The Phenomenology of Psychosis: Considerations for the Future

Over the past years, the intersubjective dimension of psychotic disorders, including schizophrenia, has gained increasing phenomenological attention (Henriksen & Nilsson, 2017; Sass & Pienkos, 2015; Van Duppen, 2017). Psychopathologists and philosophers have developed ideas on how the social aspects of psychotic symptoms and experiences could be understood, in particular in their relation to the ipseity disturbance model, namely the idea that schizophrenia is essentially a disorder of the minimal self. Although the exact characteristics of the ipseity disorder hypothesis can differ from author to author, emphasizing certain phenomenological aspects like temporality (Fuchs & Van Duppen, 2017) or embodiment (Stanghellini, 2009), most of these views shared the idea that the social or intersubjective dimension of schizophrenia is secondary to a more primordial disorder of the self.

However, philosophers have argued for the social or intersubjective nature of the minimal self, while similarly, psychopathologists have started to question whether disturbances to intersubjectivity are indeed merely secondary, or whether the intersubjective dimension would instead be a vital or ‘core’ aspect of psychotic disorders (Ratcliffe, 2015).

Although the ipseity disturbance model has proven to be a major advance for phenomenology inspired psychopathology, an overemphasis on the self-disorder might lead us to overlook the social dimension of psychotic disorders and schizophrenia in particular. There are, in fact, different reasons to consider the social dimension as essential to the phenomenology of psychosis:

First, as Singh (2021) rightly illustrates with case descriptions, some of the factors associated with increased risk for psychosis are directly related to the social context: early life adversity, growing up in an urban environment, and minority group position (van Os, Kenis, & Rutten, 2010). It is worth asking how exactly they could increase this risk. What is it about moving into an unfamiliar context that could somehow contribute to psychotic experiences, experiences often described as alienating and isolating? How does adverse or traumatic social interaction lead to psychosis? Would it be reasonable to consider that these social factors have in fact some causal or even phenomenologically constitutive role to play in psychosis (see Krueger, 2020)?

Second, successful treatment of psychotic disorders consists of more than mere psychopharmacological interventions, and targets what Wilfred Bion (1959) termed a key aspect of the psychotic process: attacks on linking. Here, ‘linking’ is to be understood as social linking, as our basic connection to others, the inter of intersubjectivity. Treatment therefore attempts to strengthen social embeddedness and interpersonal connection. The Open Dialogue approach (Seikkula & Olson, 2003) has shown how meaningful and effective this can be in acute psychotic phases, while projects like Soteria could offer ways of helping someone to remain socially attached after crisis or acute phases, when people sometimes keep struggling with certain experiences, despite the absence of observable symptoms or dysfunctions of some sort.

We therefore suggest that there is good reason to consider the social context, social interaction, or intersubjectivity in general as a vital dimension in the phenomenology of psychosis, both in acute and subacute phases, as well as in the long process of recovery.

To do so, however, phenomenological psychopathology will need to extend its focus and methodology, as it would imply reaching beyond the phenomenological realm of subjectivity. To increase our understanding of the social dimension, a dialogue between phenomenology and empirical research is required. One could think of a model where phenomenology inspires research questions for qualitative approaches, as we have done in previous work (Sips et al., 2020). Additionally, it can clarify the structures of experience and inform empirical research on subjective aspects of the mind.

The social turn in phenomenology of psychosis has demonstrated that pure philosophical reasoning on these matters may not suffice to increase our understanding of the actual experience of people suffering from it. It is a necessary evolution for the future of phenomenology that it opens up to first-person experience, to qualitative research and to empirical methodologies altogether.

Such research has, for example, elucidated what Sips has termed the ‘dialectic of aha- and anti-aha-experiences’ in psychosis (Van Duppen & Sips, 2018). This research has underlined the importance of ‘covering the blind spots’, of acknowledging the...