psychological Medicine. 34(3). p. 385-389. Fuchs, T. (1999) Life events in late paraphrenia and depression. Psychopathology 32: 60-69. —. (2000) Psychopathologie von Leib und Raum. Phänomenologischempirische Untersuchungen zu depressiven und paranoiden Erkrankungen. Darmstadt: Steinkopff. —. (2002) The phenomenology of shame, guilt and the body in body dysmorphic disorder and depression. Journal of Phenomenological Psychology. 33. p. 223-243. —. (2005) Corporealized and Disembodied Minds. A Phenomenological View of the Body in Melancholia and Schizophrenia. Philosophy, Psychiatry, & Psychology. 12. p. 95-107. —. (2007) The Temporal Structure of Intentionality and its Disturbance in Schizophrenia. Psychopathology. 40. p. 229-235. Gallagher, S. (2000) Philosophical Conceptions of the Self: Implications for Cognitive Science. Trends in Cognitive Science. 4. p. 14-21. —. (2005). How the Body Shapes the Mind. New York: Oxford University Press. Gallagher, S., & Zahavi, D. (2005). Phenomenological approaches to selfconsciousness. Stanford Encyclopedia of Philosophy. Available from: http://plato.stanford.edu. [Accessed: 29 November 2013]. Georgieff, N., & Jeannerod, M. (1998) Beyond Consciousness of External Events: A Who System for Consciousness of Action and SelfConsciousness. Consciousness and Cognition. 7. p. 465-477. Henry, M. (1973) The Essence of Manifestation. The Hague: Nijhoff. Jaspers, K. (1968) General Psychopathology. 7th Ed. Chicago, IL: University of Chicago Press. 290 Chapter Fifteen Kimura, B. (1994) Psychopathologie der Zufälligkeit oder Verlust des Aufenthaltsortes beim Schizophrenen. Daseinsanalyse. 11. p. 192-204. Klosterkötter, J. (1988) Basissymptome und Endphänomene der Schizophrenie. Berlin, Heidelberg, New York: Springer. Kraepelin. E. (1913) Klinische Psychiatrie. Teil 2. 8th Ed. Leipzig: Barth. McGhie, A., & Chapman, J. (1961) Disorders of attention and perception in early schizophrenia. Brit. J. Med. Psychol. 34. p. 103-116. Mead, G. H. (1924) Mind, self and society. University of Chikago Press. Merleau-Ponty, M. (1960) Le philosophe et son ombre. In: Signes. Paris: Éditions Gallimard. Minkowski, E. (1927) La Schizophrenie. Paris: Payot. —. (1933/1970) Lived Time: Phenomenological and Psychopathological Studies. Evanston, IL: Northwestern University Press. Minkowski, E., & Targowla, R. (2001). A Contribution to the Study of Autism: The Interrogative Attitude. Philosophy, Psychiatry, & Psychology. 8. p. 271-78. Neisser, U. (1988) Five Kinds of Self-Knowledge. Philosophical Psychology. 1. p. 35-39. Parnas, J. & Handest, P. (2003. Phenomenology of Anomalous SelfExperience in Early Schizophrenia. Comprehensive Psychiatry. 44. p. 121-134. Parnas, J. & Sass, L. A. (2001) Solipsism, Self, and Schizophrenic Delusions. Philosophy, Psychiatry, & Psychology. 8. p. 101-120. Parnas, J. (2003) Self and schizophrenia: a phenomenological perspective. In Kircher, T. & David, A. (Eds.). The Self in Neuroscience and Psychiatry. Cambridge: Cambridge University Press. Parnas, J., Moeller, P., Kircher, T., Thalbitzer, J., Jannson, L., Handest, P., & Zahavi, D. (2005) EASE: Examination of Anomalous SelfExperience. Psychopathology. 38. p. 236-258. Plessner, H. (1975) Die Stufen des Organischen und der Mensch. Berlin: de Gruyter. Rhodes, J., & Gibbs, R. (2008). Delusions, Certainty and the Background. Philosophy, Psychiatry, & Psychology. 15. p. 295-310. Rochat, P. (2004) The emergence of self-awareness as co-awareness in early child development. In Zahavi, D., Grünbaum, T., Parnas, J. (Eds.). The structure and development of self-consciousness. Philadelphia, PA: John Benjamins. Rümke, H. C. (1941). Das Kernsyndrom der Schizophrenie und das ‘Praecox-Gefühl’. Zentralblatt für die gesamte Neurologie und Psychiatrie. 102. p. 68-169. Schizophrenia, Embodiment and Intersubjectivity 291 Saks, E. R. (2007) The center cannot hold. My journey through madness. New York: Hyperion. Sass, L. A. & Parnas, J. (2003). Schizophrenia, consciousness, and the self. Schizophrenia Bulletin. 29. p. 427-444. Sass, L. A. (1992) Madness and Modernism. Insanity in the Light of Modern Art, Literature, and Thought. New York: Basic Books. —. (2000) Schizophrenia, self-experience, and so-called negative symptoms. In Zahavi, D. (Ed.). Exploring the self: Philosophical and psychopathological perspectives on self-experience. Amsterdam: John Benjamins. Schneider, K. (1959). Clinical Psychopathology (transl.: M. W. Hamilton). Oxford: Grune & Stratton. Seidler, G. (2000). In Others’ Eyes: An Analysis of Shame. Madison, CT: International Universities Press. Stanghellini, G. (2004). Disembodied Spirits and Deanimated Bodies: The Psychopathology of Common Sense. Oxford: Oxford University Press. Stern, D. N. (1985). The Interpersonal World of the Infant. New York: Basic Books. Thompson, E. (2005). Sensorimotor subjectivity and the enactive approach to experience. Phenomenol. Cogn. Sci. 4. p. 407–427. —. (2007). Mind in life. Biology, phenomenology, and the sciences of mind. Cambridge, MA, London: Harvard University Press. Trevarthen, C., &Logotheti, K. (1989). Child in Society, and Society in Children: The Nature of Basic Trust. In Howell, S. & Willis, R. (Eds.). Societies at Peace: Anthropological Perspectives. London: Routledge. van den Berg, J. (1972). A different Existence. Principles of phenomenological psychopathology. Pittsburgh: Duquesne University Press. Varela, F., Thompson, E. & Rosch, E. (1991) The Embodied Mind. Cognitive Science and Human Experience. Cambridge, MA: MIT Press. Wittgenstein, L. (1969). On Certainty. (transl.: G.E.M. Anscombe and D. Paul). Oxford: Blackwell. Zahavi, D. (1999). Self-awareness and alterity. A phenomenological investigation. Evanstone, IL: Northwestern University Press. —. (2005). Subjectivity and Selfhood: Investigating the First-Person Perspective. Cambridge, MA: MIT Press.