Self and World in Schizophrenia: Three Classic Approaches
Louis A. Sass
ABSTRACT: This article presents an introductory overview of the interpretations of schizophrenia offered by three phenomenological psychiatrists: Eugene Minkowski (1885–1972), Wolfgang Blankenburg (b.
1928), and Kimura Bin (b. 1931).
Minkowski views schizophrenia as characterized by a diminished sense of dynamic and vital connection to the world (“loss of vital contact”), often accompanied by a hypertrophy of intellectual and static tendencies (“morbid rationalism,” “morbid geometrism”).
Blankenburg emphasizes the patient’s loss of the normal sense of obviousness or “natural selfevidence”—
a loss of the usual common-sense background that enables normal persons to cope easily with the social and practical world. Kimura focuses on certain distortions of self-experience: a distinctive splitting of the subjective self, alienated awareness of one’s own ongoing consciousness, and profound uncertainty about the “I-ness” of the self.
In addition to a summary, this article offers a comparison and critique of these three approaches.
The three approaches are also considered in light of a more recent, phenomenological formulation of schizophrenia as a disorder of self-experience (an ipseity disturbance) involving hyperreflexivity and diminished self-affection (i.e., heightened awareness of aspects of experience that would normally remain tacit or presupposed and decline in the feeling of existing as a subject of awareness).
Je donne une oeuvre subjective ici, oeuvre cependant qui tend de toutes ses forces vers l’objectivité.—Eugene Minkowski
IT IS AN irony of intellectual history that phenomenological psychiatry should begin with a declaration, by its most brilliant exponent, of the method’s total inapplicability to the illness that would, in fact, turn out to be its prime object and source of inspiration—schizophrenia.
In his General Psychopathology, a work first published in 1913 that initiated the phenomenological movement in psychiatry, Karl Jaspers (1963) distinguishes between mental disorders that are “understandable” and those he considers closed to psychological comprehension or understanding. Presumably, only the former would be candidates for phenomenological exploration.
Whereas the phases of manic-depressive illness involve understandable exaggerations of normal mood states and associated psychological tendencies, schizophrenia is characterized by dramatic, qualitative distortions of the most fundamental features of human subjectivity. In Jasper’s view, these distortions are so profound as to defy the very possibility of empathic comprehension by normal persons; the only recourse is to attempt to explain them by seeking underlying physical causes in brain and nervous system (577–82). Jaspers particularly emphasizes mutations of self-experience that appear to contradict Descartes famous argument about the cogito—the idea that the very fact of experience necessarily implies a self who possesses these experiences.
Jaspers also mentions some other, typically schizophrenic experiences that appear to be psychologically inaccessible, including certain “abnormal body or organ sensations” as well as peculiar attitudes toward social reality and the commonsense world (581, 447).
This special issue of Philosophy, Psychiatry, & Psychology contains articles on schizophrenia by and about three phenomenological psychiatrists: Eugene Minkowski (1885–1972), Wolfgang Blankenburg (b. 1928), and Kimura Bin (b.
1931). They are, respectively, major figures of the phenomenological tradition in France, Germany, and Japan.1 As phenomenological psychiatrists, all three are indebted to Jaspers’s emphasis on “actual conscious psychic events” (2) as the proper and primary subject matter of psychopathology.
(The term “phenomenology” is used here in the standard philosophical and continental sense—that is, to refer to the study of “lived experience,” in this context, to the subjective dimension of mental disorders. This is to be distinguished from the context of Anglophone psychiatry in which “phenomenology” simply refers to readily observable signs and symptoms.) Each of the three phenomenological psychiatrists addresses the sorts of typically schizophrenic mutations that Jaspers considered to be incomprehensible.
In contrast with Jaspers, however, neither Minkowski, nor Blankenburg, nor Kimura views schizophrenia’s essential strangeness as placing it beyond the pale of phenomenological understanding. Indeed, for each, schizophrenia is not only a central topic for phenomenological psychiatry, but also one whose fundamental distortions are uniquely suited to illuminate key aspects of normal human subjectivity as well (Tatossian 1997, 11; Blankenburg 1971/1991, 106, 62). Each of the three has a distinctive way of characterizing the essential disorder or disorders in schizophrenia. But if considered against the backdrop of the dominant psychiatric approaches of the last century, certain strong affinities among their ideas quickly become apparent.
The most prominent views of schizophrenia over the past 100 years have interpreted the signs and symptoms of this illness as indicating defects or deficits of various kinds usually involving decline of one or more of the higher cognitive faculties widely considered to define the human essence, such as rationality, volition, or the capacity for abstraction or self-consciousness. There is no doubt that patients with schizophrenia do perform poorly on a wide variety of cognitive and perceptual tasks. However, within the psychiatric mainstream (at least in North America), the emphasis on quantitative decline has often been so dominant as to exclude appreciation both of the qualitative uniqueness of schizophrenic orientations and of the relevance of certain exaggerated cognitive capacities.
The notion of some basic disorder of higher functions has often encouraged a pessimistic attitude about making sense of what schizophrenics have to say; supposedly, such patients lack the kind of rationality that may be a prerequisite to meaningful speech and dialogue. Psychoanalysts have typically been more optimistic about the possibility of achieving some kind of psychological understanding of schizophrenics and their perspectives on the world. Here, however, the prevailing explanatory models have traditionally interpreted schizophrenia as regression to infantile forms of experience and as dominance of instinct over intellect or more sophisticated emotional attitudes (Sass 1992a, chap. 1).
The major exceptions to the above trends are psychiatrists and psychologists within the phenomenological tradition. The contrast to the standard approach is especially clear in the case of Minkowski, who views schizophrenia as characterized by a fundamental decline or rupture, not in higher mental capacities, but in some basic or primal sense of vitality or vital connectedness with the world, often accompanied by a hypertrophy of intellectual tendencies. In his article in this issue, Professor Kimura describes a characteristically schizophrenic splitting of the self into objective and subjective (empirical and transcendental) aspects—a splitting that, he suggests, is actually a normal feature of all human experience that happens to be more clearly revealed in the condition of schizophrenic alienation. The work of Blankenburg has similar implications.
Far from being incompatible (as Jaspers suggest ed), phenomenology and schizophrenia have a special affinity according to Blankenburg. Blankenburg (1991) endorses Husserl’s description of the phenomenological attitude and epoché (the famous “bracketing” of belief in objective reality) as no mere intellectual exercise but as demanding “a complete metamorphosis of the person” (109, 65), since it involves a stepping-outside of the usual mode of living and a replacement of the naïve-natural attitude by a more reflexive orientation. And schizophrenia, like phenomenology, involves a pulling-back from normal immersion combined with concomitant forms of reflection or self-awareness that reveal aspects of experience that would normally go unnoticed; in this way, schizophrenia—a condition of alienation from both self and the self-evident—can be said to offer “illuminating counterparts” to Husserl’s phenomenological reduction of the “natural attitude” (Spiegelberg 1972, 110). Blankenburg (this issue) considers the vulnerability to breakdown of common sense—epitomized by schizophrenia—to be part of the basic structure of being human, for to be human is to be capable of alienation and doubt.
The purpose of this special issue of Philosophy, Psychiatry, & Psychology is to introduce the work of Minkowski, Blankenburg, and Kimura to an Anglophone readership. Most of this introductory article is devoted to synopses of their important and original accounts of schizophrenia, but I also point out some similarities and differences among their respective views and offer some friendly criticisms. Discussion of related empirical research findings and directions can be found in the concluding article of this special issue, written by Sass and Parnas.
In the pages below I also take the liberty, at several points, of comparing the views of Minkowski, Blankenburg, and Kimura with the closely related phenomenological account offered in my books, Madness and Modernism (1992) and The Paradoxes of Delusion (1994), and in several recent articles (Sass 2000; Sass, in press, a, b; Sass and Parnas, submitted; Parnas and Sass, 2001). In my view, schizophrenia is best understood as a particular kind of self- or ipseitydisorder (ipse is Latin for “self” or “itself”) that is characterized by two, complementary distortions of the act of awareness, of what Merleau-Ponty (1962, 135, 157) called the “intentional arc.” The first distortion is hyperreflexivity, which refers to certain forms of exaggerated self-consciousness; the second is diminished self-affection or ipseity, which refers to a loss of the sense of existing as a self-possessed subject of awareness or activity. This notion of a two-faceted intentional-arc disturbance is not yet a highly specific or operationalized theoretical model; it does, however, offer a broad, interpretative framework that can help to organize our understanding of schizophrenia as well as to integrate the views of Minkowski, Blankenburg, and Kimura.
Eugene Minkowski Eugene Minkowski (1885–1972) is, along with Ludwig Binswanger, one of the two founders of the tradition of phenomenological psychiatry.
Although he discouraged discipleship—and certainly never founded anything like a school—
Minkowski is generally recognized as the most brilliant French thinker in this tradition and, along with Jacques Lacan and Henri Ey, as one of the most significant French-language psychiatrists of the twentieth century. Minkowski was one of the founders, in 1929, of the journal Évolution Psychiatrique. He has had an important influence on later writers from several countries, including Blankenburg and Kimura, Tellenbach and Tatossian, Lacan, Rollo May, and R. D. Laing, as well as on many younger psychiatrists and psychologists (several of whom have contributed to this issue of Philosophy, Psychiatry, & Psychology).2 In 1949, the phenomenological philosopher Maurice Merleau-Ponty described Minkowski as the first “witness among us”—the one who introduced phenomenology and existential analysis in France (Spiegelberg 1972, 233).
At first glance, Minkowski’s central place in phenomenology and phenomenological psychiatry may seem surprising. Unlike many psychiatrists and psychologists in this tradition (e.g., Binswanger, whose loyalties shifted from Husserl to Heidegger and back again), Minkowski is not a disciple of any of the major phenomenological philosophers, nor does he even refer to them with great frequency. His literary style and general intellectual orientation are also unusual. Much phenomenological philosophy and psychiatry is written in a highly technical or abstract prose that can be off-putting to the uninitiated reader.
By contrast, Minkowski was a devoté of ordinary language (see Minkowski 1997, 193) who relied for inspiration far more on his own everyday experience and encounters with patients than on any psychological or philosophical theory.
Minkowski (1999a) himself characterized his approach to psychopathology as motivated less by a concern to extend the domain of medicine than to restore to madness its human character (14). R. D. Laing (1963) described Minkowski as the first in the history of psychiatry to have made a serious attempt to reconstruct the lived experience of the other (207).
Minkowski’s almost visceral distrust of overreliance on intellectual theorizing should not be ascribed to any lack of sophistication—he corresponded with Bergson and Husserl, was a friend of Ludwig Binswanger, and participated in a circle of Parisian intellectuals that included Alexandre Koyré and Louis Lavelle. Minkowski was well aware of the necessity of theorizing about mental disorders (1999a, 35), but wished to remind his readers of what they would risk losing as a result of rigid devotion to any single theoretical perspective or even from conceptualization per se. The one philosopher who did exert a great influence on Minkowski was Henri Bergson—a thinker not generally considered part of the phenomenological tradition and one whose key ideas are founded upon a critique of abstraction and analysis.
Bergson’s influence on Minkowski is well covered in Annick Urfer’s contribution to this special issue. Here I will simply recall Bergson’s basic opposition between intellect and intuition—
the former associated with analysis and abstract reason and with geometrical or spatial modes of experience, the latter based on, and fundamentally attuned with, the vitality and temporal dynamism of experience as it is actually lived—at least by normal individuals. Bergson’s perspective had an obvious impact on Minkowski’s conception of schizophrenia and manic-depressive illness. But this Bergsonian perspective was important as well for Minkowski’s critique of “psychopathology” as an intellectual discipline—for his conception of the nature and purpose of psychiatric understanding itself.
Like Bergson, whom he so admired, Minkowski is an heir to European Romanticism who offers many of the same criticisms that the Romantic poets and philosophers directed toward Enlightenment science. Like Wordsworth (“We murder to dissect”), Minkowski sees analysis and atomistic modes of thought as precluding appreciation of the dynamism of organic life. In Minkowski’s view, for example, affect, will, and intellect are best understood not as separate faculties in external interaction but as aspects of a larger whole, an “original unity” that is the dynamism of human subjectivity itself (Minkowksi 1999b, 57ff). Similarly, he wrote, “madness, for us, does not consist in a disturbance of judgment, or of perception, or of will, but in a perturbation of the intimate structure of the self [du moi]” (1997, 114).
Also, like many of the Romantics, Minkowski rejects thought that would subordinate all of reality to the principle of causality—a principle that, by placing cause and effect on exactly the same ontological plane, “replace[s] all the richness of life with a gray and dull framework” (1999b, 48). Minkowski accepted Bergson’s emphasis on the principle of expression, a noncausal form of relationship that recognizes the different status of the inner and the outer, of that which is expressed and that which does the expressing (1997b, 214; 1999b, 121; also Taylor 1985). Psychiatric symptoms and psychological states must not be treated as isolated fragments, Minkowski insists. They are, rather, expressions of the self—“because each psychological state, by virtue of the fact that it belongs to a person, reflects and expresses the entire personality.” What is crucial is the need “to penetrate, through [and beyond] the isolated symptoms, to the living person, to seize in a single effort of knowing, his whole way of being” (1997, 94f). At times, Minkowski describes the act of understanding almost as a leap whereby one transcends oneself in order to enter into the soul of the other (99).
In the introduction to his Traité de Psychopathologie (1999a, 33), Minkowski reminds us that we tend to think and express ourselves in substantives; these have the effect of reifying what we describe as well as of isolating our object of study from its context and ground.
Minkowski notes that most manuals of psychiatry begin with a description of the diverse kinds of symptoms to be found in mental disorders: for example, distortions of memory, orientation, or perception; illusions and hallucinations grouped according to the different sense modalities; disturbances of thinking and judgment, including flight of ideas, incoherence, obsessional ideas, fixed ideas, and delusional ideas; and so forth (42). Such listings of isolated symptoms are useful for the workaday practice of clinical psychiatry.
They can, however, be profoundly misleading if taken to imply that actual clinical phenomena falling under a particular rubric, but coming from a diverse set of patients, are necessarily very similar to each other (52).
In “Psychopathology and Philosophy,” an essay from 1952, Minkowski describes, for example, how different the “ideas of grandeur” that occur in general paralysis, manic excitement, and schizophrenia tend to be. Whereas the first involves a wild dysregulation of thinking (“déreglement déchainé” [unchained unruliness]), the second stems from a playful flight of ideas, and the third involves disjunction and discordance characterized by double bookkeeping (e.g., the patient who proclaims himself Pope yet nevertheless sweeps the floor without complaint).
Minkowski also mentions concerns about the end of the world, which can be highly rationalistic and coldly expressed in schizophrenia, whereas similar ideas are intensely and profoundly lived in the twilight states of epilepsy (1997, 219f). Elsewhere, he discusses the very different psychological foundations that hypochondriacal preoccupations tend to have in anxiety states versus in schizophrenia (1997, 96) and the distinct nature of both delusions and auditory-verbal hallucinations as found in manic-depressive illness, schizophrenia, or mystical states (48).
The purpose of the phenomenological and structural approach Minkowski recommends is, then, not merely to describe subjective symptoms, but also to attempt to grasp the underlying unity or trouble genérateur characteristic of particular types of the abnormal lived world (55). He speaks of an “organized and living unity” and of symptoms as the “expression of a profound and characteristic modification of the human personality in its entirety” (1927 [1997], 12).
In his account of schizophrenia, Minkowski distinguishes two aspects that correspond to the two sides of Bergson’s dualism. Although one aspect involves decline and the other exaggeration, neither can fully be captured in quantitative terms. On one hand, such individuals tend to manifest a loss of vital contact with reality and a dulling of their subjective lives. This transformation is neither a general lowering of the mental level nor a clouding of mental life (as in dementia or delirium). It is, rather, a diminishment of the sense of vitality, or of existence itself, that defies easy description. The term “anhedonia” does not capture the phenomenon, for not merely pleasure but all experiences are affected (1999a, 304). In his Traité, Minkowski (1999a) speaks of two layers or strata of the self: one more peripheral that serves the registering of external stimuli as well as responses to these stimuli, the other more deep and central—the seat and source of the felt and the lived (“du senti et du vécu”; 309).
A characteristically schizophrenic form of splitting or fragmentation divides these two levels to the detriment of the lived. This affects the patient’s sense of the reality and vitality of the self and is clearly related to what has subsequently been called loss or diminishment of self-affection (Parnas and Sass, 2001; Zahavi 1999), but it also affects one’s experience of the world, which now seems colorless, neutral, or dull (Minkowski 1999a, 318).
Such persons may be perfectly aware of the more objective aspects of reality; yet though they “register and know,” they do not “feel” the reality of what they experience (1999a, 305). Such patients sense that they are not fully present in their actions and experiences: Although they may appear to behave just like other people, they have the sense that nothing is real, that they are only pretending, for example, to love someone or to feel happy or sad (303f). In extreme cases, a “nameless catastrophe” seems virtually to have “abolished” the human person; one such patient set fire to her clothing to make herself feel something (308, 301).
But schizophrenia is not purely a matter of dulling or devitalization. Along with this decline in the intuitive or vital aspects of existence, there is often an exaggeration of the more intellectual, spatial, or schematic modes of consciousness and expression. One manifestation of hypertrophied intellectualism is the “interrogative attitude” described by Minkowski and Targowla (this issue).
Another is a tendency toward a kind of geometrical or quasi-mathematical abstraction, vividly described by a patient treated by Minkowski’s wife, F. Minkowska: What upsets me a lot is that I have a tendency to see only the skeleton in things; it can happen that I see people in this way. It is like geography, where rivers and cities are lines and points….I schematize everything, I see people as points or circles. When I think of a meeting I attended, I see the room, I represent the people present by points. (1999a, 326f) Minkowski describes the expressive side of this as an abandonment of the mode of “representation” in favor of that of the schema. This is precisely what one patient of mine did when asked to draw a picture of his family. Instead of attempting any standard form of realistic representation, he simply drew a big circle surrounded by four or five smaller ones, then explained that this was his family sitting around the kitchen table as seen from above. Even in relationship to himself, a schizophrenic person may manifest a kind of extreme objectivity and may describe his own experiences as if speaking of a third person (354).
Minkowski generally presents morbid geometrism and morbid rationalism as having a secondary status in relation to the decline of the “intimate dynamism of our life” and of vital contact with reality, which he describes variously as the essential, fundamental, initial, and generative disturbance (“trouble initial, trouble genérateur”; 1927 [1997], 5, 77f, 83). “Loss or rupture of vital contact” is the essence of schizophrenic autism; idiosyncratic preoccupations and withdrawal into a private or delusional world are secondary features. The patient Paul’s interrogative attitude, for example, is described as a “compensation mechanism” by which Paul strives to fill the void left by his loss of any real, vital interest in the world (Minkowski and Targowla, this issue). But it is important to realize that these defensive or compensatory tendencies are themselves marked by the very condition of vital decline to which they are a response (1999a, 618–22). Schizophrenic rationalism is not merely an exaggerated rationalism, but one that lacks both the vitality and the flexibility or souplesse that is characteristic of human rationality in its more normal forms.
I would rank Minkowski’s La Schizophrénie among the most important and lasting books on schizophrenia written in the twentieth century.
Like many other writers on schizophrenia, I myself have been significantly influenced by this lucid and compelling account. Minkowski’s other books—Traité de Psychopathologie and Le Temps Vécu and his volumes of collected essays—
are also of considerable interest. Minkowski’s clinical descriptions remain unsurpassed. His interpretation of autism as loss of vital contact, and his account of morbid geometrism and morbid rationalism, were highly original when he wrote them; they focus on key aspects of schizophrenia that, even today (perhaps, especially today) tend to be neglected or even denied. There are, however, several weaknesses or lacunae that should be mentioned. Given that Minkowski’s work was published up to seventy-five years ago, some of the following comments may seem to have a somewhat anachronistic quality. But Minkowski’s perspective is of more than merely historical interest; if one wishes to bring Minkowski into present-day discussions—as he clearly deserves—then several points are worth bearing in mind.
My first concern pertains to the vagueness or uncertainty in Minkowski’s account of what he calls the trouble genérateur: In what sense can the trouble in question be said to “generate” the various aspects of the illness? Phenomenological psychiatrists and philosophers have not always been very clear about the precise explanatory relevance of their phenomenological accounts.
Minkowski equivocates as to whether the trouble genérateur precedes these other aspects as a kind of prior cause or whether it is better conceived as a central theme or “essence” of the illness. (In La Schizophrénie, he describes loss of vital contact as “not a consequence of other psychical disturbances, but an essential point [or state] from which spring, or at least from which it is possible to view in a uniform way all the cardinal symptoms” [1927 [1997], 87].) One might also wish for a more elaborate analysis of some of the phenomena he describes. What, for example, does it really mean to speak of madness as “a perturbation of the intimate structure of the self” (1997, 114)? Minkowski’s key notion of “vital contact,” which derives from Bergsonian philosophy, retains a certain metaphysical aura, and it is difficult to specify the processes of consciousness or cognition that are entailed.
My second point concerns Minkowski’s tendency to focus on a restricted set of schizophrenic symptoms and to neglect other major symptoms or syndromes of schizophrenia. His emphasis falls on what are now termed the “negative symptoms,” especially apparent decline of energy and affective response along with devitalization, disconnection, and diminished self-affection, as well as on largely compensatory forms of hyperrationalism and spatializing. Little mention is made of key features of what we would now call the “disorganization” or the “positive” syndromes (Liddle 1987)—that is, either of the more confusing and confused types of formal thought disorder and related disturbances of language and attention, or of “bizarre” first-rank symptoms of being inhabited or controlled by an alien being or force. Minkowski’s exemplary patients complain of their deadness or non-existence, and they manifest rigid rationality; seldom do they complain of the sense of bodily or mental discombobulation or of the “influences” from without that are prominent in many schizophrenic patients. In one essay, Minkowksi (1997, 108f) acknowledges his difficulty in handling Bleuler’s “secondary symptoms,” which include hallucinations and delusions. He goes on to suggest that “supplementary mechanisms,” perhaps akin to Clérambault’s “mental automatisms” and having little to do with schizophrenia per se, may be relevant.
Minkowski’s emphasis on exaggerated rationality and predilection for the static and the spatial is consistent with Bergson’s distinction between the intuitive and the rational. My third and final observation is that Minkowski may overemphasize hyperrationalism, while paying too little attention to the disruptive, often selfundermining forms of exaggerated self-awareness that I have referred to as “hyper-reflexivity” (Sass 1992a). This last point will be elaborated further below. Here I will simply say that hyperreflexivity (in contrast with morbid rationalism) seems better able to account for the disruptions of hierarchical organization characteristic of schizophrenic thought and language as well as for the radical forms of self-alienation exemplified by the first-rank symptoms.
Wolfgang Blankenburg The richest vein of phenomenological psychopathology is to be found in German-language psychiatry—not only in the works of the famous Heidelberg School (including Jaspers, Mayer-Gross, and Kurt Schneider; Von Baeyer, Grühle, Kisker, Tellenbach, and Häfner; and currently represented by Alfred Kraus and Thomas Fuchs) but also by various other writers from Germany and Switzerland (including Binswanger, Boss, von Gebsättel, and Erwin Straus; see Spiegelberg 1972; Tatossian 1997). Here too schizophrenia has received more attention than any other disorder.
Perhaps the most prominent living representative of this tradition is Wolfgang Blankenburg, for many years a professor and chairman of psychiatry at the University of Marburg. Now retired, Blankenburg has written on many aspects of psychopathology, psychotherapy, and psychiatric methodology.
Here I shall focus on his best-known work, Der Verlust der Natürlichen Selbstverständlichkeit: Ein Beitrag zur Psychopathologie symptomarmer Schizophrenien (The Loss of Natural Self-Evidence: A Conribution to the Study of Symptom-Poor Schizophrenics)—a work published in 1971 that I would rank among the most important books on schizophrenia of the last century. (Below I reference the French translation of 1991 and also, in italics, the original German edition of 1971; the book has not been translated into English.) The paper by Blankenburg translated for this special issue appeared in 1969 and can serve as an overview and introduction to The Loss of Natural Self-Evidence.
In his book of 1971, Blankenburg argues that the central defect or abnormality in schizophrenia is best described as a “loss of natural selfevidence.” This phrase is borrowed from “Anne,” the patient who serves as his central case example.
Loss-of-natural-self-evidence is something broader and more subtle than most symptomatic concepts (97f, 55f); it refers to a loss of the usual common-sense orientation to reality, that is, of the unquestioned sense of familiarity and of the unproblematic background quality that normally enables a person to take for granted so many of the elements and dimensions of the social and practical world. What occurs can be described as a disruption of the normal or “essential proportion between the sense of the obvious and its absence in amazement and doubt” (Spiegelberg 1972, 110). Blankenburg’s approach is consistent with empirical studies, which show that, although schizophrenics often do surprisingly well on many intellectual tasks requiring abstract or logical thought, they have particular difficulties with more practical or common-sensical problems, perhaps, especially, when these relate to the social world (Cutting and Murphy 1988, 1990).
Blankenburg’s (1991) perspective is descriptive, holistic, and somewhat static. He seeks to comprehend the overall tenor, dominant theme or style of existence, or fundamental conditions of possibility of the schizophrenic lifeworld. Blankenburg is well aware of the inevitable oversimplification and the potential arbitrariness inherent in any attempt to sum up the essence of schizophrenia (27–28). Nevertheless, he suggests that this distinctive but subtle disturbance of common sense, which he calls a form of “alienation,” defines a key “condition of possibility” for what he terms the “primary autism” of the schizophrenic’s form of life (1986; 1971/1991, 201, 230, 232, 139; Parnas and Bovet 1991).
Blankenburg does not, however, concern himself with causal explanation or with tracing developmental trajectories. He clearly states that, when describing “loss of natural self-evidence” as a “basic disorder” or “Grundstörung,” he is concerned not with etiology but with capturing the “essence” of the transformation (p. 27, 4). (This may distinguish it from Minkowski’s “trouble genérateur”; see above.) Blankenburg’s and Minkowski’s styles of doing phenomenological psychiatry are certainly different. Whereas Minkowski seldom refers to philosophical authors, preferring everyday language and a focus on immediate clinical realities, Blankenburg’s book is replete with philosophical references and intriguing applications of ideas from Husserl, Merleau-Ponty, Sartre, and especially Heidegger. In their views of schizophrenia, however, the two phenomenological psychiatrists have much in common. Both emphasize a disturbance or decline in the patient’s spontaneous engagement with the world, which can be combined with an overreliance on (or hypertrophy of) the more intellectual forms of experience or coping. Although “loss of natural self-evidence” has a more cognitive, and “loss of vital contact” a more dynamic or affective flavor, this difference of emphasis diminishes on more careful examination. Both Minkowski and Blankenburg recognize that knowing and caring are inseparable, that is, that our cognizing is normally imbued with the motivations and affects that both anchor and orient us in the world. Blankenburg writes, in fact, that “in the ability to judge, feeling [is] an organ of cognition” (this issue).
According to Blankenburg, the essential or basic mutation of schizophrenic subjectivity appears in its purest and most easily discernable form in “symptom-poor” patients who lack the florid symptoms of the illness. Along with Minkowski’s La Schizophrénie, his book offers perhaps the richest available account of the often neglected, subjective side of the “negative” or predominantly “deficit” syndromes of schizophrenia (see also Sass 2000). But Blankenburg (1991) believes that loss of self-evidence underlies many of what would be called the positive and disorganization symptoms as well: He calls it the “nonspecific specificity” (30, 97, 6, 55) that defines the essence of schizophrenic illness and helps to account for many of its characteristic features.
One characteristic feature of loss-of-naturalself-evidence is how difficult it is to describe: Patients complain that they cannot capture in words that which is afflicting them so profoundly.
Since it is not an object or an appearance but the horizon of possibility for a certain kind of experience, it lies everywhere and nowhere—so familiar that it recedes into the background of our awareness. (Blankenburg compares loss of self-evidence to Heidegger’s discussion of how “being” announces itself precisely by retiring; 230) As Blankenburg notes (87, 49), language is not well suited to describing dimensions of existence on which language itself is founded and which it tends to presuppose.
Blankenburg’s patient Anne speaks of lacking “something small…but so important that without it one cannot live” (103, 60). Normal people, she says, all have some sort of “way,” “manner of thinking,” or “frame within which everything plays out” (126, 140; “eine Bahn, eine Denkweise”; “der ‘Rahmen’ in dem sich alles abspiele”—79, 90); and it is by following this manner or way that “one thinks…that action is guided…that one behaves” (126, 79). But whereas others have a “natural relationship” with this manner or way, Anne describes herself as finding “everything, everything in general [to be]
so problematic. No matter how, I don’t understand anything at all” (121, 75). She complains of not being able to stay on a single continuous pathway and of continually finding herself somehow in a different world, having to start anew (138–40, 88–90). What ensues is not so much theoretical confusion or intellectual incomprehension as a kind of practical incompetence and perplexity that disrupts the ease and smooth flow of normal experience and everyday practical activity and impedes independent functioning in daily life. Such persons have particular difficulty in domains that require subtle interpretation and practical judgment; they may prefer fields that are more logical and clear-cut, such as physics or mathematics (this issue). “The only thing that remains for me, says Anne, “ is to rely upon rational grounds” (82; “Dann bleibt mir nichts, als mich auf Vernunftsgründe zu verlassen”, 47).
Although patients themselves will often speak of having a deficit or Defekt (Blankenburg 1991, 89, 51), it is wrong to understand this loss in purely quantitative or negative terms—as a simple privation of something normally present (namely, common sense). For as Blankenburg notes, what he calls loss of natural self-evidence involves a qualitative alteration of the constitutive foundations of experience as well as a kind of dialectical negation (100f, 58).
The loss of natural self-evidence in negativesymptom patients is, in fact, often accompanied by exaggerated forms of self-conscious awareness (hyperreflexivity) in which patients focus on aspects or processes of action and experience that, in normal experience, would simply go unnoticed (107–22, 63–75). Blankenburg speaks of a characteristically “schizophrenic alienation” (34, 201, 9, 139)—a sense of being outside the usual customs and concerns of the shared social world, detached from the usual taken-for-granted background of assumptions and practices, and somehow dislodged from the usual sense of being rooted in one’s own being: “I am somehow strange to myself; I am not myself,” said Anne (94; “Ich bin mir irgendwie fremd—bin nicht ich selbst,” 54). “It is as if I watched from somewhere outside the whole bustle of the world” (113; “Es ist als ob ich das ganze Weltgetriebe so von aussen anschaue,” 68). Anne speaks of being “hooked to” or “hung up on” (79f; hängen bleiben, 44) obvious or self-evident problems and questions that healthy people simply take for granted—questions that she herself often found pointless ( 91,139, 52, 89). “It is impossible for me to stop myself from thinking,” she said (82, 46). Blankenburg describes such patients as experiencing an impoverishment of all vital relationships apart from the reflective relationship to oneself (76; “mit ausnahme des reflektierenden Selbstbezugs,” 41).
According to Blankenburg (94, 54), loss of natural self-evidence is what underlies the characteristically schizophrenic “perplexity” (Ratlösigkeit) described in classic German psychopathology (Störring 1939 [1987]). To understand this perplexity, it is not sufficient to stress the patient’s sense of declining vitality and activation or the fact that, with the awareness of the normally tacit, the patient’s consciousness is now flooded with more input, in a state of cognitive overload.
More crucial, I would argue, is a radical qualitative shift, namely, that when tacit dimensions become explicit, these dimensions can no longer perform the grounding, orienting, in effect, constituting function that only what remains in the background can play.
Normally, says Anne, a person’s “way” or “manner of thinking” develops spontaneously over time, and largely unnoticed, like one’s character itself. Anne, however, feels herself to be at an enormous distance from any such thing: “In my case,” she says, “everything is just an object of thought” (127; “Bei mir ist das alles nur angedacht,” 79). Another patient speaks of “a process of reversal in which what is most interior moves toward the exterior”: “Schizophrenia,” he says, “it’s exactly as if I turned a carton inside out” (135; “Die Schizophrenie ist genau so, wie wenn ich einen Karton nach aussen stülpe,”86).
A consequence of the loss of natural self-evidence, of the normal sense of embeddedness in a framework, is that the patient must devote energy and a kind of active, conscious effort and control to processes that would normally take place automatically. The very constitution of self and world—normally a “transcendental operation” (“transzendentale Leistung”; 1971 84; 1991, 132) that arises via preconscious passive syntheses—comes to seem fragile and now requires an almost physical effort that uses up available resources. This need for effort—which is at the root of schizophrenic autism (1991, 156, 104)—may account, at least in part, for the lack of energy and general sense of exhaustion so common in schizophrenia (what Blankenburg calls schizophrenic “asthenia”; 132–33, 153, 155–56, 84f, 101, 103f).
Blankenburg likens the schizophrenic’s sense of amazement before that which would seem to be most self-evident to the wonder achieved by a phenomenological philosopher who engages in what Husserl called bracketing or the epoché—
who suspends the normal assumptions of the “natural attitude” in order to bring those assumptions to light (112, 67). This detached awareness and querying of normally unnoticed frameworks or social conventions account for the hyper-abstract or quasi-philosophical quality in the thought and speech of many schizophrenic persons. But Blankenburg also discusses some important differences between schizophrenia and phenomenology that are no less revealing of the nature of both schizophrenia and normalcy.
As Blankenburg notes, the phenomenologist’s suspension of natural self-evidence is largely the result of a theoretical position. Personal or temperamental factors play no more than an ancillary role, whereas in schizophrenia, some kind of endogenous foundation seems key.3 Blankenburg also emphasizes the importance in schizophrenia of abnormalities in what he calls the foundational, ante-predicative aspects of experience, that is, in the automatic, association or gestalt-based processes that Husserl called “passive genesis” and Merleau-Ponty (1962, xviii) referred to as the level of “operative” intentionality (in contrast with the more active, volitional, or “reflective” modes). Whereas the phenomenological epoché is theoretically motivated and largely volitional in nature, schizophrenic loss of self-evidence is a more insidious process grounded in endogenous abnormalities of the cognitive-affective apparatus. And whereas the philosopher is likely to have to struggle against the natural attitude, which the phenomenologist Eugen Fink characterized as the “natural inclination of life” (Blankenburg 1991, 116, 71), the schizophrenic is more likely to struggle to prevent it from falling away. Indeed, for many schizophrenic persons, it is potentially misleading to speak of a bracketing of self-evidence—the horizons of normal self-evidence were never very secure in the first place (115, 70).
Blankenburg’s Loss of Natural Self-Evidence offers the most elaborated theoretical account of the subjective dimension of the so-called “negative symptoms,” which many contemporary experts see as the core of schizophrenia. No one who wishes to understand the subjective dimension of psychosis can afford to neglect this work.
Here I will offer three comments on Blankenburg’s important book. The first concerns his focus on what might seem to be effects and his relative neglect of generative or constitutive processes.
Blankenburg’s key concept, “loss of natural self-evidence,” focuses on the kind of world or the nature of the field of awareness that is experienced by the schizophrenic person. In this respect, Blankenburg seems close to Heidegger, who conceived of human existence as a condition of being there (Dasein) and who questioned what he saw as his mentor Husserl’s overly subjectivist and Cartesian conception of mind as constituting the experiential world. Although Husserl fully recognized there is no noesis (act of consciousness) without a correlative noema (object of consciousness), he nevertheless gives a special status to the noetic acts, which he describes as “animating construals” or “apprehensions” that are responsible for the transcendental constituting of the objects and field of our awareness (Husserl 1983, 226, 238, 277). One may certainly debate the merits of a Heideggerian versus a Husserlian approach (Tatossian 1997, 12). It is worth noting, however, that the Husserlian interest in constituting mental processes and the genesis of experiential worlds is probably more congruent with the aspirations of contemporary psychology and cognitive science, which seek to identify mental processes that underlie and in this sense account for the experiential abnormalities.
My second comment on Blankenburg (1991) is that, although he states that loss of natural self-evidence is the basic mutation underlying all forms of schizophrenia ( 21, 201, v, 138), he does not actually explain just how it might underlie the “positive” symptoms. My final criticism is that Blankenburg takes too restricted a view of reflexive awareness in schizophrenia and therefore tends to downplay the central role it may play in the illness. I would argue that an expanded view of hyperreflexivity has the potential to integrate Blankenburg’s crucial insights into a more comprehensive account of schizophrenia.
Blankenburg certainly considers reflexivity to be an important and, in many respects, distinctive characteristic of schizophrenia (he explains, e.g., how the all-inclusive character of the schizophrenic’s self-conscious doubting and perplexity distinguishes it from that of the obsessive neurotic; 91, 52). It is important to note, however, that when Blankenburg speaks of “reflexivity,” he is referring primarily to what might be termed (following Merleau-Ponty) a reflective type of reflexivity (the German terms Blankenburg uses include Reflexivität, Reflexionskrampf, Reflexion, Reflektierheit, and reflektierte Alienation; 53, 54, 59, 121). This is the sort that has at least a semi-volitional quality and that typically engages processes of understanding or introspection of an intellectual or even hyper-rational sort.
(It occurs, he says, “mit Hilfe des Verstandes reflektierten…Selbstverhältnis,” 1971, 102 [“as a relationship with oneself that is reflected upon with the aid of the understanding,”1991, 154].) Also, Blankenburg generally describes schizophrenic reflexivity as a “secondary” process that develops in compensation for some more fundamental or “basal” defect (involving the loss of spontaneous attunement to common-sense reality) that is rooted in abnormalities of “passive synthesis” on the pre-reflective and pre-predicative plane ( 62, 93, 106, 113, 168, 30, 54, 62, 68, 113f).4 For Blankenburg, then, reflexivity seems to be primarily a response or an effect, that is, not a feature of the basic abnormality, and not something that might itself make a major contribution to the loss of natural self evidence (however, see 92, 53).
But as I have argued in detail elsewhere (Sass 1992a, chap. 7; 2000), it seems likely that reflexive ruminations compensating for a more basic loss will often have the counterproductive effect of further distancing the patient from any sense of naturalness or capacity for spontaneous action, thereby increasing the patient’s perplexity and making it more difficult to break out of what can easily become a kind of self-propagating spiral. The person who attempts, for example, to reassert control and reestablish a sense of self by means of introspective scrutiny may end up exacerbating his self-alienation and fragmentation.
“My downfall was insight,” explained one young man with schizophrenia. “Too much insight can be very dangerous, because you can tear your mind apart.” “Well, look at the word ‘analysis,’” he said on another occasion. “That means to break apart. When it turns in upon itself, the mind would rip itself apart.” “Once I started destroying [my mind], I couldn’t stop” (quoted in Sass 1992a, 337f). Introspectionist studies with normal individuals show that a kind of hyperreflection—
in this case produced in a purely volitional manner—can bring on some alterations of the sense of both self and world that are strikingly reminiscent of what occurs in schizophrenia (Hunt 1985, 1995; Sass 1994, 90).5 Although Blankenburg’s views are perfectly consistent with this point, in his formulations he does not give it any emphasis.
I would, in fact, go further and argue that forms of what might be termed “hyperreflexivity” may also have a more fundamental role in the disorder—that they may be an aspect of what could be called the Grundstörung itself.
It is true that the more intellectually introspective forms of hyperreflexivity on which Blankenburg focuses may not be basic enough to play a truly primary role in the etiology of the illness.
Hyperreflexivity, however, includes not merely actively directed or reflective forms of self-consciousness, but also a host of other, more passive, automatic, or “pre-reflective” ways in which an agent or subject comes to focus on itself or features of its own functioning (Sass 2000). These “operative” forms of hyperreflexivity, as we might call them (following Merleau-Ponty 1962, xviii), include experiences in which the normally transparent field of experience can become increasingly disrupted by a kind of automatic and passively experienced popping-up of unusual sensations, feelings, or thoughts that come to acquire object-like quality. Patient reports suggest that in the early, premorbid stages of schizophrenia, this is first experienced as a largely passive process, more like an affliction, and typically involving cenesthesias, a loss of the automaticity of movement, and certain cognitive and perceptual disturbances—phenomena that, in German research on the so-called “basic symptoms” of schizophrenia, are designated with the apt term “basal irritation” (Klosterkötter, Schultze-Lutter, Gross, Huber et al. 1997). These experiences appear to involve hyperreflexive awareness of sensations and other phenomena that would not normally be attended to in any sustained fashion (Frith 1979; Sass 1992a). Although experiences akin to the basic symptoms very rarely occur in healthy persons or in neurotic or character disorders (Huber 1986, 1137), they are, in fact, remarkably similar to the experiences reported by normal subjects who adopt an abnormal kind of detached, introspective stance toward their own bodily experience (see Angyal 1936; Hunt 1985, 248; 1995, 201; Sass 1994, 90–97, 159–61). They are, we might say, the perfectly normal sensations implicit in ongoing experience and action but now experienced in the perfectly abnormal condition of hyperreflexivity and altered self-affection.
The work of the philosopher Michael Polanyi (1964, 1967) illuminates the nature of the crucial relationship between the tacit and the focal in the automatic constitution of each act of consciousness.
Tacitness, he argues, is the medium or index of normal self-affection, for what we tacitly know, we inhabit or “indwell.” Any disturbance of this tacit-focal structure, or of the ipseity and focus it implies, is likely to have subtle but broadly reverberating effects that upset the balance and shake the foundations of both self and world. I would suggest, then, that operative hyperreflexivity, which disrupts the tacitness necessary for passive synthesis, may be a key element in what Blankenburg refers to as the basic structural modification of schizophrenic Dasein—an element that is implicated in a broad range of schizophrenic symptoms (and, I might add, that is congruent with a variety of contemporary neuro-cognitive hypotheses that emphasize disturbances in the deployment of attention to novel stimuli in the light of past experience).6
It is not difficult to see how such operative hyperreflexivity, along with more compensatory, reflective forms that it may inspire, could be conducive to loss of natural self-evidence, with all the perplexity and disorganization this implies, and also to the disruption and slowing of activity and thought that can occur in schizophrenia.
“I found recently that I was thinking of myself doing things before I would do them,” said one patient with schizophrenia. “If I am going to sit down, for example, I have got to think of myself and almost see myself sitting down before I do it. It’s the same with other things like washing, eating, and even dressing—
things that I have done at one time without even bothering or thinking about at all.…All this makes me move much slower now.” (McGhie and Chapman 1961, 107) The lapsing into silence, inaction, or inexpressiveness characteristic of the negative syndrome can be understood not only as a direct consequence of progressive distortion of normal selfexperience, but also as a defensive reaction to these disconcerting changes. When I go “completely still and motionless,” one patient explained, “things are easier to take in” (McGhie and Chapman 1961, 106) But operative hyperreflexivity and its sequelae may also help to account for the development of the first-rank symptoms that dominate the positive syndrome.
Longitudinal studies of premorbid and prodromal symptoms of schizophrenia (Klosterkötter 1988) clearly document a progressive shift from “basal irritation” to full-blown first-rank symptoms through increasing objectification and externalization of normally tacit inner phenomena.
They show that particular first-rank symptoms are generally preceded by subtle subjective experiences of alienation occurring in the same experiential domain, that is, by “basal irritation” affecting the same realm (e.g., bodily sensation, thought, or affect) that eventually becomes externalized and thematized in the form of first-rank symptoms affecting that realm (Klosterkötter 1992, 3, 37). To have focal awareness of what would usually be tacit is to objectify or alienate that phenomenon—to cause it to be experienced as existing at some kind of remove from what Husserl (1989, sec. 41) called the “zero point” of orientation of ongoing experiential selfhood. At the extreme, the patient loses the sense of inhabiting his own actions, thoughts, or sensations and may feel that these are under the control of some alien being or force—as in the first-rank symptoms.
Kimura Bin The most important representative of phenomenological psychopathology in contemporary Japan is Dr. Kimura Bin (the Japanese custom is to place family names first, hence, Kimura Bin.), for many years a professor of psychiatry in the city of Nagoya and later in Kyoto. During his psychiatric training, Kimura spent two years at the university clinic in Munich (1961–1963); later he served as a visiting professor in Heidelberg (1969–1970). Kimura is well versed in European, especially German, phenomenology, and in addition to his own contributions has translated into Japanese works by Heidegger, von Weizsacker, Binswanger, Tellenbach, Ellenberger, and Blankenburg. A number of Kimura’s articles on psychiatric phenomenology appear in French translation as Écrits de Psychopathologie Phénoménologique (1992). In a commentary in this issue, John Cutting discusses the essays in this collection covering the topics of temporality and intersubjectivity. Here I will concentrate on what, to me, is Kimura’s most intriguing contribution: his discussion of disorders of self-experience and excessive self-reflection in schizophrenia.
Kimura begins a brief but highly suggestive essay, “Réflexion et soi chez le schizophrène” (1992, 117–27) with some ideas from Nagai Mari, a Japanese psychiatrist whose career was cut short by an early death. Nagai distinguished two kinds of excessive reflection in schizophrenia.
The first—what Nagai called “subsequent reflection”—can be found in many other conditions as well, including melancholia and normal adolescence. It is a purely quantitative exaggeration of the normal human capacity to engage in critical self-observation and involves taking oneself as an object of awareness—as when one imagines how one must look in the eyes of another.
Adopting Husserlian vocabulary, Kimura describes “subsequent reflection” as a condition in which “a noetic reflecting self and a noematic reflected self…separate themselves clearly from each other” (118). (Recall that noesis is Husserl’s term for the act of consciousness; noema refers to its intentional correlate, viz., the object and world of which we are aware [Sokolowski 2000, 59–61].) The second type, “simultaneous reflection,” is far more distinctive of schizophrenia, according to Nagai and Kimura; certainly it is very rare in normal individuals. Here the observing and the observed are more difficult to distinguish, for in this case the self that is observed does not have the status of a Husserlian noema or of what Sartre would call the “en soi,” but instead retains the status of a subject or agent (of noesis or “pour soi”). Kimura (1992) writes, “one single noetic self divides itself into two simultaneous ‘moments’ that alternatively occupy the place of the watcher and the watched, and which, as a result, do not remain any the less subjectivenoetic” (118). Simultaneous reflection seems to involve a certain kind of self-consciousness of oneself as a consciousness.
Kimura stressed the difficulty, at least for normal individuals, of sustaining a simultaneous partitioning of the subjective self. The problem can be compared to that of eyes that are unable to see themselves, at least in any direct, unmediated fashion (120), or that of light that is so ubiquitous as to remain itself invisible. Subjectivity is not, after all, an object or a thing but, rather, a dynamic vector of relationship to the world, a constant yet elusive condition of possibility for the very appearance of anything—as is suggested by Heidegger’s concept of Dasein and Sartre’s of the nothingness of the pour soi. To capture the peculiar ephemerality intrinsic to selfconsciousness, Kimura quotes Kierkegaard’s definition of the human self as “a relationship relating itself to itself” and supplements this with the Japanese philosopher Nishida Katoro’s description of jikaku (auto-perception) as the act “of reflecting oneself in oneself without anything being the reflected” (122). Animals and infants do not seem capable of the more complex forms of self-consciousness and certainly not of consciousness of self as consciousness, which probably requires the development of language; and this, suggests Kimura, may be the reason why schizophrenic psychoses seem to be specifically human (120). There is something distinctly peculiar about simultaneous reflection in schizophrenia; the possibility of this kind of self-consciousness seems, however, to be a constituting paradox that is bound up with the essence of human nature.
Indeed, as Blankenburg has noted and Kimura (108) acknowledges, the heightened self-consciousness or hyperreflexivity in schizophrenia has something in common with the kind of reflection that is both the goal and method of phenomenology. Like Nagai’s “simultaneous reflection,” the phenomenologist’s self-consciousness involves an explicit consciousness of self as consciousness that is difficult for the normal but untrained person to achieve; hence, Husserl’s insistence on the need for special training to overcome the “natural attitude.” But in schizophrenia an analogous kind of self-consciousness occurs quite spontaneously—sometimes almost attacking the person in a way that can undermine the person’s stability and dissolve the structures of the outer world. A remarkable illustration of this peculiar possibility is a passage in which the writer Antonin Artaud (who suffered from schizophrenia) uses the image of “rootlets…at the corners of my mind’s eye” to describe what seems to be an encroaching awareness of his own mind in its world-constituting role and in which this disconcerting self-awareness presages an experience of the world trembling and threatening to disappear (Artaud 1976, 60; Sass 1994, 96).
In “Réflexion et soi chez le schizophrene,” Kimura (1992) notes that in the simultaneous reflection characteristic of schizophrenia, one or the other of the two noetic selves is felt to be “other” at a given instant. When this alienation or “other-ing” affects the reflecting self, it results in the delusions of being observed by other people that are so common in paranoid schizophrenia.
But if it is the observed subject that is experienced as alien, while nevertheless retaining its position as a subject of will, then, says Kimura, the patient will have the experience of an alien subjectivity who exists somehow at the intimate heart of his being (119). And this experience of diminished ipseity will be manifest in experiences or delusions of influence and alien possession—
as when a schizophrenic feels that his actions or thoughts are under the control of some other person or force, or when he senses that someone else is actually having his sensations or looking out his own eyes.
In a closely related article, “Topologie de l’autre dans le délire,” Kimura contrasts schizophrenia with non-schizophrenic forms of paranoid psychosis: Whereas in non-schizophrenic paranoia, the other appears as a menacing presence situated in the space of the real external world, in delusional schizophrenia what is experienced as the other is actually a “virtual image of the self” that is felt to exist as a kind of internal enemy.
“At the noetic level of the pour soi,” claims Kimura, “the self alters itself, transforming into a not-self and is only secondarily projected into exterior space” (1992, 192). Many such patients with delusional schizophrenia will experience a specific other, for example, a persecutor of some kind, but what is more significant is a kind of transcendental otherness that underlies this seemingly paranoid structure (138): A pure and absolute otherness, or otherness in general, somehow insinuates itself into the patient’s subjectivity, thereby depriving him of the ipseity or self-affection that would normally be present.
Kimura’s discussion of self-experiences in schizophrenia is rich and suggestive with intriguing implications on both a theoretical and clinical level. He makes an admirable attempt to distinguish schizophrenic self-disturbance from what may seem to be analogous phenomena in other disorders, including borderline personality, melancholia, and ordinary depersonalization experiences (1992, 124ff). The abnormal experiences Kimura describes would certainly test anyone’s powers of description and imagination; I admire his effort to come to grips with the sheer strangeness of schizophrenic experience without attempting to reduce this strangeness by assimilating it to something more familiar. Still, one wonders whether it might be possible to be more specific or clear or to describe consciousness or cognition in ways more amenable to empirical study or perhaps interdisciplinary collaboration with the cognitive neurosciences. What, for instance, does it really mean to speak of experiencing a “virtual image of the self” within the self, or a kind of ‘transcendental alterity’ in general”?
(192, 138). It would be interesting to attempt to translate these notions into some of the concepts of contemporary philosophy and cognitive science (see Gallagher 1997; Gallagher and Shear 1999). Also, Kimura (at least in this book) says little about the relationship among the several forms of schizophrenic abnormality that he describes, and this leaves the structure of his conceptual model somewhat obscure.
Kimura (1992) does mention both aspects of the self-disorder that I would see as crucial: exaggerated reflexivity and a closely allied diminishment of normal ipseity (e.g., 117, 191). But—
at least in this collection of essays—he says little about how one should conceive the relationship between these phenomena. Are hyperreflexivity and diminished self-affection to be understood as intimately intertwined yet distinct processes that can interact or give rise to each other, or, perhaps, as aspects of a single whole that is described from different angles of vision? Kimura does not specifically address this question. I would suggest that it is most consistent with the holism of a phenomenological perspective—and with Kimura’s approach in particular—to conceive hyperreflexivity and diminished self-affection as two complementary (or equiprimordial) facets of a basic experiential transformation of the act of consciousness. Polanyi’s notion of the tacit dimension may help to illuminate this complementarity: Whereas the notion of hyperreflexivity emphasizes the way in which something normally tacit becomes focal and explicit, the notion of diminished self-affection can be seen to emphasize 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-forgranted selfhood. It may be, then, that hyperreflexivity and diminished self-affection are aspects of the very same phenomenon, the same distortion of the intentional arc that we are merely looking at from different angles and describing in different words.
It would be consistent with the Husserlian approach mentioned in the previous section to view these aspects of the act of consciousness as the primary or constitutive disturbance with alterations in the field of awareness—such as loss of natural self-evidence—having a somewhat secondary status. (This would seem to jibe with Kimura’s statement that “a healthy individualization of the self is necessary to assure a healthy constitution of natural evidence” [188].) Such a view would not imply that hyperreflexivity and diminished self-affection (the two facets of the disturbed act of consciousness) exist independently of, or prior to, the disturbance at the object pole of awareness—it is, after all, essential to consciousness that it be consciousness of something.
Hyperreflexivity and diminished self-affection would not be the cause so much as the condition of possibility for the object-pole disturbance.7
I would argue, then, that these three aspects need to be understood as complementary aspects of mental activity as a whole (Marbach 1993, 35), with hyperreflexivity and diminished selfaffection considered to be two facets of the noetic act, and loss of self-evidence as a key feature of the noematic field of awareness. Phenomenological analysis is less a matter of discovering interacting processes than it is of unfolding the different facets of conscious activity in order to provide a richer grasp of its lived texture and internal structure.
Conclusion There are obviously many differences between Minkowski, Blankenburg, and Kimura—differences of style and intellectual approach as well as in their preferred ways of describing schizophrenia.
But it would be a mistake to let these differences obscure the affinities that link these approaches together and allow them to compose a reasonably coherent vision of schizophrenic disorders.
All three phenomenologists are clearly at odds with the defect or deficit models prominent in psychiatric theories of schizophrenia; as we have seen, each puts considerable emphasis on exaggerations of intellectual, rational, or other “higher” processes. Also, each of these phenomenologists adopts a holistic perspective that is inconsistent with many of the modular approaches common in contemporary cognitive science as well as with the emphasis on symptom over syndrome or diagnostic entity that has become popular in current psychiatry. Each of them emphasizes paradigmatic cases (e.g., Minkowski’s and Targowla’s Paul, Blankenburg’s Anne) rather than statistical generalizations. It is obvious as well that all three psychiatrists reject Jaspers’s pessimism about the possibility of understanding the strange experiences or utterances of such individuals.
Minkowski, Blankenburg, and Kimura all believe that empathy and the imagination, combined with the conceptual tools provided by Bergson, Husserl, Heidegger, Nishida Katoro, or other thinkers, can provide an entrée into the lived-world of schizophrenia.
One should also note that none of the three phenomenologists appears to be very sympathetic to the largely developmental account of schizophrenia that is common in the psychoanalytic tradition—where schizophrenia has generally been seen as regression to or fixation at a developmentally immature or primitive form of consciousness.
In his Traité de Psychopathologie (1999a, 389–411), Minkowski argues that the oft-asserted parallel between schizophrenia and the primitive mind is based on a superficial resemblance between symptoms taken in isolation.
In his view, the “magical participation” described by the anthropologist Levy-Bruhl and others, for example, has nothing in common with the fragmented or vague and diffuse thinking found in schizophrenia (400). Kimura, too, conceives of schizophrenia as antithetical to the typical configurations of personality or self in traditional societies (1992, 135). I would agree with their criticisms of the primitivity view. There are, in fact, interesting parallels between the forms of experience and expression in schizophrenia and in modernist and postmodernist culture, affinities that reveal the central role of alienation and hyperreflexivity in the schizophrenia spectrum (Sass 1992a).8
As I mentioned before, madness has traditionally been defined as a loss or severe diminishment of “higher” mental abilities, especially reason but also including the capacities for volition, abstract thought, and self-conscious or self-critical awareness. For this reason, madness has often been viewed as the very antithesis of philosophy—the field of intellectual endeavor whose querying and quest for meaning may seem the purest expression of these capacities and the ideals they represent.
According to one influential tradition, philosophical reflection is a sort of ultimate expression of the vitality of the human essence, but there is another tradition that has seen philosophy as something unnatural and “out-of-order,” contrary to the health of the human condition (Arendt 1971, 78–79, 123). In this context, Blankenburg’s comparison of the schizophrenic attitude with phenomenological bracketing (the epoché) is of particular interest, for bracketing is not only central to phenomenological philosophy but also emblematic of the withdrawal and self-examination that seems essential to philosophy itself (Husserl 1964, 19). The views of Minkowksi and Kimura have similar implications.
The “interrogative attitude” Minkowski describes can seem almost a parody of certain forms of philosophical curiosity and doubt (see Wittgenstein’s On Certainty 1969). Kimura’s account of the self-dividing or self-alienating introspection often found in schizophrenia is highly reminiscent of the kind of abstract speculation on these matters to be found in such philosophers as Kant and Husserl; it recalls as well the tensions between internal and external or between subjective and objective points of view that the philosopher Thomas Nagel (1986) has characterized as pervading human life and as especially important for the generation of philosophical problems (6).
As I have pointed out, the self-alienating, selffragmenting implications of schizophrenic selfconsciousness also have interesting affinities with attitudes toward the self to be found in Hume and William James (Sass 1992a, chap. 7). The diagnosis and analysis of traditional or “metaphysical” philosophy offered by Ludwig Wittgenstein can, in fact, be used to illuminate the structure of key symptoms of schizophrenia (Sass 1994). Like the “metaphysical” philosopher whom Wittgenstein criticizes, the schizophrenic tends to lose contact with everyday social and practical realities and to rely instead on alienated but self-validating forms of abstraction and selfreflection.
Recognizing these parallels between philosophy and madness forces one to go beyond the simplistic conception of “insight” that is prevalent in contemporary psychiatry.
In contemporary psychiatry, “lack of insight” is commonly said to be one of the most distinctive features of schizophrenia (Amador and David 1998). This is certainly true if “insight” is defined in the specific, psychiatric sense of the term, that is, as a tendency to agree with the medical or psychiatric view that one is suffering from a mental disorder or disease and that one’s unusual experiences and actions are consequences of this disorder. Persons with schizophrenia may also lack insight in the sense of lacking a quick, intuitive grasp of the conventional import of a social or practical situation. But if “insight” is understood more broadly, then the situation in schizophrenia is not nearly so clear. Certainly, schizophrenics themselves often feel that they engage in deep and serious thought. “When I am walking along the street,” said one such individual, “it comes on me. I start to think deeply and I start to go into a sort of trance. I think so deeply that I almost get out of this world.” (McGhie and Chapman 1961, 109). And persons with schizophrenia often feel they have privileged access to or awareness of the true nature of the human psyche or the cosmos itself. Indeed, they may “believe that they have grasped the profoundest of meanings; concepts such as timelessness, world, god, and death become enormous revelations which when the state has subsided cannot be reproduced or described in any way” (Jaspers 1963, 115). This feeling of insight may, of course, be nothing more than the illusion of insight—as Jaspers suggested was often the case in schizophrenia. There may, however, be something about the schizophrenic or schizoid condition that allows at least some such individuals not only to reveal but also to have heightened awareness of aspects of human subjectivity and its relationship to the world (Sass 1992b; 2000 [2001]).
In The Phenomenology of Perception, Merleau-Ponty (1962) describes an experience that is common in schizophrenia as well as in phenomenological reflection: the feeling that one is privy to a kind of insight or self-awareness more profound than is available to people more fully engaged with the concerns of normal life. “Reflection,” he writes, “slackens the intentional threads which attach us to the world and thus brings them to our notice; it alone is consciousness of the world because it reveals that world as strange and paradoxical” (xiii). Merleau-Ponty knew that the disengagement and introspection characteristic of phenomenological reflection did not necessarily offer a surefire route to reality or the truth, that these orientations are, in fact, as capa ble of distorting the nature of human experience as of revealing it (1968, xlvi, 31, 38f, 43). He therefore called for a kind of meta-reflection or sur-réflexion that would recognize the distortions that reflection itself—even in its phenomenological form—is capable of imposing.
Many persons in the schizophrenia spectrum of disorders do seem to have a special predilection both for disengagement and the forms of consciousness it entails—with all their potential for both insight and illusion. In this sense we might echo Blankenburg in saying that schizophrenics, at least some schizophrenics, are natural phenomenologists—though seldom of the kind that engages in the self-critical, self-transcending sur-réflexion for which Merleau-Ponty called.
Perhaps it is not so surprising, then, that phenomenological psychiatry has had such an affinity for this paradigmatic psychiatric disorder: It is a disorder whose very strangeness may well strike the phenomenologist as having an uncanny, and rather disconcerting, familiarity.
References
Amador, X. F., and A. S. David, eds. 1998. Insight and psychosis. New York: Oxford University Press.
Angyal, A. 1936. The experience of the body-self in schizophrenia. Archives of Neurology and Psychiatry 35:1029–59.
Arendt, H. 1971. Volume I: Thinking of the life of the mind. San Diego: Harcourt Brace Jovanovich.
Artaud, A. 1976. Antonin Artaud: Selected writings, ed. S. Sontag, trans. H. Weaver. New York: Farrar, Straus, & Giroux.
Blankenburg W. 1971. Der Verlust der Naturlichen Selbstverstandlichkeit: Ein Beitrag zur Psychopathologie Symptomarmer Schizophrenien. Stuttgart: Ferdinand Enke Verlag. (German pages in italics in text.) ———. 1986. Autismus. In Lexicon der Psychiatrie. Gesammelte Abhandlungen der gebrauchlisten psychiatrischen Begriffe, 2d ed., ed. C. Müller, 83–89. Berlin: Springer.
———. 1991. La Perte de L’Évidence Naturelle: Une Contribution a la Psychopathologie des Schizophrénies Pauci-Symptomatiques (French translation of 1971 above), trans. J.-M. Azorin and Y. Totoyan. Paris: Presses Universitaires de France.
———. (this issue). First steps toward a psychopathology of “common sense,” trans. A. Mishara.
Philosophy, Psychiatry, & Psychology. 1969. Ansatze zu einer Psychopathologie des ‘common sense.’
Confinia Psychiatrica, 12:144–63.
Bosch, R. van den (1994). Context and cognition in schizophrenia. In Advances in the neurobiology of schizophrenia, eds. J. A. den Boer, H. G. M. Westenberg, and H. M. van Praag. Chichester, UK: Wiley (WWW: http://www.psy.med.rug.nl/0014).
Cutting, J., and D. Murphy. 1988. Schizophrenic thought disorder: A psychological and organic interpretation.
British Journal of Psychiatry 152:310–19.
———. (1990). Impaired ability of schizophrenics, relative to manics or depressives, to appreciate social knowledge about their culture. British Journal of Psychiatry 157:355–58.
Frith, C. D. 1979. Consciousness, information processing, and schizophrenia. British Journal of Psychiatry 134:225–35.
Gallagher, S. 1997. Mutual enlightenment: Recent phenomenology in cognitive science. Journal of Consciousness Studies 4:195–214.
Gallagher, S., and J. Shear, eds. 1999. Models of the self. Thorverton UK: Imprint Academic.
Gray, J. A., J. Feldon, J. N. Rawlins, D. R. Hemsley et al. 1991. The neuropsychology of schizophrenia. Behavioral and Brain Sciences 14:1–20.
Huber, G. 1986. Negative or basic symptoms in schizophrenia and affective illness. In Biological psychiatry 1985, ed. C. Shagass, R. C. Josiassen, W. H. Bridger et al., 1136–41. New York: Elsevier.
Hunt, H. T. 1985. Cognition and states of consciousness. Perceptual and Motor Skills 60:239–82.
———. 1995. On the nature of consciousness. New Haven, Conn.: Yale University Press.
Husserl, E. 1964. The idea of phenomenology, trans.W. Alston and G Nakhnikian. The Hague: Martinus Nijhoff.
———. 1983. Ideas pertaining to a pure phenomenology and to a phenomenological philosophy, first book, trans. F. Kersten. Dordrecht, Holland: Kluwer.
———. 1989. Ideas pertaining to a pure phenomenology and to a phenomenological philosophy, second book, trans. R. Rojcewicz and A. Schuwer. Dordrecht, Holland: Kluwer.
Jaspers, K. 1963. General psychopathology, trans. J.
Hoenig and M. W. Hamilton. Chicago: University of Chicago Press.
Kimura, B. 1992. Écrits de psychopathologie phénomenologique.
Paris: Presses Universitaires de France.
———. (this issue). Cogito and I: A bio-logical approach.
Philosophy, Psychiatry, & Psychology.
Klosterkötter, J. (1988). Basissymptome und Endphänomene der Schizophrenie. Eine empirische Untersuchung der psychopathologischen Übergangsreihen zwischen defizitären und produktiven Schizophreniesymptomen. Berlin: Springer.
———. (1992). The meaning of basic symptoms for the development of schizophrenic psychoses. Neurology, Psychiatry, and Brain Research 1:30–41.
Klosterkötter, J., F. Schultze-Lutter, G. Gross, G. Huber et al. 1997. Early self-experienced neuropsychological deficits and subsequent schizophrenic diseases: An 8-year average follow-up prospective study. Acta Psychiatrica Scandinavica 95:396–404.
Laing, R. D. 1963. Minkowski and schizophrenia.
Review of Existential Psychology IX:195–207.
Liddle, F. 1987. The symptoms of chronic schizophrenia.
British Journal of Psychiatry 151:145–51.
McGhie, A., and J. Chapman. 1961. Disorders of attention and perception in early schizophrenia.
British Journal of Medical Psychology 34:103–16.
Marbach, E. 1993. Mental representation and consciousness.
Towards a phenomenological theory of representation and reference. Dordrecht: Kluwer.
Merleau-Ponty, M. 1962. The phenomenology of perception, trans. C. Smith. London: Routledge &
Kegan Paul.
———. 1968. The visible and the invisible, trans. A.
Lingis. Evanston Il.: Northwestern University Press.
Minkowski, E. 1927 [1997]. La schizophrénie: Psychopathologie des schizoïdes et des schizophrènes.
Paris: Payot.
———. 1997. Au-Delà du rationalisme morbide. Paris: Harmattan.
———. 1999a. Traité de psychopathologie. Paris: Institut Sythelabo.
———. 1999b. Vers une cosmologie. Paris: Editions Payot & Rivages.
Minkowksi, E., and R. Targowla. (this issue). A contribution to the study of autism: The interrogative attitude. Philosophy, Psychiatry, & Psychology.
Nagel, T. 1986. The view from nowhere. New York: Oxford University Press.
Parnas, J., and P. Bovet. 1991. Autism in schizophrenia revisited. Comprehensive Psychiatry 32:7–21.
Parnas, J., and L. Sass. In press. Self, solipsism, and schizophrenic delusions. Philosophy, Psychiatry, &
Psychology, 8:101–120.
Polanyi, M. 1964. Personal knowledge. New York: Harper Torchbooks.
———. 1967. The tacit dimension. Garden City, N.Y.: Anchor Books.
Sass, L. 1992a. Madness and modernism: Insanity in the light of modern art, literature, and thought. New York: Basic Books (Harvard University Press paperback 1994).
———. 1992b. Heidegger, schizophrenia, and the ontological difference. Philosophical Psychology 5:109–32.
———. 1994. The paradoxes of delusion: Wittgenstein, Schreber, and the schizophrenic mind. Ithaca, N.Y.: Cornell University Press.
———. 2000. Schizophrenia, self-experience, and the so-called “negative symptoms.” In Exploring the self: Philosophical and psychopathological perspectives on self-experience, ed. D. Zahavi, 149–82.
Amsterdam: John Benjamins.
———. 2000/2001. Schizophrenia, modernism, and the “creative imagination”: On creativity and psychosis.
ed. L. Sass and D. Schuldberg, Creativity Research Journal 13:55–74 (special issue on “Creativity and the schizophrenia spectrum”).
———. 2001. Deep disquietudes: Reflections on Wittgenstein as anti-philosopher. In Wittgenstein, biography and philosophy, ed. J. Klagge, 98–155.
New York: Cambridge University Press.
———. In press (a). Self-disturbance in Schizophrenia.
To appear in The Self in Neuroscience and Psychiatry, ed. T. Kircher and A. David. Cambridge, UK: Cambridge University Press.
———. In press (b). “Negative symptoms,” common sense, and cultural disembedding in the modern age. To appear in The edge of experience: Schizophrenia, culture, and subjectivity, ed. J. Jenkins and R. Barrett. Cambridge, UK: Cambridge University Press.
Sass, L., and J. Parnas. (submitted). Schizophrenia, consciousness, and the self.
Sèchehaye, M. 1956. A new psychotherapy in schizophrenia.
New York: Grune & Stratton.
Sokolowski, R. 2000. Introduction to phenomenology.
Cambridge, UK: Cambridge University Press.
Spiegelberg, H. 1972. Phenomenology in psychology and psychiatry. Evanston Il.: Northwestern University Press.
Störring, G. 1939 [1987]. Perplexity. In The clinical roots of the schizophrenia concept, ed. J. Cutting and M. Shepherd, 79–82. Cambridge, UK: Cambridge University Press.
Tatossian, A. 1997. La Phénomenologie des Psychoses.
Paris: L’Art du Comprendre (Juillet 1997, Numero double, hors serie).
Taylor, C. 1985. Theories of meaning. In Taylor, Philosophical papers, vol I: Human agency and language, 248–92. Cambridge: Cambridge University Press.
———. 1993. Engaged agency and backround in Heidegger. In The Cambridge companion to Heidegger, ed. C. Guignon, 317–36. Cambridge, UK: Cambridge University Press.
Wittgenstein, L. 1969. On certainty. Oxford, UK: Blackwell.
Zahavi, D. 1999. Self-awareness and alterity: A phenomenological investigation. Evanston, Il: Northwestern University Press.
Notes 1. I am very grateful to Wolfgang Blankenburg and Kimura Bin for their kind cooperation with this project, and to Eugene Minkowski’s daughter, Mme. Jeannine Pilliard-Minkowski, for conversations about her father.
Thanks also to Pierre Bovet and James Walkup for helpful comments on the manuscript of this introductory essay, and to Annick Urfer for consultation on Minkowski’s essays.
All translations in this article are my own, and nearly all are translated from French. In the case of works by Blankenburg (1991) and Kimura (1992), written originally in German and Japanese, respectively, I worked from French translations (though I consulted the German in the case of Blankenburg).
2. Kimura Bin reports (e-mail communication to L.A.S., February 19, 2002) that it was his reading, while a medical student, of a Japanese translation of Minkowski’s La Schizophrénie that made him decide to go into psychiatry.
3. Of relevance here is the prominence of schizoid features in many important philosophers. See, e.g., Sass (2001) re Ludwig Wittgenstein.
4. But see Blankenburg (1991, 29, 5f), where he questions this distinction between fundamental or basal versus secondary or compensatory aspects, stating that in schizophrenia, the two components may not easily be separated. Blankenburg’s characterizations of reflexivity do, however, nearly always give it a secondary status.
In one passage, Blankenburg endorses Jaspers’s description of how abnormal reflexive self-awareness can insert itself in an almost automatic or consequential (as opposed to compensatory) fashion once it is no longer actually excluded by the natural, spontaneous flow of immediate life experience; Blankenburg speaks here of “insertion of reflection within immediacy “ (101; “Einbau der Reflexion in die Unmittelbarkeit,” 1971, 59).
5. It seems that diminished ipseity can also develop in a compensatory and quasi-intentional fashion. Patients with Dissociative Identity Disorder or Post-Traumatic Stress Disorder, e.g., seem to undergo a loss of the sense of their own reality or existence as experiential subjects that is, at least in part, defensively motivated.
Similar developments can occur in the schizophrenia-spectrum: One patient, e.g., describes using prolonged fixation of attention (staring at a spot) to bring about an at least quasi-intentional self-obliteration: “I hold fast to my spot and drown myself in it down to its very atoms” (Sèchehaye 1956, 32).
6. The notion of a (hippocampus-based) dysfunction of the “comparator system,” e.g., might help to explain the emergence of operative hyperreflexivity; for, in the absence of this normal function, what is usually presupposed (e.g., tacit sensations of bodily awareness) are likely to emerge into focal awareness (Gray, Feldon, Rawlins, Hemsley et al. 1991). Distortions of working memory could also be relevant. For a summary, see Bosch (1994).
7. This constitutive type of relationship conforms to neither of the two types emphasized by analytic philosophers (e.g., Donald Davidson): It is neither “a psychophysical link holding between states of affairs or events” nor “a relationship of making intelligible holding between sentences.” But as Charles Taylor (1993, 318, 326) points out, these two alternatives do not exhaust the space of possibilities. The “world-shaping relationship” between the body and our “way of experiencing” is one example of a constitutive type of relationship.
8. This need not imply a causal link between schizophrenia and modernism; the parallels could be more a matter of affinities than of direct influence (Sass 1992a).
It would not be surprising, however, if a propensity for breakdown of common sense or natural self-evidence were at least exacerbated in cultural contexts in which skepticism and reflexivity are the rule; this might help account for the greater chronicity of schizophrenia in fully modernized societies (Sass, in press [b]).
