Schizophrenia and Selfhood

This chapter introduces some of the central concepts, themes, and issues addressed in the book. First of all, it discusses the concept of ‘minimal self’ and its recent application to schizophrenia and auditory verbal hallucination (AVH). Then it raises the question of whether minimal self includes only the sense of having some kind of experience or, in addition, a more specific sense of the type of intentional state one is in. A refined account of minimal self is proposed, according to which it centrally involves the latter: a grasp of the modalities of intentionality. It is further argued that certain anomalous experiences centrally involve disturbances of modal structure. Following this, the chapter considers an alternative account of AVHs, according to which they are diagnostically non-specific, meaningful symptoms of interpersonal trauma. In so doing, it stresses the need to place more emphasis on the interpersonal aspects of psychiatric illness, and shows how minimal self, as conceived of here, could turn out to be both developmentally and constitutively dependent on ways of relating to other people.

Metaphilosophical Conclusion

This chapter draws the discussion to a close by summarizing and further exploring some philosophical implications of the book’s overall position. Among other things, it addresses the nature of ‘belief’, and argues that this term, even when it is used in a restrictive and technical way, most likely accommodates a range of subtly different kinds of conviction, different ways of taking something to be the case. This applies not only to psychiatric illness, but also more generally. Issues are therefore raised for the practice of philosophy itself. When one is said to believe a philosophical claim, it is not always clear what kind of conviction is involved or, for that matter, which kinds of conviction are appropriate to which kinds of philosophical position. More generally, the structure of intentionality encompasses a wide range of different intentional state types and does not respect clear-cut, categorical distinctions between them. These subtleties are masked by certain uses of language, in philosophy and elsewhere. Reliance on univocal notions of ‘belief’, ‘desire’, and the like is thus rendered problematic.

Varieties of Hallucination

This chapter widens the scope of the discussion, to include types of hallucination not so far considered. It begins by drawing on Merleau-Ponty’s remarks on hallucination in Phenomenology of Perception, in order to identify a type of experience that differs both from orthodox hallucination and from the kinds of experience described in earlier chapters. The chapter goes on to consider auditory verbal hallucinations (AVHs) that console and bring comfort. The discussion focuses specifically on kinds of ‘hallucination’ that arise during grief. The phenomenology of grief serves to further illustrate the extent to which the integrity of experience depends on relations with others, and -in this case- on specific individuals. It is also noted that, during profound grief, experiences of the presence and absence of the deceased are multi-faceted and often ambiguous. Hence it is wrong to think of these experiences in simple terms, as someone seeming to be there or seeming not to be there. Again, it is apparent that the sense of ‘presence’ and ‘reality’ is not singular or unitary.

Intentionality and Interpersonal Experience

This chapter addresses several interrelated ways in which other people are implicated in the development, sustenance, and disruption of the modal structure of intentionality. It first considers some of the roles that relations with others play in shaping perceptual experience, focusing on how the cohesive, anticipatory structure of perceptual experience is interpersonally regulated. After that, it turns to belief, arguing that the structure of belief, the intelligibility of the distinction between what is and is not the case, rests on a more primitive sense of certainty. It then proceeds to develop a more general account of how the sense of being in a given type of intentional state is largely attributable to its distinctive anticipation-fulfilment profile. All such profiles, it is argued, depend on an overarching pattern of anticipation and fulfilment, in the guise of habitual confidence or certainty. This pattern is inextricable from a certain way of experiencing and relating to other people in general. When the overall anticipation-fulfilment structure of experience is disrupted, the boundaries between intentional state types become less clear. This renders a person susceptible to more pronounced and localized disruptions, of the kind involved in many delusions and hallucinations.

Trauma and Trust

This chapter address the nature of certain non-localized phenomenological disturbances that often follow traumatic events inflicted by other people. These events are frequently described as shattering something that was previously in place. A kind of all-enveloping trust, confidence, or certainty is eroded or lost. To interpret such experiences, the chapter introduces and further develops an analysis offered by Edmund Husserl in some of his later work, according to which the modalities of intentionality depend for their integrity on a distinctive kind of anticipation-fulfilment structure, which involves a habitual, bodily sense of certainty. First-person accounts of traumatic experience point to global disruption of this structure. Interpersonal trauma might by thought to impact on how one experiences and relates to other people, rather than the world more generally. However, the chapter concludes by showing that the style of our interpersonal relations is inextricable from the wider integrity of experience.

Voices of Anxiety

This chapter develops a detailed account of what auditory verbal hallucinations (AVHs) consist of and how they arise. It focuses, to begin with, on those that involve a quasi-perceptual experience of ‘inner speech’ or ‘inner dialogue’. Such experiences are often preceded by heightened social anxiety, and it is argued that anxious anticipation of one’s own thought contents as they arise can constitute an experience of thought content as ‘alien’. This approach is then broadened to accommodate not only inner dialogue but also imagination and memory. The chapter further proposes that other kinds of AVH, which are experienced as external in origin and more akin to veridical auditory experiences, can likewise be accounted for in terms of anxious anticipation, but that they come about in a different way. It is also made clear how AVHs can fall somewhere in between the ‘internal, non-auditory’ and ‘external, auditory poles’, rather than fitting neatly into one or the other category. The chapter concludes by noting that AVHs tend to be associated with wider-ranging disturbances in a person’s relationship with the social world, which are often preceded by unpleasant interpersonal circumstances.

Introduction

This chapter outlines the overall argument of the book, emphasizing its two principal theses. First of all, it sketches the position that thought insertion, and also a substantial proportion of auditory verbal hallucinations, consist of disturbances in the sense of being in one or another kind of intentional state, in the modal structure of intentionality (meaning our grasp of the various modalities of intentionality, such as believing, perceiving, remembering, and imagining, as distinct from one another). Second, it introduces the view that the integrity of human experience, including what we might term the most basic experience of self, depends on ways of relating to other people and to the social world as a whole. The chapter concludes with summaries of the seven chapters that follow.

Thought Insertion Clarified

This chapter begins by considering the possibility that a number of factors contribute to the sense of being in an intentional state, and that these can come into conflict. The remainder of the chapter argues that thought insertion (TI) and certain kinds of auditory verbal hallucination (AVH) are to be understood in this way. There is a difference between experiencing a process of thinking as alien and experiencing thought content as alien. It is argued that TI involves the latter. Hence it could just as well be described as experiencing one’s own thought contents in a strange, perception-like way. To further support this interpretation, the chapter considers AVHs and shows that a substantial proportion of experiences that are described in AVH terms can equally be conveyed in terms of TI. What we have is an anomalous experience that lies somewhere between thinking and perceiving. The content of the experience continues to resemble that of a thought. Even so, a sense of perceiving predominates. The chapter concludes by arguing that it is unhelpful to conceive of AVH / TI in terms of a distinction between agency and subjectivity or ownership.