Phenomenological Psychopathology and Schizophrenia: Contemporary Approaches and Misunderstandings

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Phenomenological Psychopathology

and Schizophrenia: Contemporary

Approaches and Misunderstandings

Louis Sass, Josef Parnas, and Dan Zahavi

Abstract: The present paper clarifies key issues in phenomenology and phenomenological psychopathol-ogy (especially of schizophrenia) through a critique of a recent article that addresses these topics. Topics include (1) Phenomenology’s role in clarifying issues not amenable to purely empirical methods; (2) The relationship between a phenomenological approach (focusing on the subjective life of the patient) and em-pirical science, including neuroscience; (3) The nature of self-experience, especially in its pre-reflective form (“ipseity”—involving “operative intentionality”), and its possible disturbance in schizophrenia (“hyper-reflexivity” and “diminished self-affection”); (4) The relationship between self-disturbance in schizophrenia and disorders of both temporality and (what Husserl termed) “passive syntheses”; (5) The role of intentional or quasi-volitional processes in the perceptual (and other) disorders in schizophrenia; (6) The nature and diversity of phenomenology’s potential contribution to the enterprise of “explanation”; and (7) The meaning of several concepts: “hermeneutic” or “existential” ap-proach, phenomenological “reflection,” and “negative symptoms.”

Keywords: self-disorder, pre-reflective self-awareness, ipseity, hyperreflexivity, self-affection, phenomenologi-cal reflection, phenomenological explanation

The phenomenological approach to schizophrenia has undergone something of a renaissance in Anglophone psychiatry

in recent years. There has been a proliferation of works that focus on the nature of subjectivity in schizophrenia and related disorders, and that take inspiration from the work of such German and French philosophers as Husserl, Heidegger, and Merleau-Ponty, and such classical psychiatrists as Minkowski, Blankenburg, and Binswanger (Rulf 2003; Sass 2001a, 2001b). This trend in-cludes predominantly theoretical articles, which typically incorporate clinical material as well as reviews of empirical and experimental findings in psychopathology. Some very recent examples (since 2000) are studies of self-experience (Sass and Parnas 2003), temporal experience (Fuchs 2005), delusions and delusional mood (Parnas and Sass 2001; Fuchs 2005), and psychiatric classification and diagnosis (Parnas & Zahavi 2002), as well as of values and disturbances of common-sense (Stanghellini 2001, 2004; Stang-hellini and Ballerini 2007), affect or emotion (Ratcliffe 2008; Sass 2007a), negative symptoms

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(Sass 2003a), perception (Nelson and Sass 2008; Sass 2004c; Schwartz et al. 2005), and personhood and autonomy (Sass 2007b, 2011). A major event of recent years is the appearance of a series of empirical studies that demonstrate the reality of clinical-phenomenal disorders of self-experience as a core factor in early schizophrenia and that differentiate diagnosis of schizophrenia-spectrum from other forms of psychosis or psychopathol-ogy (Møller and Husby 2000; Parnas et al. 1998; Parnas et al. 2003; Parnas, Handest, et al. 2005; Parnas, Møller, et al. 2005).

This trend does not, of course, represent the first attempt to study subjectivity in schizophre-nia, nor is it the first time that the continental phenomenological tradition has been introduced. Both Mayer-Gross’s famous textbook of psychia-try (1954) and Fish’s Schizophrenia (Hamilton 1984, originally1962) attempted—nobly but with limited success—to bring phenomenological psychopathology into the mainstream of English-language psychiatry. The work of Karl Jaspers’ disciple, Kurt Schneider, on the “First Rank Symp-toms” of schizophrenia, was clearly Jaspersian on the methodological plane, but unfortunately was interpreted more in an operational than a truly phenomenological sense. Existence, an anthol-ogy edited by Rollo May, Ernst Angel, and Henri Ellenberger (1958), influenced humanistic trends in American clinical psychology. An important precursor to the above-mentioned empirical work is the research on schizophrenia-patients’ experience of the so-called “basic symptoms” of schizophrenia, carried out since the end of the 1960s by Huber, Klosterkötter, and colleagues in Germany (Klosterkötter 1988, 1992; Klosterkötter et al. 1997, 2001).

The most prominent Anglophone attempt to emphasize the importance of the subjective di-mension of schizophrenia was R. D. Laing’s first and finest book, The Divided Self (1959), a work admired by many who remain skeptical of Laing’s later contributions. The Divided Self, which uses ideas from Sartre, Heidegger, Minkowski, and Binswanger, was something of a bolt from the blue. Laing’s own interests and influence were soon diverted in an anti-psychiatric and sometimes ro-manticizing or otherwise anti-scientific direction.

There was, in fact, very little writing—at least in English (for French and German contributions, see Tatossian 1979; Naudin 1997)—specifically treat-ing the phenomenology of schizophrenia in the 25 years between the publication of Laing’s book and the appearance, starting in the mid 1980s, of articles by several authors. These include Sass (1985, 1987, 1988a, 1990a, 1990b, 1992b)—cul-minating in his books, Madness and Modernism: Insanity in the Light of Modern Art, Literature, and Thought (1992a), and The Paradoxes of Delusion (1994)—Schwartz and Wiggins (1987; also Wiggins et al. 1990), Cutting and Dunne (1989), and Parnas and Bovet (1991; Bovet and Parnas 1993) . A superb anthology of classical European contributions on schizophrenia, edited by John Cutting and Michael Shepherd, appeared in 1987. Cutting’s (1997) book on brain laterality had a strong phenomenological component. Now, however, we are seeing a reasonably broad-based attempt to bring phenomenological perspectives to bear on scientific psychiatry, particularly on schizophrenia, in the now-dominant world of Anglophone psychiatry and clinical psychology.

These recent developments in phenomeno-logical psychopathology coincide with significant trends in both the mental health professions and the mind sciences. One such trend is a growing disillusionment, within mainstream psychiatry, with the extreme emphasis on operationalizable concepts that began with the advent of DSM III in 1982. A number of recent editorials by key figures in North American and European psychiatry (Andreasen 2007; Maj 2005; see also Mullen 2007; Parnas et al. 2008) have noted the relative lack of real scientific progress in the study of schizophrenia and many other disorders, and have related this to the loss of validity that can occur when there is an over-focus on reliability (operational concepts). These editorials have re-lated this lack of progress to the loss, which they lament, of the rich, psychopathological tradition of European psychiatry, which is strongly (but not exclusively) rooted in phenomenology. This disillusionment coincides with a certain malaise, notable among younger psychiatrists and clinical psychologists, who are frustrated with the increas-ingly mechanical role they are expected to play in

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a clinical world defined by bureaucratic demands, and doubtful about a scientific world dominated by empirical methodologies that can seem divorced from significant theoretical issues.

Another, more broad-based trend is the disil-lusionment with purely neurocentristic, cognitiv-ist, and computationalist approaches that seems to be spreading among scholars and scientists in philosophy and the various sciences of mind, brain, and behavior. One can find a diverse group of thinkers including Dreyfus (1979), Varela et al. (1991), Clark (1997), Gallagher (2005), Zahavi (2005), Thompson (2007), and Gallagher and Zahavi (2008), who all in various ways have criticized the standard picture by insisting on the need for a renewed focus on subjectivity and on the embodiment and embeddedness of the human subject. More recently, the concepts of self and of self-experience have also gained something of a renaissance in philosophy, psychology, and the cognitive sciences (cf. Gallagher and Shear 1999; Kircher and David 2003; Sass et al. 2000).

The revival of a phenomenological approach to psychiatry precedes the most recent of these trends, but fits in comfortably with current de-velopments. The phenomenological approach emphasizes the need to delve below superficial levels of behavioral description or common-sense, symptomatic descriptions (Parnas and Sass 2008; Zahavi and Parnas 1998). By offering a richer and more empirically grounded theoretical approach to the understanding of abnormal action and experience, it promises an escape from the opera-tionalist cul-de-sac that contemporary psychiatry is in danger of entering. The phenomenological study of schizophrenia in particular is of signal importance, not only because of schizophrenia’s preeminent place in the history of psychiatry, but also because of the profound, enigmatic, and potentially revelatory nature of the alterations of subjectivity and selfhood that it involves. The increased focus, over the last 15 years, on early intervention for mental disorders, particularly psy-chotic disorders, has particularly highlighted the importance of understanding subjective experience in pre-schizophrenic and schizophrenic conditions, which may be relevant for the prediction and identification of high risk, as well as treatment

efforts (Nelson, Sass, Skodlar et al. 2009; Nelson et al 2008; Parnas 2005).

A Source of Misunderstandings

In this context, it is surprising that, very re-cently, an article should have appeared, addressed to a general psychiatric audience, in which recent trends in the phenomenological psychopathology of schizophrenia and key notions of phenomeno-logical philosophy are presented in a manner that is not only confusing, but highly inaccurate. Rath-er than clarifying matters, the article in question blurs key theoretical issues and leaves the reader with the impression that much of phenomeno-logical psychiatry must be, at its core, an obscure discipline, incomprehensible and somehow deeply anti-scientific in nature.

The article in question, published in Current Opinion in Psychiatry in 2007, was authored by Aaron Mishara and carries the title “Missing links in phenomenological clinical neuroscience: Why we still are not there yet.” Mishara’s critique primarily targets two articles by Sass and Parnas (2003, 2007), but also criticizes Sass (1992a), Parnas (2003), and Zahavi (2005). In his contribu-tion, Mishara strives to offer an ambitious review of the relationship between phenomenology and neuroscience, and to construct a stark opposition between what he calls “neo-phenomenology” ver-sus “existential or hermeneutic phenomenology.” Mishara wishes to associate the first term with the work of Sass, Parnas, and Zahavi, and the second term with his own work and that of such figures as Binswanger, Blankenburg, Conrad, von Weiz-saecker, Matussek, and Wiggins and Schwartz. As we argue, however, the distinction in question is confused and misleading.1

The publication of Mishara’s account is not entirely to be lamented, however: it articulates certain misunderstandings that may be widespread enough to be worth addressing in detail, thereby giving us the opportunity to correct potential mis-apprehensions and to explain some basic points about our own approach and the phenomeno-logical enterprise more generally. In the present article, we take his publication as an occasion for

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clarifying a number of important issues (sometimes overlapping) concerning phenomenology and its role in the study of psychopathology in general and schizophrenia in particular; in this way, we offer a discussion that should be of general interest (see also Gallagher and Zahavi 2008). The issues treated below are the following:

1. The role of phenomenology in clarifying issues not amenable to purely empirical methods.

2. The relationship between a phenomenological ap-proach (focusing on the subjective life of the patient) and that of empirical science, including neurosci-ence. (This relationship involves what is sometimes referred to as the “naturalizing” of phenomenology.)

3. The nature of self-experience, especially in its pre-reflective form, and its possible disturbance in schizophrenia.

4. The relationship between self-disturbance in schizo-phrenia and disorders both of temporality and of (what Husserl termed) “passive syntheses.”

5. The possible, contributing role of intentional or quasi-volitional processes in the perceptual disorders in schizophrenia.

6. The nature—and especially the diversity—of phe-nomenology’s potential contribution to the enterprise of “explanation” (broadly understood, in contrast with “mere” description).

7. We also provide a number of necessary clarifications: of the meaning of a “hermeneutic” or an “existen-tial” approach; of the nature and role of “reflection” in phenomenological accounts; and of the meaning of the concept of “negative symptoms.”

Mishara’s main justifications for distinguishing between what he calls “neo-phenomenology” and “existential/hermeneutic phenomenology” are two. The fact that his article vacillates between the two justifications, without distinguishing them clearly, adds to the confusion. One justification is largely methodological in nature, having to do with the status and role of phenomenology. Ac-cording to Mishara (2007a), whereas (so-called) “neo-phenomenology claims to circumvent experi-mental procedures,” the (so-called) “existential phenomenology” with which he associates himself is, by contrast, “in an excellent position to supply hypotheses [and “testable constructs”] for further experimental study” (pp. 559–60). The second justification is more substantive: it pertains to dis-cussions related to the structure of consciousness and the specific nature of the psychological abnor-

mality in schizophrenia. Here Mishara rejects the claim that consciousness is as such characterized by a pervasive but tacit dimension of pre-reflective self-consciousness, and denies that self-disturbance is a central core feature of schizophrenia. We con-sider Mishara’s claims and criticisms to be both mistaken and misleading. We begin with general methodological and philosophical issues, namely, with Mishara’s views on the relevance of phenom-enology, the notion of “constraint” (a term we use), and the nature of phenomenological “facts.” Later we turn to selfhood and other topics.

Nature and Role of Phenomenology

In his article, Mishara states that Sass and Parnas (2007) and Zahavi (2005) “proposed that phenomenology is able to constrain neuroscience when applied to disorders such as schizophre-nia” (Mishara 2007a, 559, emphasis added). He explains this point by stating that, according to Sass, Parnas, and Zahavi, “phenomenology provides conclusive knowledge or limits, what Zahavi calls ‘facts’, about the patient’s subjective experience” (Mishara’s words). We are said to believe that these facts could (in Mishara’s words once again) “be directly incorporated into clini-cal neuroscience” without requiring any kind of “experimental procedure.” Mishara continues: “Rather than furnishing hypotheses or testable constructs to neuroscience, neo-phenomenology claims to circumvent experimental procedure by offering constraints about the nature of (human) subjectivity with a foundation in philosophical phenomenology.” He contrasts this with what he calls the “existential-phenomenological . . . view that phenomenology provides initial systematic means” for studying subjectivity and seeks only to “supply hypotheses for further experimental study” (p. 560). Mishara’s account is problematic. Not only does he not grasp the standard meaning of “constrain” as this term is used in recent dis-cussions on the relation between phenomenology and cognitive science, he also fails to capture our own view of the matter, and ultimately provides a superficial picture of what the phenomenological tradition has to offer contemporary psychiatry or


the project of the “naturalization” of conscious-ness (the inclusion of consciousness within a general scientific perspective).

We agree, of course, that a major role for phenomenology is indeed to supply hypotheses for further empirical study. However, we reject the idea that phenomenology’s relevance should be restricted to this role. Psychiatry, after all, is faced with a host of philosophical questions—for example, questions concerning the nature of rationality, the definition of delusion, and the possibility of empathy with abnormal states of mind. To think that such questions can be settled by clinical trials or other purely empirical methods would amount to a kind of scientism that would certainly be rejected by all the major theorists of phenomenology. Phenomenology, together with other philosophical approaches, has something to say on these issues.

Mutual “Constraints”; Phenomenological “Facts”

To clarify phenomenology’s role within the mind sciences, we must consider precisely what it means to say that phenomenology can constrain neuroscience. When using the term “constrain” (Sass and Parnas 2007, 73), we cited a well-known paper by Gallagher (1997): “Mutual enlighten-ment: Recent phenomenology in cognitive sci-ence.” In the next paragraph, we cited another well-known article: “Neurophenomenology,” in which (the late) Francesco Varela (1996) speaks of “mutual” or “reciprocal constraints” between “phenomenological accounts of the structure of experience and their counterparts in cogni-tive science” (p. 343). Thompson (2007), who collaborated extensively with Varela, clarifies: “By ‘reciprocal constraints’ [Varela] means that phenomenological analyses can help guide and shape the scientific investigation of consciousness, and that scientific findings can in turn help guide and shape the phenomenological investigations” (p. 329).

The term “constrain” does not, then, mean anything like “inhibit” or “dictate to in a rigid or unilateral fashion.” To say that the facts of subjec-tive life “constrain” neurobiological explanation

is simply to say that these facts are among those that an adequate neurobiology must ultimately take into account. It would seem that any person with a remotely phenomenological bent would have to accept this latter point; indeed, it should even be accepted by reductionists who believe that consciousness is entirely dependent on the biologi-cal substrate. After all, conscious experience is “an explanandum in its own right” (Chalmers, 1995, 209). And “without some idea . . . of what the subjective character of experience is, we cannot know what is required of physicalistic theory” (Nagel 1979, 71).

This does not, by the way, rule out the possibil-ity that cognitive or neurobiological findings might actually suggest new ways of thinking about and describing aspects of phenomenal experience. On the contrary, we (like both Gallagher and Varela) are precisely arguing that the influence goes both ways, that is, it would also be a question of letting phenomenology profit from—and be challenged by—empirical findings.2

When it comes to cashing out this idea about mutuality or reciprocity in more concrete detail, various complementary proposals are currently on offer. One proposal, entitled neurophenomenol-ogy, was initially proposed by Varela (1996) and subsequently developed by Lutz (2002), Lutz and Thompson (2003), and Thompson (2007). Here, the basic idea is to train experimental subjects to gain greater intimacy with their own experiences. Subsequently, the subjects are asked to provide descriptions of these experiences using an open-question format, thus minimizing the imposition of predetermined theoretical categories. The ensuing descriptive categories are subsequently validated intersubjectively and then used to interpret corre-lated measurements of behavior and brain activity. At the same time, however, it is also suggested that, say, a consideration of insights from neurobiol-ogy and dynamical systems theory can help us to improve and refine the classical phenomenological analyses (see Varela 1996; Thompson 2007). How is that supposed to happen?

The basic idea is quite simple: let us assume, for instance, that our initial phenomenological description presents us with what seems to be a simple and unified phenomenon. When studying

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the neural correlates of this phenomenon (e.g., with magnetic resonance imaging), we discover that two quite distinct mechanisms are involved, mechanisms that are normally correlated with distinct experiential phenomena, say, perception and memory. This discovery might motivate us to return to our initial phenomenological description to see whether the phenomenon in question is truly as simple as we thought. Perhaps a more careful analysis will reveal that it harbors a concealed complexity. However, it is important to empha-size that the discovery of a significant complexity on the subpersonal level—to stick to this simple example—cannot by itself force us to refine or revise our phenomenological description. It can, however, serve as motivation for further inquiry.

More recently, Gallagher (2003) has made a slightly different proposal that he has entitled front-loaded phenomenology. Rather than focus-ing on training experimental subjects, the idea is to start with the experimental design, and to allow insights developed in phenomenological analyses to inform the way experiments are set up. To take a concrete example, let us consider the study of self-consciousness within developmental psychol-ogy, where the so-called “mirror-recognition task” has occasionally been heralded as the decisive test for self-consciousness (Lewis 2003). A phenom-enological approach suggests moving beyond reliance on mirror-recognition alone—which phe-nomenologists would typically consider evidence for the presence of a rather sophisticated form of self-consciousness—and attempting to detect the presence of more primitive forms of propriocep-tive body awareness (Zahavi 2005). To front-load phenomenology, however, does not imply that one simply presupposes or accepts well-rehearsed phe-nomenological results. Rather, it involves testing those results and, more generally, incorporates a dialectical movement between previous insights gained in phenomenology and preliminary trials that will specify or extend these insights for pur-poses of the particular experiment or empirical investigation (Gallagher and Zahavi 2008).

Once one grasps the actual (and, in this dis-course, standard) meaning of “constrain,” one immediately sees that the opposition Mishara poses—between phenomenology serving as a

“constraint” versus as a generative source of hy-potheses—is entirely spurious. Indeed, it is only because experience is implicated in the overall causal/explanatory nexus (which is to say, that it serves as a “constraint”—according to the standard understanding of “constrain”) that it could possibly be relevant for hypothesizing. It is precisely this kind of “mutual constraint” (between empirical data on neurodevelopmental problems, phenomenological data on initial stages of the illness, and neurobiological data concern-ing ontogenesis of cortico-cortical connectivity) that led one of the present authors to propose, in 1996, a binding problem associated with the phenomenological core features of schizophrenia, within a distributed mis-connectivity model of neurodevelopmental vulnerability to the illness (Parnas et al. 1996, 2001, 2002).

Before leaving the issue of methodological “constraints,” it is interesting to consider the peculiar way in which Mishara tries to establish our supposed commitment to the idea that phe-nomenology can provide conclusive and substan-tive knowledge about the nature of the mind that would determine the boundaries of neuroscientific research in a unidirectional manner. The textual evidence Mishara offers consists in only three quotations and references, all to works by Zahavi (2004, 343; 2005, 136; see Mishara 2007a, 559). These Zahavi references are quotations taken out of context or tendentious attempts to paraphrase. Indeed, Mishara himself seems to recognize this last point, for he immediately goes on to admit (quite correctly) that “Zahavi himself does not endorse this position.” No quotations from Parnas or Sass are offered. But where, then, is the evidence that any of the three of us actually adopts the view Mishara attributes to us?

A closely related misunderstanding concerns Mishara’s characterization of our understanding of phenomenological “facts.” Nowhere do we say that phenomenological methods generate abso-lutely precise and certain descriptions that cannot possibly be criticized or improved upon—that is, that are not defeasible, in the sense of being in prin-ciple open to revision or valid objection. It is odd, then, to find Mishara claiming for himself the label of “hermeneutic phenomenology.” If hermeneutic


phenomenology means a phenomenology that rejects aspiration to apodictic certainty in favor of a more humble understanding of the nature of the phenomenological enterprise (i.e., as an enterprise that requires interpretation rather than offering infallible description), then our work—like that of many others—certainly falls under the rubric “hermeneutic.”3 Mishara (2007a) has no basis for claiming that we believe our phenomenological accounts to be “immune to error” (p. 561). Nor does Mishara offer any textual evidence to sustain his claim that “neo-phenomenology” “claims to circumvent experimental procedures.” Actually, a considerable amount of empirical work has been done and is underway to test the validity and rel-evance of our phenomenologically inspired model of schizophrenia (see further below).

The Ipseity- or Self-Disturbance (IHM) View

The second major way in which Mishara distin-guishes between what he calls “neo-phenomenolo-gy” and “existential phenomenology” is by saying that, whereas the former postulates disorders of selfhood (ipseity-hyperreflexivity model [IHM]) as the core of psychopathology of schizophrenia, the latter emphasizes, rather, disorders of “passive syntheses,” binding, temporalization, and percep-tual organization. In his article, the IHM becomes an object of Mishara’s passionate attack.4 Here, however, Mishara misunderstands most of the key elements of our ipseity-, self-disturbance, or IHM view, which are clearly laid out in the two articles he targets (Sass and Parnas 2003, 2007). Briefly, this model claims that instability of pre-reflective self-awareness is a core, generative feature of schizophrenia; the disorder affects what in cogni-tive literature is called minimal or core self. Here are some key passages from our account (Sass and Parnas, 2007, 68–70, unless otherwise noted).

IPSEITY DISTURBANCE: [T]he core abnormality in schizophrenia is a particular kind of disturbance of consciousness and, especially, of the sense of self or ipseity that is normally implicit in each act of aware-ness. (Ipseity derives from ipse, Latin for “self” or “itself.” Ipse-identity or ipseity refers to a crucial sense of self-sameness, of existing as a subject of experience that is at one with itself at any given moment [Henry

1973; Ricoeur 1992; Zahavi 1999].) This self or ipseity disturbance has two main aspects or features that may at first sound mutually contradictory, but are in fact complementary. The first is hyper-reflexivity—which re-fers to a kind of exaggerated self-consciousness, that is, a tendency to direct focal, objectifying attention toward processes and phenomena that would normally be “in-habited” or experienced as part of oneself. The second is diminished self-affection—which refers to a decline in the (passively or automatically) experienced sense of existing as a living and unified subject of awareness.

“Ipseity disturbance” also involves a concomi-tant disturbance of the field of awareness that we label “disturbed hold” or “grip” (Sass 2004c; Sass and Parnas 2003, 436).

HYPERREFLEXIVITY: The notion of hyperreflexivity includes some fairly volitional, quasi-volitional, or intel-lectual processes, which we term “hyper-reflectivity.”5

However: the hyperreflexivity in question is not, at its core, an intellectual, volitional, or “reflective” kind of self-consciousness; nor is it merely an intensi-fied awareness of something that would normally be taken as an object (e.g., in the case of an adolescent’s self-consciousness about his or her appearance). Most basic to schizophrenia is a kind of “operative” hyper-reflexivity that occurs in an automatic fashion. This has the effect of disrupting awareness and action by means of an automatic popping-up or popping-out of phenomena and processes that would normally remain in the tacit background of awareness (where they serve as a medium of implicit self-affection), but that now come to be experienced in an objectified and alienated manner (see Merleau-Ponty 1962, p. xviii re: “operative intentionality”—fungierende Intentionalität).

Phenomenally speaking, hyperreflexivity can be manifest as an emergence or intensification of experience as such or a prominence of proximal over distal aspects of stimuli (see e.g. Sass 1994 re: “phantom concreteness”), or as focal awareness of kinesthetic bodily sensations, “inner speech,” or the processes or presuppositions of thinking.

DIMINISHED SELF-AFFECTION involves diminished sense of being a vital, first-person perspective on the world. It pertains to a fundamental sense of existing as an experiencing entity, . . . as a kind of implicit subject-pole that would normally serve as the vital center-point of subjective life. . . . [One] patient with schizophrenia described the condition of lacking this crucial if inef-fable self-affection that is essential to normal ipseity: “I was simply there, only in that place, but without being present.” (Blankenburg 1971, 42; 1991, 77)

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The hyperreflexivity and diminished self-affection central in schizophrenia involve distinc-tive disruptions of the tacit-focal structure of experience.

[T]hese two features are best conceptualized not as separate processes but as mutually implicative aspects or facets of the intentional activity of awareness. Thus, whereas the notion of hyperreflexivity emphasizes the way in which something normally tacit becomes focal and explicit, the notion of diminished self-affection emphasizes a complementary aspect of this very same process—the fact that what once was tacit is no longer being inhabited as a medium of taken-for-granted self-hood. (Sass and Parnas 2003, 430)

It makes little sense, incidentally, to character-ize our ipseity or IHM view by using a simple opposition between “too much” versus “too little” self-experience—as do Lysaker and Lysaker (2008a, 32) in their interesting study of dialogical dimensions of schizophrenia. On our view, there is a sense in which the person with schizophrenia has both too little sense of self (diminished self-affection) and too much self-consciousness (hy-perreflexivity). Selfhood is too complex an issue to lend itself to unidimensional characterization and requires, among other things, sophisticated phenomenological analysis (Zahavi 2005). Before elaborating on theoretical issues, we outline recent empirical work that supports our self-disorder position.

Empirical Support for the Ipseity-Disturbance (IHM) View

Like virtually all scientific work, the IHM is partly rooted in theoretical work, including such psychopathological studies as Sass (1987, 1992a, Chapter 7) and Spitzer (1988), as well as philo-sophical work including Henry (1973, 1975) and Zahavi (1999), among many others. It is important to point out, however, that our phenomenological claims concerning anomalous self-experience as a core feature of schizophrenia-spectrum disor-ders, is not a product of arm-chair theorizing or anecdotal discussion, as Mishara portrays it, but derives, in large measure, from years of clinical experience and considerable empirical research.

This includes descriptive and follow-up studies of different diagnostic categories (Vollmer-Larsen 2008), predictive work on early psychosis (see below), and also some experimental work correlat-ing anomalies of experience with neurocognitive measures (Parnas et al. 2001).

Thus, in contemporary psychiatry the notion of self-disorders as the initial, core features of schizophrenia was almost simultaneously first reported from a Danish study of 19 first-onset schizophrenia-spectrum patients (Parnas et al. 1998) and a Norwegian study of 20 first admitted schizophrenia patients (Møller and Husby 2000). These findings were subsequently supported in a longitudinal study of 155 first admitted patients, of whom about 60% suffered from schizophrenia or schizotypal disorders (Handest and Parnas 2005; Parnas, Handest, et al. 2005). These pa-tients have been reassessed at a 5-year follow-up, showing that self-disorders are predictive of new incident cases of schizophrenia spectrum disorders (Vollmer-Larsen 2008). A separate study compar-ing residual schizophrenia patients with remitted psychotic bipolar illness patients demonstrated that self-disorders were characteristic of schizo-phrenia (Parnas et al. 2003), suggesting a certain specificity to schizophrenia spectrum disorders. Currently, several other samples are being studied (Skodlar et al. 2008), and data analyses are being conducted on opportunistic samples of high-risk and genetic research performed in Copenhagen. Similar research projects and studies on early identification of schizophrenia are being under-taken in several European countries, Israel, and Australia. A phenomenologically oriented, semi-structured psychiatric interview—the EASE scale (Parnas, Møller, et al. 2005)—has been developed and shown to achieve good inter-rater reliability (Vollmer-Larsen et al. 2007). The EASE scale’s description of self-disorders seems to have satisfied a clinical void as testified by the fact that the scale has so far been translated into seven languages. In summary, there is now considerable empirical evidence available that shows “trait-like” presence of self-disorders in the schizophrenia spectrum disorders. The measures of self-disorder are now being included in studies targeting early recogni-tion and treatment of schizophrenia.


In his article, Mishara omits all the (then available) empirical studies mentioned. Oddly, however, he does mention one vignette from a conceptual publication by Parnas and Handest (2003), only to warn his readers that “we must be careful not to draw conclusions from anecdotal self-reports” (Mishara 2007a, 565, italics added).

The Notion of Ipseity or Pre-Reflective Self-Awareness

Mishara (2007a) also gets the central theoreti-cal features of our view on self-disorder (ipseity disturbance) wrong in various ways. Consider his statement that we view “the core deficit in schizophrenia to be on the level of intentionality of fully constituted objects and self” (p. 560, italics added). This is incorrect.

The IHM model claims that a central phenom-enon of the schizophrenia spectrum disorders is a disturbance in pre-reflective self-awareness (or ipseity, from Latin: ipse = self, itself), that is, a disturbance of the very mineness or first-person perspective that characterizes any experience.

What do we mean by first-person perspective, by pre-reflective self-awareness, and what does the mineness of experience refer to?

When we refer to the mineness of experience, we are not referring to a specific content of experi-ence, like yellow, or being salty or spongy. We are referring to the first-personal presence, givenness-to-me, or perspectival ownership of experience, to the fact that experience feels like something for somebody. For a subject to own something in a perspectival sense, is for the experience in question to present itself in a distinctive manner to the subject whose experience it is. Ipseity could be defined as the self-presence (the presence to itself) of the self-as-subject. These pre-reflective aspects of experience contribute to what we (and others) call the minimal self (cf. Zahavi 1999, 2005).6 We admit, however, that an analysis of the minimal self is something of an abstraction as long as it fails to include the temporal dimen-sion (more about this in a moment). The basic or minimal self-experience to which we refer is not something willed or explicitly assumed, nor does it involve reference to a full-fledged self, as Mis-

hara seems to think. It is a passive and automatic process that must be regarded as the diachronic and synchronic prerequisite or precondition for any more substantial or elaborate sense of self.

Having or embodying a first-person perspec-tive does not, incidentally, require being able to articulate it linguistically. Indeed, it provides an experiential grounding of the latter possibility All the major figures in phenomenology—includ-ing Husserl, Merleau-Ponty, Sartre, and Michel Henry—considered a minimal form of self-con-sciousness to be an integral part of experience. This, for instance, is what Sartre meant when he declared that self-consciousness constitutes the mode of being of intentional consciousness (Sartre 1956, liv).

The Issue of Phenomenological “Reflection”

Mishara (2007a) claims that Zahavi’s (2005) argument for the existence of a pervasive pre-reflective self-awareness (ipseity) is tenuous because of numerous conceptual problems. He then mentions the following difficulty: there is no way of knowing whether what I describe in reflection was truly there before reflection, because the reflecting itself may have somehow added or inserted precisely those aspects I was looking for (Mishara 2007a, 561). As is widely acknowl-edged, recognition of this methodological or epistemological problem is an utter commonplace in phenomenological discussion. It was broached by Husserl himself (see, e.g., his discussion with H.J. Watt in §79 of Ideas I [Husserl 1982]) and was later discussed by numerous authors within the phenomenological tradition (cf. Chapter 4 in Zahavi 2005).

All the phenomenologists recognized that, rather than merely copying or repeating the origi-nal experience, reflection actually transforms it, or as Husserl explicitly admitted, it alters it (Husserl 1950, 72; 1987, 89). Husserl spoke of reflection as a process that discloses, disentangles, explicates, articulates, and accentuates (herausgehoben) all those components and structures that were implic-itly contained in the pre-reflective experience (Hus-serl 1984, 244; 1966a, 129; 1966b, 205, 236).

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One might see the phenomenological position as being situated between two extremes. On one hand, we have the view that reflection merely cop-ies or mirrors pre-reflective experience faithfully; on the other, the view that reflection distorts lived experience irredeemably. The middle course is to recognize that reflection involves both a gain and a loss. For Husserl, Sartre, and Merleau-Ponty, reflection is constrained by what is pre-reflectively lived through; it is answerable to experiential facts and is not constitutively self-fulfilling. But at the same time, they recognized that reflection qua thematic self-experiences does not simply re-produce the lived experiences unaltered, and that this may be precisely what makes reflection cogni-tively valuable. As Husserl put it, in the beginning we are confronted with a dumb experience that through reflection must then be made to articulate its own sense (Husserl 1950, 77; Merleau-Ponty 1945, 207).

A widely held view, to which we adhere, then, is that phenomenological reflection does contain the potential for a kind of iatrogenic error, and that this is one reason why its results cannot be considered to have the status of apodictic certi-tude. This does not, however, preclude the value of phenomenological reflection so long as this reflection is imbued with a self-critical awareness of precisely such dangers. Moreover, as Husserl argued, any skeptical claim to the effect that reflec-tion necessarily falsifies the lived experiences and that they consequently elude it completely is self-refuting: after all, this very claim must presuppose knowledge of those very same lived experiences, and how should one obtain that except through some kind of reflection (Husserl 1982, §79)?

Thus, rather than adding new, distorting components and structures to the experience reflected upon, a reflection might, at best, simply be accentuating structures already inherent in the lived experience. But how does this apply to the specific issue of the first-personal givenness of ex-perience that we were just discussing? To claim, as Mishara does, that it is reflection that creates the distinctive first-personal quality of experience, that experience lacked such qualities before becoming the object of a first-person thought, is to attribute quite exceptional powers to reflection. Such a

view is not, however, unprecedented. Indeed, on one reading, this is precisely the position adopted by many “higher-order thought” theorists in contemporary analytic philosophy of mind. Some of them have bitten the bullet and accepted the consequences of their position regarding the as-cription of phenomenal consciousness to creatures that lack the capacity for higher-order first-person thoughts. Carruthers, for instance, holds the view that animals (and children under the age of three) are simply blind to the very existence of their own mental states; and that there is, in fact, nothing at all that it is like for them to feel pain or pleasure (Carruthers 1998, 216). Such a position certainly seems counterintuitive. And as Carruthers himself notes, it might have profound implications for our moral attitudes toward animals and animal suffering (Carruthers 1996, 221). Is this the kind of position that Mishara is endorsing?

Self-Awareness and Absorption in the World

Throughout his writings, Husserl, the founder of phenomenology, is very explicit in arguing that self-consciousness—rather than being something that only occurs during exceptional circumstances, namely, whenever we direct explicit attention to our conscious life—is a feature characterizing normal human subjectivity as such, no matter what worldly entities the subject might otherwise be conscious of and occupied with. As Husserl for instance puts it in Zur Phänomenologie der Intersubjektivität II, “To be a subject is to be in the mode of being aware of oneself” (Husserl 1973, 151). It is clearly erroneous, then, for Mis-hara to take Husserl as supporting his claim that world-absorption and self-awareness are mutually exclusive (Mishara 2007a, 560–1). When Husserl talks about Selbstverlorenheit in connection with our intentional absorption in the world, he does not refer to a complete loss of self, as Mishara (2007a) seems to think (p. 561), but to the ab-sence of a thematic or reflective self-experience (see Zahavi 1999).

Heidegger—a key figure for “hermeneutic” and “existential” trends in phenomenology—is also referring to pre-reflective self-experience when


he argues that the self is present and implicated in all of its intentional (world- or object-directed) comportments; that the co-disclosure of the self belongs to intentionality as such (Heidegger 1989, 225). Heidegger also wrote that every worldly experiencing involves a certain component of self-familiarity, and that every experiencing is characterized by the fact that “I am always some-how acquainted with myself” (Heidegger 1993, 251; 1989, 225).

Mishara’s draws a supposed contrast between, on one hand, Sass and Parnas’s (2003) claim that “we are self-aware through our practical absorp-tion in the world of objects” (p. 430), and, on the other hand, what he calls the “existential phenomenological” notion that what he terms “self-awareness” and “absorption in experience” are “mutually exclusive” (Mishara 2007a, 560). There is, in fact, no contrast here at all: it is just that two different notions of self, both clearly distinguished in much of the phenomenological tradition, are being conflated by Mishara. As Sass and Parnas emphasize, the self-awareness (ipseity) to which they primarily refer is not self-as-intentional-object-of-experience, but rather the implicit or pre-reflective self-awareness of the self-as-subject—which most phenomenologists see as a concomitant of object awareness and a pre-requisite of reflective self-awareness (for details see Zahavi 1999; 2005). Thus, Paul Ricoeur (1966, 60–1), the most prominent synthesizer of phe-nomenology and hermeneutics, criticizes the view that “consciousness turned toward the other [is] unconscious of itself” and that “self-consciousness [he is referring to pre-reflective self-consciousness or ipseity] corrod[es] the consciousness which is directed toward something other than itself.”

It is noteworthy that, here again, there seems to be slippage in Mishara’s treatment of the issues: at one point, he seems to acknowledge the non–object-like and (in a sense) non-representational nature of ipseity: citing Sass and Parnas (2007), he notes that the IHM model speaks of a “disruption of a tacitly functioning operative intentionality which forms the background of consciousness” (Mishara 2007a, 560). But then, when he at-tempts to argue against ipseity’s fundamental role in experience, he clearly conflates ipseity with

an object-like or representational mode—what he now calls “self-awareness (in terms of self-reference)” or an “image-representation of self, that is, having a self, a “me,” rather than being a self, an ‘I’” (p. 560). Yet the distinction between pre-reflective self-experience and the experience of self-as-object is at the very heart of the articles by Sass and Parnas (2003; 2007) that Mishara criticizes and a book by Zahavi that Mishara also cites (Zahavi 2005; also 1999).

In summary: the IHM does not focus on distur-bance of a fully constituted self or self-as-object nor of fully constituted object, nor does it speak of a focal, thematic intentionality. Rather, we speak of disturbed or unstable preconditions for the normal, concordant, and smooth articulation of the self-object correlation. Once one grasps this key point, one sees that the dynamic, ever-shifting qualities of self-experience that Mishara (2007a) rightly emphasizes (p. 563) are, in fact, perfectly consistent with what we mean by ipseity. It is obvious that the pre-reflective self would not be a static entity, but something more like an ongoing process that must exist and constantly reconstitute itself in time.7

“Passive Syntheses” and “Operative Intentionality”

As a supposedly “existential-phenomenological response” or alternative view, Mishara (2007a) proposes that the primary disorder of schizophre-nia resides in “passive syntheses” of “pre-attentive binding between subcomponents of the self (e.g., I, me, and mine. . .)” (p. 562). (He does not, how-ever, say much about how this would cash out in fundamental clinical features of schizophrenia.) Mishara wants to offer the reader a polarized choice between ipseity, on one hand, and passive synthesis or temporality, on the other, as potential candidates of a generative disorder in schizophre-nia. In this way, he falsely reifies phenomenological concepts into mutually exclusive natural-kind–like categories, while failing to grasp key distinctions between levels of discourse and of psychological reality.

Mishara thus fails to grasp that, when we speak of such phenomena as schizophrenic autism, lack

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of self-affection, operative hyperreflexivity, lack of common sense, loss of natural self-evidence, diminished feelings of immersion, perplexity, and other aspects of the ipseity disturbance, we are also referring to the phenomenal manifestations of disturbed passive synthetic processes. Our use of the term “operative intentionality,” coined by Husserl and elaborated by Merleau-Ponty, refers precisely to the tacit, pre-objectival, largely “pas-sive” processes that found the coherence of the experiential field of the embedded subject (Sass 2003a , 157; Sass and Parnas 2007, 69, 82–85). Mishara (2007a) does in one passage (p. 560) note our use of the phrase “operative intentionality,” but then ignores this key point when he goes on to criticize our position.

In a recent article by Uhlhaas and Mishara (2007) our IHM or ipseity-disturbance approach is described as being essentially a top-down model that emphasizes “deficits in higher cognitive func-tions” or “an excess of rationality and reflective-ness” (pp. 142–3, 150). Uhlhaas and Mishara describe Sass (1992a) and Sass and Parnas (2003) as “claim[ing] that fragmentation and destruction of the self come from above by means of an excess of rationality or hyper ‘self-consciousness’” (p. 146). As summaries of the IHM or Sass’s current or earlier writings, these are clearly misreadings.

Hyperreflexivity certainly can involve intel-lectual or volitional processes, which can indeed have pathogenetic importance. (The parallel with modernism makes these processes especially salient in Sass’s Madness and Modernism.) But contrary to what Uhlhaas and Mishara imply, both Sass and Sass and Parnas have stated explicitly that hyperreflexivity should not be equated with intellectual or volitional processes of a “higher” nature—which might better be termed “hyper-reflectivity”—but also involves the popping out, in a kind of automatic fashion, of phenomena that would not normally be in the focus of awareness. Sass (2003b, 249) and Sass and Parnas (2007, 69, 82–85) term this latter process “operative hyper-reflexivity.” They state that the operative type is likely in fact to be more primary in a pathogenetic sense than is the reflective type of hyperreflexivity (p. 83),8 “affecting what Blankenburg (following Husserl) calls the ‘fundamental receptivity’ of the

automatic or ‘passive syntheses’ that structure the basic act of consciousness and constitute a person’s most immediate and fundamental rela-tionship to self and to world” (Sass 2003a, 167, 157). Earlier Sass (1992a) noted the possibility of neurophysiological “disturbance of those ‘lower’ and more automatic processes that normally al-low for spontaneity while providing a sense of natural embeddedness in the practical and social world” (p. 396).

Mishara’s characterization of our position as one that views schizophrenia as essentially deter-mined by “higher” or volitional processes is thus a misrepresentation of what is, in fact, an attempt to demonstrate the complexity of the interaction of intentional/reflective and non-intentional or “operative” factors.

In a recent article, Lysaker and Lysaker (2008b) adopt this mistaken view, portraying Sass as plac-ing exclusive emphasis on the “withering” effect of an “inward gaze of radical intensity” (p. 335). As their citations and phrasings indicate, their discussion of Sass’s views derives largely from a single, second-hand source: a paper by Mishara (2004). They cite only one paper by Sass (2000), while ignoring passages from that paper that contradict theirs and Mishara’s portrayal. The Lysakers’ uncritical acceptance of Mishara’s inter-pretation mars the treatment of phenomenology in their otherwise useful review article, and seems to have lead them into absurdities of which they are perhaps unaware. Thus, they portray Parnas and Sass as having incompatible views when, in reality, Parnas and Sass have been close collaborators for ten years, with congruent views as co-authors of papers on self-disorder and the phenomenology of schizophrenia.

Also misleading is the Lysakers’ (2008b, 335) reference to what they call “Mishara’s suggestion” (emphasis added) regarding the core pathogenetic role of disruption of “bodily systems that allow persons, without self-conscious effort, to suddenly attend to novel information.” In fact, the pathoge-netic significance (for schizophrenic cognition) of disruption of automatic processes that normally orient attention toward the novel, is perfectly explicit in work by Hemsley and Gray, who em-phasize disorders of the hippocampus-based


“comparator system” (Hemsley 1987, 2005). Also mistaken is the Lysakers’ presentation of this view as somehow antithetical to Sass’s position (also implied by Uhlhaas and Mishara 2007, 150, who cite Hemsley). Indeed, this view is perhaps the main neurocognitive hypothesis Sass singles out for its compatibility with his own position (see references in Sass 1992a; 2007a, 83, and other ar-ticles).9 In Madness and Modernism, Sass (1992a, 228) discusses the role such factors might play in self-fragmentation and bodily alienation—the very point the Lysakers ascribe to a 2005 publica-tion by Mishara. The compatibility of Hemsley’s comparator approach with Sass is acknowledged in Hemsley (1998).10

Temporality and Self-Experience

Here we will not attempt to discuss, in any detail, the relationship between temporality and self-experience. Clearly, however, there is some-thing absurd, from a phenomenological stand-point, about treating self-experience and temporal experience as if these were distinct faculties of the mind—as Mishara (2007a, 565) seems to do when arguing that temporality is more basic than self in the schizophrenia disturbance. Indeed the central point of Zahavi’s influential interpretation of Husserl’s writings on time was precisely that the latter’s notion of inner time-consciousness amounts to a form of pre-reflective self-awareness (Zahavi 1999, 2003a, 2003b).

The temporal distortions of schizophrenia have long been recognized, in both the experimental and phenomenological literature on schizophrenia (e.g., Bovet and Parnas 1993; Minkowski 1927; 1933/2005). Before being convinced that tempo-rality in particular is playing a foundational role in the pathogenesis of schizophrenia, it would be necessary to show (at least) that (A) the disorder is reasonably specific to schizophrenia in particular and (B) the temporal abnormality is more striking than other abnormalities in schizophrenia (thereby addressing some of the concerns raised long ago by Chapman and Chapman 1973). Mishara has not addressed either of these concerns.

By now it should be clear that in his article, “Missing links in phenomenological clinical

neuroscience,” Mishara tends to oversimplify, misrepresent, and offer misleading polarization of alternatives. So far we have focused primar-ily on his polemical treatment of our own work. Oversimplification and polarization are also characteristic of his conceptualizations of the possible underlying psychopathology of schizo-phrenia. Both tendencies emerge with clarity if we compare Mishara’s with Sass’s discussion of the German Gestalt psychiatrist Matussek’s ideas about prodromal features (including the so-called Wahrnehmungstarre) and of the relevance of Wolfgang Blankenburg’s work for understanding negative symptoms, and also Mishara’s attack on Sass and Parnas’s (2007) exploration of the pos-sible explanatory relevance of phenomenology.

Die Wahrnehmungstarre and the Existential Complexity of Schizophrenic Symptoms

In Madness and Modernism (1992a, Chapter 2), Sass uses the phrase “Truth-taking stare” to capture the phenomenon described in German psychiatry by the term Wahrnehmungstarre. Wah-rnehmungstarre refers to the fixed gaze that can be especially common in early phases of schizophre-nia; it would typically be translated as “rigidity of perception” (as both Sass 1992a, 423, n4 and Mishara 2007a, 564n note). In his article, Mishara claims that Sass’s use of the phrase “truth-taking” is a “fanciful but apocryphal” (p. 564) mistransla-tion, which suggests that Sass misunderstands the meaning of the German term Wahrnehmungstarre, which means “perceptual rigidity”; and that this is one indication of what Mishara calls a gross lapse of “textual/philological accuracy” that should call Sass’s scholarly reliability and hermeneutic competence into question. Mishara goes so far as to accuse Sass of “overlook[ing] the fundamental hermeneutic principles” by “granting [himself] the license to slip at these basic levels of textual-philological accuracy (e.g., translation, historical context, or careful and correct citing of sources)” (p. 564f).

It is not difficult to show that the misunder-standings and textual/philological “lapses” are entirely Mishara’s. This should be apparent from

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Mishara’s apparent failure to take into account the following endnote, which is appended to Sass’s first mention of the term Wahrnehmungstarre: “War-hrnehmung means ‘perception’ or ‘observation’ in German. I have chosen to translate this in an unusually literal way—as ‘truth-taking’—because this seems better to capture the schizophrenic experience in question” (Sass 1992a, 44, 423).

Wahr in German means “true,” as in the term “Wahrheit,” meaning “truth.” Nehmung is derived from “nehmen” as in “to take.” (Starre means “stiffness” or “rigidity.”) The above-quoted note makes it perfectly obvious that Sass was de-liberately and overtly using a kind of poetic license (in accordance with the etymology of the parts of the word, and with full knowledge of the standard meaning of Wahrnehmung) to convey a sense of the patient’s experience of a kind of revelation that can accompany the fixed or rigid stare common in prodromal schizophrenia. There is, incidentally, something of a tradition of this kind of creative etymology within phenomenology, especially in the later Heidegger.

Mishara commits other “textual/philological lapses” against both Sass and Matussek. At one point, Mishara (2007a, 564) criticizes Sass for not following Matussek’s lead more closely, and thereby failing to appreciate the role of “rigidity or attentional capture” while overemphasizing instead what Sass calls a “mode of deliberateness and hyperawareness.” In fact, Sass (1992a, 72, 427f, notes 43, 44) criticizes Matussek’s (Gestalt) theoretical account for downplaying the role of intentionality, while noting that, in his clinical de-scriptions, Matussek emphasizes both intentional and non-intentional aspects. Matussek (1987) does say that the schizophrenic “is held captive by the object”; but he also writes, “The schizophrenic . . . is capable, to a much greater degree, of fixing his attention on an isolated object,” noting the patient’s “ability” and “pleasure” in doing so (p. 93–4, emphasis added).

Mishara’s characterization of Sass displays a lack of familiarity with the arguments put forward in the works he criticizes. In writing on schizo-phrenia, Sass never denies the role of deficien-cies, dysfunctions, or other forms of “affliction.” Indeed, Sass (1992a, 73) states that it would be

“absurd” to claim that schizophrenic states are entirely under the patient’s control, and “foolish to view schizophrenia as purely volitional and entirely self-aware” (p. 114).

Mishara’s attempt to appropriate for himself the label “existential phenomenology” is peculiar. The approach Mishara offers in his article fails, in fact, to go beyond a rather mechanical or passive vision of the nature of schizophrenia, in which the patient’s role is simply to be afflicted with disturbances of passive synthesis; little if anything is said about broader human or “existential” consequences or about the patient’s conscious and self-conscious project of “being-in-the-world.” By contrast, much of the work that Mishara criticizes does explore these aspects in considerable depth (see especially Sass 1992a, 2003a, 2004a; Sass and Parnas 2007). Recently, Sass has focused on the nature of both personhood (2007b) and autonomy (2011) in schizophrenia, noting, for example, that schizophrenia, a heterogeneous condition, can sometimes involve not simple diminishment of autonomy, but more complex disruptions of the normal balance between independence and de-pendence or between autonomy and heteronomy

Mishara’s overly mechanical portrayal of passive syntheses seems particularly unsuited to accounting for the remarkable variability of schizophrenic symptoms and cognitive/affective abnormalities, which as often noted (e.g., Bleuler 1950, 72) may vary with context, motivation, and attitude. It is noteworthy, for example, that cognitive and perceptual disorganization is by no means constant, and often disappears in the presence of a strong motivation toward practical activity (for references see Sass 1992a, Chapter 1, p. 24 and notes 47, 48, 49; Chapter 2, p. 71 and notes 105, 112). In this sense it seems to be linked up with particular orientations of the self (including forms of reflexivity and self-affection). An understanding of ipseity disturbances is also relevant for conceptualizing psychotherapeutic interventions. It suggests the potential danger in overemphasizing certain forms of confrontation and self-reflection in the therapeutic process. It may also help to illuminate the potentially agen-tive role of the patient, and thereby suggest more subtle ways of helping patients both to identify


with their experiences and to engage in the thera-peutic encounter (Nelson, Sass, and Skodlar 2009).

Negative SymptomsIn the same paragraph in which Mishara ques-

tions Sass’s translation of Wahrnehmungstarre, he accuses Sass of another scholarly error; but once again, it is Mishara who commits errors of both fact and logic. Mishara (2007a, 565) says that the phrase “negative symptoms” had not been applied to schizophrenia at the time that the phenomeno-logical psychiatrist Blankenburg published his book, The loss of natural self-evidence, in 1971, and that for this reason it is inappropriate for Sass to consider the book to be relevant to what we now call “negative symptoms.”

As it happens, Mishara is wrong on the histori-cal point: several French psychiatrists, including De Clerambault, Nayrac, and Ey, spoke of negative symptoms in schizophrenia quite early in the twen-tieth century (Berrios 1985, 1991). This historical error is almost beside the point, however. Even if Mishara had been factually correct, his point would amount to a non sequitur that, if taken seriously, would preclude our finding much of contemporary relevance in older works of psycho-pathology, which often apply somewhat different terminology to recognizable conditions that now have different labels. (Often, of course, the over-lapping of categories is only partial, and this com-plicates the comparisons.) Mishara (2007a) also states that what Blankenburg calls “schizophrenia simplex” is a “very different diagnostic category” from that of negative-symptom schizophrenia (p. 565). The concept “negative symptom” is not, however, a diagnostic category at all, but part of a currently popular way of subtyping symptoms of schizophrenia (and some other conditions); nega-tive symptoms are typically distinguished from positive and disorganization symptoms.

It is obvious, in any case, that “schizophrenia simplex,” which lacks both positive and dis-organized symptoms, exemplifies at least one, particularly clear type of the negative syndrome. Indeed Mishara’s own description of schizophrenia simplex, in the article of his own that he cites here (his only relevant citation on the issue; Mishara

2001, 319–20), actually describes schizophrenia simplex (following ICD-10) in clear negative-symptom terms, namely, as “exhibit[ing] the basic but not the accessory symptoms of schizophrenia,” as being “fairly undramatic and inconspicuous in its own right,” as manifesting “decline in total performance,” and as having the “characteristic ‘negative’ features of residual schizophrenia (e.g., blunting of affect, loss of volition) [which] develop without being preceded by any overt psychotic symptoms.” If this is not a negative-symptom syndrome, what is?

Phenomenological Explanation

We end by considering the important but complex topic of phenomenology’s relevance for explanation. We approach this issue by discussing the inaccuracies in Mishara’s characterization of Sass and Parnas (2007), “Explaining schizophre-nia: The relevance of phenomenology.” Mishara describes Sass and Parnas as offering a “proposal to conflate explanation and understanding” in their 2007 article, and as somehow suggesting that phenomenological explanation need “not rely on experimental procedure.” He also states that “Sass and Parnas opt to associate their phe-nomenology with everyday explanation” (p. 563). Each of these three statements is flatly mistaken. It is not surprising, then, that in the paragraphs containing these statements, Mishara offers virtu-ally no quotations from Sass and Parnas (2007) (except a single phrase, and even that turns out to be inaccurate; on page 87, the phrase used is not “explanatory power” but “explanatory sig-nificance”; see Mishara 2007a, 563).

The first point to be realized is that the Sass and Parnas article from 2007 does not in any way deny the crucial role of neurobiological factors in the explanation of schizophrenia (nor does Sass 1992a, which in fact contains a lengthy appendix discussing “Neurobiological Considerations”). The article focuses, rather, on the distinct yet of-ten complementary role that an understanding of subjectivity can play. The second point is that the article does not focus primarily on the distinction between understanding and explanation, but on

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that between description and explanation. Sass and Parnas (2007) attempt to show that a com-monly held view—namely, that phenomenology is relevant only to description and not to expla-nation—is inaccurate. It then proceeds to differ-entiate a variety of senses of the word “explana-tion.” The paper explicitly offers a “preliminary taxonomy of six forms of phenomenological explanation” (p. 67) divided into two groups, the first involving a kind of “phenomenological implication,” the second a kind of “at least quasi-causal significance.” The diversity of these modes of explanation is central to the argument.

The point, then, in Sass and Parnas (2007), is to show that phenomenological accounts are not merely descriptive. But this in no way implies that all that is nondescriptive, or “explanatory” in some sense of the latter term, is somehow the same—as Mishara’s accusation regarding “con-flating” would seem to imply. (If A = not-x and B = not-x, this does not imply that A = B.) On the contrary, the whole point of the article is to make it very clear that not only the general term “explana-tion.” but also the forms of explanation to which phenomenology is relevant. are extremely various, ranging from the demonstration of meaningful unities to the clarification of causal sequences and interactions.

In the article, Sass and Parnas (2007) note that phenomenology (namely, the description of forms of experience or of subjective life) can help to “explain,” in one sense of that term, by showing, for example, how seemingly distinct features of conscious experience may actually be mutually interdependent in the sense of being different as-pects of the same experiential whole (this is called a kind of “implicative” relationship). In another sense of the term “explanation,” phenomenology can help one to understand (and also to explain) how one form of experience might lead into an-other, as when unusual features of the subjectively experienced perceptual field (e.g., perceptual frag-mentation) can inspire or motivate certain forms of (over-focused) attention, which can in turn lead to further transformations of the perceptual field (eventually involving, say, “delusional per-cept”—as discussed by Matussek, 1987, and also Sass 1992a, Chapter 2). The understanding of

such sequences has “explanatory significance” in the sense that it clarifies forms of causal or quasi-causal relationship that link one phase to another (viz., it is because the visual world has a certain kind of peculiar look—a feature of subjectivity—that the patient is motivated to scrutinize what is before him, and this in turn leads to certain consequences). Sass and Parnas take the view that mental patients are conscious human beings; and that, in addition to manifesting the relatively direct consequences of neurobiological abnormali-ties, they will also react to their abnormalities in all kinds of ways that may sometimes require the categories of meaning and experience in order to be understood or explained.

There is something surprisingly mechanistic about the proposal Mishara (2007a) makes. Al-though he does not say this in so many words, he discusses the patient as if he or she were exclusively the victim of brain events—as if intentional activ-ity were irrelevant and subjective experience no more than epiphenomenal. Mishara’s characteriza-tion of natural science as generally “seeking out explanatory relationships between ever-smaller parts” (p. 563) represents a highly reductionistic vision of science that runs counter to mainstream views in both modern and contemporary philoso-phy of science (re the latter, see articles in Kendler and Parnas, 2008)

Sass and Parnas do not dispute that neural abnormalities play a crucial role, nor indeed that they may often play the most fundamental role in terms of kicking off the sequence of events. “In its most primary form, then, this ‘irritation’ may well occur in a largely passive manner, and therefore represents an ‘operative’ rather than ‘reflective’ kind of hyper-reflexivity,” write Sass and Parnas (2007, 83; also Sass 1992a, 68–73, 374–97). “This ‘irritation’ may, in fact, be a rather direct consequence of a neurally based cognitive dysfunction.” As examples of the latter dysfunc-tion, Sass and Parnas mention disturbances of the hippocampus-based comparator system or of ‘cognitive coordination’ (citing Gray et al. 1991; Phillips and Silverstein, 2003).

This does not mean, however, that experi-ential phenomena, together with responses to these phenomena, involving different degrees of


volition, may not also play a key role. After all, even in the case of major physical illnesses, we are nearly always confronted with a complex combination of factors, which include both the organism’s and the person’s defensive and com-pensatory responses to the originating cause. In the case of psychiatric disorders, these responses are particularly likely to involve reactions (both “consequential” and “compensatory”; Sass and Parnas 2007) to lived experiences of various kinds. Bleuler (1950), who firmly believed in the physical nature of schizophrenia, nevertheless recognized the crucial importance of these factors, as can be seen in his subtle discussion of the precise nature of the affective disturbance in schizophrenia (see pp. 40–53, 363–73). Even if something like a neurologically based disorder of attention (see, for example, Hemsley 2005 for an especially plausible account) is primary in a chronological sense, we are nevertheless presented with a person who, over time, develops a particular cognitive/perceptual style, way of living, and world perspective—none of which can be entirely reduced to the attentional dysfunction itself (Sass 2007b). Understanding such styles or perspectives is of obvious relevance for understanding pathogenetic pathways and also in the therapeutic encounter and for devising new forms of psychological intervention.

Consideration of possible psychological, meaning-driven sequences is not, incidentally, something that can be separated from the search for neurobiological causes. Just one possible contribution of the former type of analysis, for instance, is that it may help the neuroscientist to pare away features that may not be directly related to a malfunctioning or abnormal neural substrate (because these features are psychologically ex-plicable) to have a purified understanding of the more direct cognitive or behavioral consequences of the substrate condition. But it is also true that a predilection for particular modes of attention or experience may have its effect on the neuro-biological plane (sometimes termed “downward causation”). In his discussion, Mishara shows no sensitivity to these possibilities.

It is also simply false to say that Sass and Par-nas “opt to associate their phenomenology with everyday explanation” (Mishara 2007a, 563).

Indeed, in the article Mishara criticizes, Sass and Parnas (2007, 74–6) explicitly contrast the distinc-tive explanatory contribution of phenomenology with the practical syllogism and the belief-desire paradigm of mental causation that is commonly proposed in analytic philosophy and that is gener-ally associated with everyday forms of explana-tion. Sass and Parnas do not deny the relevance of the belief–desire paradigm for explaining certain things. However, they note the problems inherent in applying this unadulterated form of everyday explanation to many apparently irrational actions and beliefs (such as found in schizophrenia); and they argue that phenomenological explanation typically directs one’s attention in a different direction, namely, “toward formal or structural features that involve more pervasive aspects or in-frastructures of human experience (e.g., modes of temporal or spatial experience, general qualities of the object world, forms of self-experience)” (Sass and Parnas 2007, 76). As Sass and Parnas say, the latter features are typically not part of everyday ex-planation—which is one reason why psychiatrists and psychologists would do well to be familiar with the phenomenological tradition—precisely to be able to go beyond the resources of everyday or common-sensical explanation (Gallagher and Zahavi 2008; Parnas and Sass 2008; Parnas and Zahavi 2002; Zahavi and Parnas 1998).

In several publications, Bovet, Parnas, and Sass (Bovet and Parnas 1993; Parnas and Sass 2001, 2008; Sass 1990b, 1992a Chapter 9, 1992b, 1994, 2004b) have emphasized, for example, the relevance of such non-everyday, phenomenological distinctions as Heidegger’s between the “ontologi-cal” and the “ontic” for the understanding and explanation of delusions. They have noted, for example, that whereas many paranoid delusions do imply fairly straightforward forms of “poor re-ality-testing” (the patient believes something false about a world whose structure is largely analogous to the normal world—“ontic” or “empirical” delu-sions), this is not so clearly the case with some of the more bizarre or metaphysical (“ontological”) delusions in schizophrenia. Recently Sass (2004b, 2007a) has argued that phenomenological notions about ipseity and the “horizons” of experience can help to explain some of the anomalies of

18 ■ PPP / Vol. 18, No. 1 / March 2011

emotion and affect in schizophrenia (including certain neurophysiological findings), notably the curious possibility that such patients can experi-ence a heightening of certain forms of affectivity (awe, ontological anxiety) simultaneous with a diminishment of the more passionate or standard forms of emotionality.

ConclusionOverall, Mishara’s arguments in “Missing link”

betray misunderstanding of the relevant phenom-enological and psychiatric literature as well as failure to grasp the key points of the publications he criticizes. In this article, we have addressed most of Mishara’s errors, attempting to do so in a way that serves the larger purpose of clarifying gen-eral issues pertaining both to phenomenological psychopathology and to our own perspective on schizophrenia. We have concentrated especially on several broad points: these include the mutuality of the relationship between the phenomenological en-terprise and cognitive (neuro)science; the nature of self-experience—particularly ipseity or pre-reflec-tive self-consciousness together with the notions of hyperreflexivity and diminished self-affection and their possible disturbance in schizophrenia; the potentially complex interactions of intentional or quasi-volitional with non-volitional processes in the formation of symptomatology; and the pos-sible (and diverse) contribution of phenomenology to psychological explanation.

Notes1. An additional reason for rejecting Mishara’s use

of the term “neophenomenology”: it has already been used extensively by Herman Schmitz (2003).

2. Mishara himself quotes the phrases “reciprocal constraint” and “mutual enlightenment,” even including them in the abstract, in Mishara et al. (1998).

3. Sass’s Madness and Modernism (1992a, see pp. 9, 10, 27) is perhaps the most extended recent attempt (together with his The Paradoxes of Delusion [1994]) to offer an explicitly hermeneutic-phenomenological approach to schizophrenia. For introductions to her-meneutic phenomenology’s relevance, see Sass 1988b, 1998. (In retrospect, Sass would revise his discussion of Husserl in these latter articles—along lines inspired by Zahavi [2003a] and explained in Thompson [2007, appendix A].)

4. A more accurate (but impossibly unwieldy) label for the overall model would perhaps be the IHRDSAM, standing for the Ipseity/HyperReflexivity/Dimished-Self-Affection Model.

5. Hyper-reflective processes are not always active; they can, for example, be quasi-automatized. There are many nuances to the activity/passivity issue.

6. More could be said about this topic (self-aware-ness vs self), but detailed analysis is beyond the scope of this paper. See Zahavi (2005, 2009).

7. For discussion of how seeking a static, object-like entity precludes finding the self-as-subject, see discussion of William James in chapter 7 of Sass (1992a).

8. Mishara (2007a) misses the relevant point when he acknowledges that, for the IHM, “hyperreflexiv-ity (or exaggerated self-reflection) may itself become automatic in schizophrenia leading to the ‘pop out’ of irrelevant background stimuli and disruptive bottom up processes” (560; also in Mishara 2007b, p. 716n). Sass and Parnas do indeed mention this latter kind of development (which involves an automatizing of reflec-tion). It would have been more relevant, however, to recognize that, according to our IHM view, operative hyperreflexivity is more fundamental, temporally and causally, than is hyper-reflection (Sass and Parnas 2007, 69, 82–5)—the latter point directly refutes Mishara’s critique.

9. Sass (1992a, 228) writes:

[The] mode of exigent introspection . . . could also reflect some more specific cognitive factor rooted in neurobiological abnormalities, such as an incapacity (or a disinclination) to synthesize larger Gestalts or, perhaps, an inability to desist from paying attention to stimuli that are habitually experienced and that would not normally be focused on (kinesthetic and other “in-ner” sensations would be one important subset of such sensations). In these latter cases, fragmentation of the self would be not just a consequence but, in a sense, also a cause of a certain kind of hyperfocused introspection.

An attached note cites Hemsley as well as Matussek and Conrad.

10. The “top down-versus-bottom up” or “from above-versus-from below” distinction misconstrues the difference between Mishara’s and our view, as explained. Also erroneous is using Nietzsche’s notion of the “Dionysian” to describe the view that common sense fails “because perceptual and automatic meaning processing are [sic] disrupted ‘from below’” (Lysaker and Lysaker 2008a, 32; 2008b, 335, citing Mishara). In Nietzsche’s Birth of Tragedy, Dionysianism refers to self-dissolution from excess of passion or instinct. This has nothing in common with the disrupted perceptual/automatic-processing view and seems antithetical to the nature of schizophrenia (Sass 1992a, Prologue; 2007a).


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Phenomenological Psychopathology and Schizophrenia: Contemporary Approaches and Misunderstandings

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