Clinical Case Studies

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Medusa’s Stare: A Case Study of Working With Self-Disturbance in the Early Phase of Schizophrenia Barnaby Nelson and Louis A. Sass Clinical Case Studies 2009; 8; 489 originally published online Nov 24, 2009; DOI: 10.1177/1534650109351931 The online version of this article can be found at: http://ccs.sagepub.com/cgi/content/abstract/8/6/489

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Medusa’s Stare: A Case Study of Working With SelfDisturbance in the Early Phase of Schizophrenia

Clinical Case Studies 8(6) 489–504 © The Author(s) 2009 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1534650109351931 http://ccs.sagepub.com

Barnaby Nelson1 and Louis A. Sass2

Abstract The present therapeutic case study demonstrates how concepts from phenomenological psychiatry can be applied to treatment of the early phase of schizophrenia. The case described here is of a 22-year-old man seen at a youth mental health service who experienced a catatonic episode with residual cognitive symptoms. The notion of a disturbed basic sense of self— based on the ipseity-hyperreflexivity model and the concept of ontological anxiety—formed the basis of the clinical formulation and treatment. These concepts highlight the patient’s vulnerabilities and difficulties in interpersonal contact. In addition they help to clarify potential dangers inherent in “objectifying” the patient, in stimulating excessive self-reflection, and in encouraging interpersonal engagement that is overly intense. Alternative strategies guided by a phenomenological appreciation of the centrality of a disturbed basic sense of self (disturbed ipseity) are described. These include certain forms of empathic understanding, including use of phenomenological concepts to help the patient comprehend their difficulties, encouraging a “second person” perspective, prominent use of the therapeutic relationship, and strategies that engender a form of immersion or absorption in present activity. Keywords schizophrenia, prodrome, phenomenology, self

1 Theoretical and Research Basis During the past 15 years, there has been an international movement toward early diagnosis and staged treatment of schizophrenia and other psychotic disorders (Edwards & McGorry, 2002; McGlashan, 1998; McGorry, Edwards, Mihalopoulos, Harrigan, & Jackson, 1996; McGorry & Yung, 2003). Treatment delay may be reduced by early detection and intervention, resulting in improved short-term and longer-term outcome (Killackey & Yung, 2007). Psychosocial interventions have played a central role in the treatment for both first-episode and “at risk” clinical populations. Psychosocial interventions have included case management (providing general support and assisting with social, financial, family, legal matters, etc); psychological therapy 1 2

University of Melbourne,Victoria Rutgers University, Piscataway, NJ

Corresponding Author: Dr Barnaby Nelson, Orygen Youth Health Research Centre, Centre for Youth Mental Health, 35 Poplar Rd (Locked Bag 10), Parkville,Victoria 3052, Australia Email: [email protected]


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(predominantly cognitive-behavior therapy [CBT]); support/therapy groups focused on skill development and psychosocial rehabilitation; and vocational and social rehabilitation (Edwards & McGorry, 2002; Killackey & Yung, 2007). CBT has been found to be effective in improving symptom outcome (Lewis et al., 2002) and adaptation to illness (Jackson et al., 2005) compared with routine care in first-episode psychosis populations. It has also been found to reduce persistent positive psychotic symptoms and hasten recovery from acute episodes in schizophrenia (Tarrier, 2005). The CBT at issue derives from strategies for treating mood and anxiety problems; it largely involves strategies for managing positive psychotic symptoms, such as identifying and changing cognitive styles and behavioral dynamics that may contribute to these symptoms. Over recent years, some researchers have argued that insights from phenomenological psychiatry may be usefully applied to early intervention efforts, in the areas of early identification (Nelson, Yung, Bechdolf, & McGorry, 2008; Parnas, 2005), prediction of outcome (Nelson et al., 2008), and therapeutic work (Nelson, Sass, & Skodlar, 2009). Phenomenologically oriented researchers have proposed that a disturbance of the basic sense of self is a phenotypic trait marker of psychotic vulnerability, particularly of schizophrenia spectrum disorders (Nelson et al., 2008; Parnas, 2000, 2003; Parnas, Handest, Jansson, & Saebye, 2005; Parnas, Jansson, Sass, & Handest, 1998; Sass, 1992; Sass & Parnas, 2003). This formulation is based on a combination of empirical research, clinical experience, and phenomenological considerations (Parnas, 2000, 2003; Parnas et al., 1998; Parnas, Handest et al., 2005; Parnas, Handest, Saebye, & Jansson, 2003; Parnas, Moller et al., 2005; Sass, 1997, 2003; Sass & Parnas, 2003, 2007). The type of self-disturbance being referred to in this approach is a prereflective level of selfhood. This refers to a first-person “givenness” of experience—the (implicit) awareness that this is “my” experience. This is sometimes referred to as the “minimal” self or as “ipseity” (ipse is Latin for “self” or “itself”), reflecting the notion that this level of selfhood is the ground or basis of various aspects of conscious experience, as opposed to more elaborated levels of selfhood, such as reflective or narrative selfhood (Parnas, 2003; Zahavi, 2005). Various disturbances of basic self-experience are evident in schizophrenia spectrum conditions. They include disturbed sense of presence, corporeality, stream of consciousness, self-demarcation, and existential reorientation, all of which are intimately interrelated (Parnas, 2003; Parnas & Sass, 2001). These phenomena have been described in detail elsewhere (see Parnas, 2003; Parnas & Handest, 2003; Parnas, Moller et al., 2005; Parnas & Sass, 2001; Sass, 1992, 1994) and will only be described in brief here. Presence. Normal human experience consists of being absorbed in activity among a world of (animate and inanimate) objects and this absorption provides us with a sense of “inhabiting” our self in a prereflective, tacit, or automatic fashion (Merleau-Ponty, 1962). This is referred to as presence. Our experiences appear to us in a first-person mode of presentation—that is, we automatically or prereflectively experience them as our experience. This sense of “mineness” constitutes a basic form of self-awareness. In the prodromal period, disturbed presence is often evident, with a characteristic sense that the self no longer “saturates experience” (Parnas & Handest, 2003, p. 125) but instead stands alienated from itself. Corporeality. A disjunction between one’s subjectivity and bodily experience is frequently observed in schizophrenia spectrum conditions, particularly during the preonset or prodromal phase, as represented in many of the bodily basic symptoms, such as cenesthesias and impaired bodily sensations (Klosterkötter, Hellmich, Steinmeyer, & Schultze-Lutter, 2001; Maggini & Raballo, 2004). An experiential distance emerges between the self and bodily experience, suggesting a tendency to experience one’s body as an object, rather than an “inhabited” aspect of selfhood. Stream of consciousness. As with corporeality, the early phase of schizophrenia is marked by an emerging experiential gap between the self and mental content. The sense of “mineness” of mental content is disrupted, as if thoughts were taking on an almost autonomous identity.


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Self-demarcation. Subtle transitivistic (inability to distinguish self from not-self) phenomena are apparent in schizophrenia spectrum conditions. Existential reorientation. A common finding in studies of the early psychotic phase has been of a developing preoccupation with philosophical, supernatural, and metaphysical themes (Møller & Husby, 2000; Yung & McGorry, 1996). The rupture in “normal” self-experience motivates such a preoccupation; in cognitive terms, the patient is attempting to accommodate his anomalous experience to existing schemas. Feelings of centrality or solipsism may come to the fore. The processes that are thought to underlie the anomalous self-experience described above are the complementary distortions of hyper-reflexivity and diminished self-affection (Sass, 1992; Sass & Parnas, 2003). Hyper-reflexivity is a form of exaggerated self-consciousness and heightened awareness of aspects of one’s experience. This style of awareness objectifies aspects of oneself that are normally tacit (e.g., awareness of the act of breathing or sensations while walking), thereby forcing them to be experienced as if they were external objects. It is important to note that hyper-reflexivity is a concept that includes hyper-reflectivity (or “reflective hyperreflexivity”— that is, an exaggerated intellectual or reflective process) but is not limited to this: it also refers to acts of awareness that are not intellectual in nature, and that may not occur voluntarily, as in the case of kinaesthetic experiences “popping” into awareness; these latter, which are probably more basic in a pathogenetic sense, are termed operative hyperreflexivity (see Sass & Parnas, 2007). Diminished self-affection refers to a weakened sense of existing as a subject of awareness. Sass and Parnas (2003) considered hyper-reflexivity and diminished self-affection to be complementary aspects of disturbed “ipseity.” They write: Whereas the notion of hyperreflexivity emphasizes the way in which something normally tacit becomes focal and explicit, the notion of diminished self-affection emphasizes a complementary aspect of this very same process—the fact that what once was tacit is no longer being inhabited as a medium of taken-for-granted selfhood. (p. 430) These complementary distortions are necessarily accompanied by certain kinds of alteration or disturbance of the subject’s “grip” or “hold” on the conceptual or perceptual field of awareness (Merleau-Ponty, 1962, pp. 250, 302), that is, of the sharpness or stability with which figures or meanings emerge from and against some kind of background context, thus leading to the sense of perplexity so common in schizophrenia. Normal ipseity (basic self-experience) is in this sense a matter of “mattering”—of constituting a lived point of orientation and the correlated pattern of meanings that make for a coherent and significant world. In the absence of vital selfaffection and the usual tacit/focal structuring, the organized nature of the worlds of both thought and perception will be altered or even dissolved. The model just described is sometimes referred to as the ipseity-hyperreflexivity model (IHM; Parnas, Sass, & Zahavi, 2008). Considerable empirical evidence has accumulated for the concept of self-disturbance as a trait-like, phenotypic marker of schizophrenia spectrum disorders present during various phases of disorder, including the prodromal phase (see Nelson et al., 2008 for a review.) We recently addressed the implications of this phenomenological model of self-disturbance in schizophrenia spectrum disorders for psychological therapy with patients, particularly during the early phase of the disorder (Nelson et al., 2009). We argued that many psychological therapies that encourage further self-reflection and “thinking about thinking” (meta-cognition), such as some forms of CBT, may in fact be counterproductive. This is because such therapeutic approaches may exacerbate hyperreflexivity, one of the core pathological processes at play. We explored alternatives for psychotherapy that emerge from phenomenological accounts of


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schizophrenia, while recognizing some paradoxical aspects of psychotherapy with this patient population. These alternatives included: (a) strategies that provide an intersubjective space where patients can evolve a more robust pre-reflective self-awareness (first-person perspective), second-person perspective, and experience of trustworthy relationships when encountering others; (b) empathic attunement afforded by the phenomenological approach’s sensitivity to psychotic experience; and (c) strategies that encourage a form of immersion or absorption in present activity, including mindfulness and creative “flow.” We also suggested the possible value of combining therapeutic modalities, even ones that may seem contradictory, such as treatments that encourage a reflective distance from hyper-reflexivity together with treatments that encourage more direct engagement, such as gardening, creative arts and so on. Here, we present the case of a young man (“Adam”) in the early phase of schizophrenia. We describe how his presentation can be understood in terms of phenomenological accounts of selfdisturbance and outline how this theoretical background informed the treatment approach adopted for this patient. We describe his progress through therapy and, finally, suggest implications of this case study for psychotherapy with patients with similar presentations.

2 Case Presentation Adam is a 22-year-old young man who was admitted to hospital with a range of physical complaints (see below). After admission, he developed some more clearly psychotic symptoms and was transferred to a youth mental health service for the early identification and treatment of mental health disorders. He was seen as an outpatient at this service, which consisted of regular (approximately weekly) sessions with a psychologist and a psychiatrist. At the time of writing, Adam has been seen at the service for approximately one year and remains in treatment.

3 Presenting Complaints Adam was admitted to hospital with a range of physical complaints, including headaches, faintness, numbness, heaviness and weakness of his limbs, particularly his peripheries, unsteady gait, and “electric shock”-type sensations. He also presented with panic attacks associated with general concerns about his physical health (e.g., “I am not retaining any water from what I am drinking and always feel thirsty,” concern that he had “neck lumps,” etc.) and thoughts that he may be dying (e.g., that he may have acquired immunodeficiency syndrome (AIDS) or cancer.) Once admitted to hospital, Adam experienced a 1-month period of severe psychomotor retardation, catatonia, including posturing, motor stereotypies and echolalia, and formal thought disorder, including thought blocking, poverty of speech, and tangentiality. No overt delusions or hallucinations were evident. Although an MRI scan revealed an Arnold Chiari 1 malformation with mild dilation of the ventricles, a neurologist and neurosurgeon assessed Adam’s symptoms as not being related to this abnormality. No other medical conditions were identified. Once discharged from hospital, Adam engaged in outpatient treatment with a psychologist and psychiatrist. He was diagnosed according to DSM-IV with schizophrenia, catatonic type. Over the course of these sessions, Adam described an array of anomalous experiences during his catatonic episode, which he continued to experience in attenuated form and which have been present to some extent throughout his life. These experiences included prominent depersonalization experiences, such as not feeling “present” in his body or feeling as though his centre of experience or perspective was what he described as “20 centimeters behind” his physical body. This included some “out of body” experiences, which involved watching himself from another part of the room. He also described derealisation experiences, including a sense that the world and people around him were not entirely real, but may in fact be figments of his imagination.


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He described a distance and spoke of feeling the sense of a “buffer” between himself and the rest of the world, as though he could not engage or contact the world and others directly. He stated that his “relationship to the world had vanished.” A concomitant state was feeling that he was not affected by what was going on around him, as though he was not fully participating in the world. Adam also described cognitive difficulties. He spoke of having enormous difficulty “thinking clearly” and choosing between different options. Everything required a lot more thought and effort, prompting him to “give up” and remain immobile and unresponsive. He stated, “I lost my automatic things—They became conscious. Everything I did was a conscious effort—For example, picking up a glass.” His thoughts were slowed down and disconnected, as though they lacked a meaningful flow. But he also experienced episodes of thought pressure, sometimes during his catatonic periods. At times, his thoughts also took on the auditory quality of “Gedankenlautwerden” or “thoughts out loud.” He also experienced significant difficulty expressing himself, either because he was unable to find appropriate words for what he wanted to say or because he found himself saying things whose meaning differed from what he intended to communicate. Despite his lack of “presence” in the world and loss of automatic understanding and activity, Adam also reported a sense of “heightened meaning” associated with the most quotidian things. For instance, he mentioned that a cup of tea or movements and expressions of people visiting him in his hospital room seemed imbued with significance, yet the precise significance of these things remained indeterminate: there was an atmosphere of heightened meaning, without this meaning being definable. He also described a sense of having insights into reality that he had not previously experienced—for example, becoming preoccupied with the following thought/sentence: “Life is the question. Death is the answer.” Finally, Adam also described an array of perceptual disturbances, such as focusing on parts of a visual scene rather than seeing it as an overall Gestalt. For example, he saw faces as collections of individual features (nose, lips, etc.), rather than as unitary wholes. Adam explained: “it [referring to faces] wasn’t expression, wasn’t human anymore, I couldn’t know whether somebody was annoyed or happy, they were disconnected parts.” He described being captivated by isolated elements in his visual field, such as a door, and having to examine these elements closely. Adam’s symptoms clearly exemplified the abnormalities of basic selfhood or ipseity, as well as the disturbances of perceptual or conceptual “grip” or “hold,” described in the above-mentioned phenomenological accounts (Parnas, Moller et al., 2005; Sass, 1992; Sass & Parnas, 2003).

4 History Prior to his admission to hospital, Adam had experienced a 2-month history of social withdrawal, perplexity, and low mood (including anhedonia and a sense of guilt and worthlessness). This period was marked by a slowing of speech and movement and difficulties reading and understanding words. He had not experienced any other significant mental health problems over his life. There was chronic schizophrenia in his family history. Adam’s father, who died when he was 17 years old, had had multiple inpatient admissions and persistent low functioning throughout his life. Adam’s parents separated when he was 2 years old. Premorbidly, Adam was an intelligent, social and thoughtful young man who enjoyed reading science and philosophy. Although he struggled in the final year of his schooling he was planning to start a university degree in the humanities in the next few years. He had been employed full-time as a factory shift worker until 2 months prior to presentation. He quit this job, reporting that he found it too stressful. Adam had been in a romantic relationship for the last year. Prior to the onset of symptoms Adam had several close friends, although he often found social interaction difficult and awkward. He often felt “different” from other people, and explained that his persistent tendency to “think about [his] own thinking” made it difficult to interact with other people with ease.


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5 Assessment As noted above, a neurological examination revealed an Arnold Chiari 1 malformation. However, Adam’s symptoms were not thought to be related to this abnormality. No other medical conditions were identified. The psychiatrist in charge of Adam’s care at the youth mental health service diagnosed him with schizophrenia, catatonic type according to DSM-IV.

6 Case Conceptualization Adam’s symptoms included an array of anomalous subjective experiences that are consistent with the phenomenological model of self-disturbance in schizophrenia spectrum conditions described above (the IHM model). His symptoms indicated hyper-reflexive awareness of his own cognitive and corporeal processes, involving both hyper-reflective and more automatic, non-effortful or “operative” forms (Sass & Parnas, 2007); a sense of distance and even alienation from his own experience (disturbed presence); dissolution of “common-sense” understanding or ease of grasping meaning (Blankenburg, 1969, 2001); and a breakdown of integrated gestalt perception into atomistic elements (Sass, 1992). The presence of these anomalous forms of experience seemed to underlie, and arguably led to, the withdrawal and inactivity of his catatonic state; in this sense, so-called “positive” and “disorganization” symptoms could be said to underlie the “negative-symptom” presentation of his catatonic state (Sass, 2003). In retrospect (and to some extent during) he characterized the physical immobility of his catatonic periods as accompanied by a stance of passive, distantiated observation and nonparticipation in everyday life. Such experiences were not transitory. They had been present to some degree throughout his life and continued in attenuated form after his catatonic episode, suggesting an ongoing, trait-like disturbance of basic selfhood and persistent vulnerability to psychotic breakdown. The family history of schizophrenia is noteworthy here. The direction that psychotherapy took with Adam provides a useful avenue for conceptualizing his case, particularly his psychotic breakdown. In therapy (see below), Adam frequently spoke about his year-long relationship with his girlfriend, “Fiona.” It transpired that a central dynamic in this relationship involved feelings of exposure, vulnerability, and subservience. Adam was prone to experience Fiona as controlling and intrusive in her attitude toward him; also, he felt that she did not trust him. For example, she would check his Internet usage, leave him feeling guilty if he wanted to spend time with friends, and question him closely (“she badgers me”) regarding his activities and plans. Although Adam tolerated this relationship dynamic, it created in him a sense of anxiety and entrapment (e.g., “It makes me feel tight, like I’m caged. . . ”). Adam described this relationship dynamic as being very stressful for him over the last year. The relationship dynamic may have helped trigger Adam’s psychosis in two ways: First, the controlling/monitoring dynamic in the relationship seemed to have intensified Adam’s own persistent self-monitoring or hyper-reflexive attitude (a central feature of the IHM model). In other words, his partner’s perceived questioning and monitoring of him encouraged in Adam an inner vigilance and anxious monitoring of the self by the self [see Sass (1992, chapter 8) for discussion of the Panopticon as a metaphor for self-scrutiny in schizophrenia]—and thereby further undermine an already fragile self-structure. Adam commented: It would make me always question myself, over-think things. And I’d keep getting full of doubt, like “Is that the right way to do something?” “Am I acting strangely here?” “Am I being deceptive?” On and on. . . And that’s what I do anyway like we were saying. This intensified hyperreflexivity may have encouraged his pre-existing anomalies of selfexperience to evolve into more clearly psychotic symptoms.


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The second route is more directly grounded in the problem of interpersonal interaction than in the self’s relationship with itself. It has often been noted (e.g., Laing, 1960; Sass, 1992) that people with schizotypal or schizoid personality structures—who, according to the IHM model, have a disturbed basic selfhood—can find relationships threatening, intrusive, and difficult to tolerate. Romantic relationships can be especially problematic, given the high level of intimacy and involvement with another person in such relationships. Due to what he experienced as her controlling and intrusive behaviors, Adam’s relationship with his girlfriend may have enhanced these inherent difficulties of relating to others associated with his self-structure. It is relevant here to consider ethnographic research that has shown that chronic schizophrenia patients seem to do best (as indexed by lowered rates of readmission to hospital) when they are allowed to find their own interpersonal equilibrium, rather than being pressured toward more intense social interaction (Corin, 1990; Corin & Lauzon, 1992). In these studies, this typically meant a life with significant but, at the same time, highly limited social contacts (e.g., one individual who counted on his daily encounter with a friendly though busy waitress at a donut shop). Adam’s relationship with Fiona was in direct contrast to this—not only in frequency and intensity of contact but also in that its central features of control and monitoring were, by their nature, being imposed on him. In his existential-phenomenological model of psychotic vulnerability, Laing (1960) identified the difficulties for the schizoid individual1 in interpersonal relationships as involving fear of what he terms engulfment, implosion, and petrification of the self due to a persistent ontological anxiety. The ontological anxiety referred to here is a pervasive sense of insecurity, weakness, inferiority, or generalized low-grade anxiety, sometimes experienced as a subtle, pervasive sense of something ominous impending (Parnas, Moller et al., 2005), and grounded in insecurity about the very existence of the self as a real, alive, whole, and continuous being. The person experiencing ontological anxiety has a sense of being exposed and feels that the basic features of the world are somehow unreliable or unstable. He or she tends to feel particularly vulnerable to the intrusive or objectifying gaze of other people, as Laing notes. The fear of petrification emerging from this ontological anxiety may be of particular relevance in Adam’s case. Laing (1960) argued that the schizoid individual fears that others will regard him as an object, fixing him, as in the case of Medusa’s stare, into a lifeless shell. Thus others can be experienced as a threat to the schizoid individual’s very sense of existence as a subjective presence. Such concerns seem to have emerged for Adam in his general discomfort around others, his sense that he could only “be himself” when he was alone, and his greater comfort with Internet-based rather than face-to-face interaction, because the former allowed him to retain the sense of a private self held apart from direct social encounter. Adam’s partner’s excessive attempts to control him, her excessive awareness and monitoring of his activities and behavior, may be understood as—or at least may have been experienced by Adam as—an attempt to objectify him (to “fix” him in place). Statements such as “She is draining me of myself,” “I can’t be me,” “I have nowhere to hide and recover,” “I lose my way of seeing things”; also Adam’s sense of entrapment—all these suggest ontological anxieties that go beyond standard concerns about intimacy. Adam may have been particularly sensitive to what he experienced as attempts to control him, given the underlying fears of engulfment or “petrification” associated with his schizoid form of ontological anxiety. The dynamic established in the year-long relationship with his girlfriend may have made his underlying schizophrenic vulnerability manifest into a psychotic episode, initially characterized by panic-like anxiety symptoms and then catatonic features. To summarize, Adam’s concern about being controlled and monitored by his intimate partner may have helped to trigger the onset of his psychotic episode—by intensifying his persistent self-monitoring or hyper-reflexive attitude and also his fear of being objectified through interaction with others (Laing’s “petrification”). Both problems are grounded in the underlying


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vulnerability inherent in self-disturbance and expressed as a form of pervasive ontological anxiety. Apart from this threat to his basic or “minimal” sense of self (“ipseity”), Adam also experienced forms of anxiety that were grounded in more explicit forms of narrative or reflective self-identity—namely, concerns about developing the identity of a chronic mental patient, like his father. The anxiety associated with this possible future may have exacerbated his self-destructive propensities toward hyperreflexive self-scrutiny. In addition, they sapped his basic sense of selfconfidence and self-worth, thereby discouraging him further from engaging in the forms of world-oriented action that might have helped him to emerge from his withdrawn form of selfpreoccupation and apathy.

7 Course of Treatment and Assessment of Progress Adam generally engaged well with treatment as an outpatient, although he would often arrive late for therapy sessions and sometimes failed to attend. His formal thought disorder had subsided and his anxiety symptoms had reduced significantly since the resolution of his catatonic episode and discharge from hospital. The components of outpatient treatment consisted of psychotherapy and antipsychotic medication (olanzapine). The psychotherapy (ongoing) was conducted within an early intervention program involving a CBT approach, broadly conceived (Phillips & Francey, 2004). The therapist (BN) was, however, involved in reading and research concerning the phenomenological, self-disorder approach. Hence he adapted the treatment along lines suggested by the latter approach, with a greater emphasis on identifying and understanding subjective experience rather than on developing cognitive-behavioral change strategies. One significant therapeutic effect of familiarization with the IHM, phenomenological approach, which became an explicit part of treatment (see below), concerned the issue of “insight” and commitment to a treatment regime. In the early stages of therapy, Adam remained committed to the view that his symptoms had a purely medical or physical basis. However, he progressively moved away from this position and acknowledged the role of psychological processes. Previously, this patient’s attitude toward his own illness had been somewhat wavering and ambivalent, characterized at times by a tendency to deny that he had any psychiatric illness and to question the possibility of receiving any help from psychiatric intervention. He sometimes had difficulty believing that he fulfilled certain clinical criteria. However, once he encountered the phenomenological account of self-disorder, he was able to recognize himself therein, and this improved the nature of the therapeutic alliance. The focus on subjectivity inherent in the IHM model seemed to provide a useful balance between subjective and objective perspectives on the self. It seems to have provided a way in which Adam could see himself as fulfilling certain criteria and fitting into a category, while at the same time recognizing the inner, subjective perspective on his difficulties—and in a way that placed primary emphasis on qualitative specificity of his modes of experience rather than on defects or deficits in comparison with an implicitly valorized condition of normalcy. Adam was quite explicit about recognizing himself in the IHM model as well as the notion of ontological anxiety: “This does describe what’s been going on,” he said in one session. “I haven’t given it a name before. . . It’s amazing how much this (the IHM, self-disturbance model) relates to what’s been going on for me.” Often he would volunteer or hypothesize how his own subjective experience might relate to or provide examples of aspects of the model. All this allowed the phenomenological, self-disturbance model to form a basis for dialogue with the therapist and also to provide a guide and justification for further therapeutic work.


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Frequently the IHM model was discussed in connection with Adam’s relationship with his girlfriend. This involved identifying his feelings of being controlled, monitored and trapped, and tracing the possible impact of the associated anxiety, as described above. Often these conversations evolved, in turn, into broader discussions about his self-structure and the notions of diminished self-affection, hyper-reflexivity, and ontological anxiety. This aspect of therapy involved an ongoing discussion and exploration of the IHM model and the possible role of the relationship dynamic in exacerbating his symptoms, along the lines described above. It should be noted that the IHM model did not first enter into the therapeutic conversations by any overt or intentional decision on the therapist’s part. One day, around 5 weeks into outpatient treatment, Adam noticed some words relating to the IHM model that had inadvertently been left on the whiteboard in the therapist’s office, and he asked about their meaning. The therapist described the IHM model in general terms, including the concepts of hyper-reflexivity and diminished self-affection. Adam became increasingly curious about the model, which led to further, detailed discussion. Because of his high intelligence and “psychological mindedness” Adam was well able to grasp and discuss these ideas. Discussion was initially on a fairly intellectual and impersonal level, with the therapist describing theoretical details of the model and Adam asking questions to clarify ideas. The therapist asked whether this might relate to Adam’s own experience, and Adam quickly agreed and offered examples: “It’s true, things slip easily in my mind. Things are always open for question. I think about it all too much, can’t stop my awareness, which makes me anxious.” Adam seems to have been quite relieved to learn about this model of the illness. Indeed, it would be fair to say that the therapist experienced Adam as more enlivened than ever while discussing the IHM model and how it related to his own experience. This connection of the theoretical with the experiential was also facilitated by Adam’s participation in a research study about the concept of self-disturbance, involving an interview using the Examination of Anomalous Self-Experience (EASE) questionnaire (Parnas, 2005), a semistructured interview about disturbed self-experience. The semistructured interview—with its brief descriptions of various anomalies of self-experience together with concrete examples—provided a structure for Adam to describe his own anomalous self-experience in detail. It also provided him with a sense that his unusual sense of self is a “recognized” disturbance in psychiatric literature, rather than an idiosyncratic or unrecognized problem. As noted above, Adam’s diminished self-affection, hyper-reflexivity and ontological anxiety likely had the effect of alienating or distancing him from other people. Therefore, therapy work focused on trying to establish less threatening and fraught interpersonal functioning in Adam’s life. While a more standard CBT approach would also include addressing interpersonal or social functioning, the phenomenological, self-disturbance approach provided a psychological formulation of, and sensitized the therapist to, the inherent difficulties of interpersonal encounters for Adam, rather than viewing this as a mere side-effect of dysfunctional cognitions (e.g., paranoid interpretive style). This involved addressing his relationship with his girlfriend and also using the therapeutic relationship itself. These will be described in turn. Once Adam recognized that the “controlling and monitoring” dynamic in his relationship compounded his self-disturbance, therapy focused on assisting him to make various attempts to change this dynamic so that the relationship would be less dominated by these features. This consisted of some more “concrete” behavioral interventions intended to help him express his discomfort with certain aspects of his relationship (asking him what seemed like intrusive questions) and to assert himself and feel a greater sense of independence. Including her in several therapy sessions facilitated him to change in this way. Although the therapist perceived Fiona as having at times a somewhat disgruntled, even cynical attitude toward therapy, particularly about involving herself in the process, Fiona did also recognize that the relationship dynamic may have played a role in Adam’s deterioration and cooperated in the therapeutic process. Such a focus on


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relationship dynamics could, of course, be incorporated into a range of therapies, including more traditional CBT. In this case, however, it was closely guided by the phenomenological rationale that changing the dynamic between them would allow Adam to feel less objectified or “petrified” within the relationship. This was the explicitly stated goal (both in sessions with Adam alone and with Adam and Fiona together) of modifying the tone and content of their interaction. Another important part of this process was Adam recognizing his own contribution to the “objectifying” dynamic described above. Laing (1960) described how the schizoid individual may attempt to turn others into “stone” in order to deal with his own fear of being petrified: to the schizoid individual every pair of eyes is in a Medusa’s head which he feels has power actually to kill or deaden something precariously vital in him. He tries therefore to forestall his own petrification by turning others into stones. By doing this he feels he can achieve some measure of safety. (Laing, 1960, p. 76) The schizoid individual may attempt to nullify the power of others to objectify or deaden him by denying the subjectivity or reality of other people. Adam was able to recognize that this was indeed a feature of how he related to his partner— through such actions as ignoring her, avoiding her, not being aware of her perspective, and so forth; and also that this may have had the counterproductive effect of making her more determined to monitor and control him. Therefore, therapy also attempted to address the converse of the process described above, that is, to encourage him to become more aware of her subjectivity. This occurred through reflecting and talking more (both with her and with the therapist) about her emotional life and perspective on situations, and to progressively view this as less threatening, less potentially petrifying to him. For example, the therapist would ask such questions as “Can you describe how she felt in that situation?” “What is Fiona’s view on that?” and so on. As discussed in theoretical terms by Stanghellini and Lysaker (2007) and Nelson et al. (2009), this was a means of promoting access and awareness of the other person’s perspective. Again, including Adam’s partner in sessions was valuable. In these sessions, Fiona would be asked to express her feelings and attitudes about the relationship and specific events, and Adam was given the opportunity to respond. In this way the therapy sessions provided a setting for a relatively “safe” controlled dialogue that allowed Adam to reduce his fear and anxiety regarding the “other’s” (in this case, Fiona’s) perspective of him. In addition to Adam trying to adopt Fiona’s point of view, the “second person” dialogical aspect of treatment also involved Adam’s adopting of the point of view of other people generally, including that of the therapist. Discussion with the therapist often involved going over interpersonal situations or events and encouraging Adam to imagine the perspective and feelings of other people in these situations, for example, “What do you think X was feeling then?,” “Did that have an impact on Y?” and so on. As therapy progressed, Adam would sometimes volunteer his own interpretation of what the therapist might be thinking. An instance of this was when he described unusual mirror-related phenomena, including times when he became transfixed with his own reflection. He stated, “You’re probably thinking that I couldn’t stop thinking about what I looked like (referring to hyper-reflectivity, previously discussed in therapy). But it wasn’t like that, it was more like a sort of spell, not really thinking at all.” The therapeutic relationship itself was also a potent means of developing a capacity for appropriate interpersonal ties. The process of another person trying to understand him, without this leading to catastrophic or “dehumanizing” consequences, was a means of experientially building up the view that interpersonal relationships are not necessarily dangerous or threatening. The therapist’s general attitude of gentle curiosity and concern, making sure not be too intrusive or demanding, was important here. The therapy did not include more “formal” cognitive–behavioral


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strategies of promoting adaptive interpersonal functioning, such as monitoring and recording anxiety in social situations, social skills training, cognitive challenging of negative automatic thoughts, and so on. This was due to concern that such techniques may feed into Adam’s fear of being “objectified.” Viewing his problems as a collection of dysfunctional cognitions needing to be “corrected” through cognitive “restructuring” and skill development ran the risk of objectifying or externalizing his self-experience, thereby exacerbating already overactive hyper-reflexive processes rather than helping him find a way to “re-inhabit” his self (Nelson et al., 2009). Such a process is by no means easy or straightforward, however. There were certainly times when the very intimacy of the therapeutic relationship—which was probably enhanced by the focus on the “first-person” of Adam’s subjectivity (“Describe how you feel. . . ”) and the “second-person” perspective of adopting other’s point of view (“How do you imagine Fiona perceives. . . ”)— seemed to become too intrusive and threatening for him. This in fact seemed to correspond to times when certain basic symptoms, particularly corporeal symptoms, became more prominent again—as if he were then adopting a more alienating, observational orientation that caused parts of his own body to be experienced as if they were external objects rather than intimate parts of a corporeal self that he fully “inhabited.” Adam seemed to respond to this by distancing himself from therapy by arriving late, thereby shortening the session, or not attending sessions at all. At these times it sometimes seemed helpful to return to a more third-person, objectifying approach (e.g., “People in these situations may think X, which may cause them to feel Y. . . ”). These episodes should perhaps serve as a warning about certain dangers that a phenomenological approach may incur and that are brought to the fore by the analyses of the French phenomenological philosopher Emmanuel Levinas, discussed in Treatment Implications of the Case section. Apart from being alienated and distanced in interpersonal relationships, Adam was also alienated from “engaged activity” more broadly. This was associated with the hyper-reflexivity (including hyper-reflexivity of both the operative and the reflective type) and diminished selfaffection that were such integral aspects of his functioning. Therefore, another feature of therapy was encouraging Adam to become immersed in activity, as a means of minimizing (possibly “escaping” from) his hyper-reflexive processes and bolster a sense of being “present” in activities. In concrete terms, Adam was encouraged to pursue his various interests, including watching films, reading, playing advanced computer games, and physical activities such as swimming and walking. Adam stated that these activities assisted him in “forgetting” about himself: “I have something else to pay attention to. I can give my head something else to sink into rather than eating itself.” We have previously argued that such activities may be of value in re-establishing a healthy intentional balance between tacit and focal forms of awareness; and that this may halt the kind of self-alienation that can occur when hyper-reflexive processes cause normally tacit (or background) aspects of mental or bodily activity to be experienced as if they existed at a distance from the experiencing self (Nelson et al., 2009). The IHM model recognizes the (paradoxicalsounding) fact that normal ipseity or self-experience is in fact dependent on a certain “forgetting” of the self, or at least a forgetting of the self as an objective focus of awareness, so that the more foundational sense of oneself as a subjective perspective on the world can be grounded. Adam noted that the process of having explicitly identified his tendency to “over-think” and analyze (in Adam’s words, “to deconstruct”) his experience assisted in helping motivate him to become immersed in activity and thereby minimize his detached, reflective stance. Recently, he has been looking for employment. One hopes that working will encourage a sense of absorption and reimmersion into the social world. It is likely, of course, that at least some forms of social interactions in the workplace will be anxiety-inducing and potentially pathogenic for Adam. For this reason, we have encouraged him to seek work, at least to start with, in an environment that is relatively tranquil and where the social demands are somewhat minimized.


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As noted above, developing an understanding of underlying processes has itself been of value in Adam’s treatment, as opposed to “doing something about” these processes. That is, the very fact of conveying an empathic understanding of the vulnerabilities of his self-structure, including hyper-reflexive processes, diminished self-affection, ontological anxiety and the problem of the codependence of his experience of self on his experience of others, has itself been of distinct therapeutic value, albeit with the complexities noted above of this form of understanding (i.e., the danger of the “petrifying” inherent in claiming too definitive and totalizing an understanding of his entire subjectivity).

8 Complicating Factors None.

9 Managed Care Considerations None.

10 Follow-Up At the time of writing, Adam has been involved in outpatient psychotherapy for approximately 1 year, with 1 year of time still available to him (the mental health service where he is being seen offers a maximum of 2 years treatment for patients with first episode psychosis). Therefore, it is unclear at this stage what the longer-term outcome will be for Adam. However, to date, he has made significant gains with symptom reduction. His catatonic symptoms, thought disorder, and anxiety symptoms have all resolved. The subjective anomalies or “basic symptoms” described above continue to be present and fluctuate in intensity in accordance with stressors within his relationship and his general attitude; thus they seem to intensify when hyper-reflexive processes become more prominent and when he adopts a more detached, analytical stance toward experience. Adam is also making some functional gains. He is re-establishing and trying to maintain social connections and has begun to look into study and employment options.

11 Treatment Implications of the Case As outlined above, the mechanisms of the treatment effects can be understood in a number of ways. The IHM model and other phenomenological concepts, such as ontological anxiety, provided, at the very least, a useful framework for conceptualizing the self-structure and associated psychological processes underlying Adam’s psychotic symptoms. Adam identified strongly with the ipseity-disturbance formulation. This was itself of therapeutic value, for it provided him with a way of understanding his difficulties, both in the immediate sense of his recent psychotic episode and in the longer-term sense of his ongoing vulnerability. Although IHM model was introduced in a serendipitous, more or less accidental, manner in the case reported here, the model may of course also be introduced in a more deliberate fashion. This may involve a similar process to that which was described above: a theoretical exposition of the model in nontechnical terminology, leading to discussion of how this model may relate to and inform understanding of the patient’s own experience. The phenomenological understanding of Adam’s difficulties pointed the way toward the various foci of therapy. Encouraging appropriate interpersonal engagement was a major element here. This included working on changing the tone and nature of his relationship with his girlfriend (away from the fears of “petrification”), increasing social connectedness, and forming an


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alliance with the therapist that was as productive and nonthreatening as possible. The bond of the therapeutic relationship was itself strengthened by Adam’s sense that the therapist understood important aspects of his subjective anomalies through the shared IHM model, although, as noted above, this may on occasion also have been a source of some anxiety. The phenomenological concepts helped Adam and the therapist understand both the necessity and the danger of social encounters for people with ipseity disturbance. An important ongoing concern in the therapeutic process with Adam was the dual danger of either fulfilling his fears of being objectified or of encouraging his own hyper-reflexive process. In order to avoid this trap, there was a strong focus on his subjective experience, rather than trying to abstract, record or analyze this experience. In addition, there was a particular sensitivity, perhaps more so than with other patients, to the immediate affective quality of the engagement between Adam and the therapist. The attitude the therapist adopted was one of sympathetic curiosity regarding Adam’s subjectivity, and gentle suggestions regarding ways of understanding himself, together with minimal use of challenging or excessive reflection. In other words, the emphasis was on attunement and rapport rather than on “fixing up” dysfunctional elements of a cognitive-behavioral system (Rowe, 1989). Still, there may be certain dangers that are intrinsic to the very nature of a phenomenological approach, with its goal of grasping the subjectivity of the other person. Levinas (1969) has emphasized the crucial importance, in human existence, of our encounter with the face of the other person. He argues that this involves a recognizing of the presence of other subjectivities that is fundamental not only to our moral commitments, but also to our very experience of ourselves as subjectivities (since self-experience-ipseity-and the experience of the other/mother—fundamental alterity—go hand in hand). A key point for Levinas, however, is that the face of the other always does and should represent a realm of unknowability: the person who thinks he or she can fathom the depths of the Other has not appreciated the essential otherness of the other—which always goes beyond what can be known from any external point of view, no matter how subtle or penetrating. This idea has interesting implications for psychology and psychotherapy. In particular, it brings out both the advantages and some possible pitfalls of a phenomenologically oriented approach. It suggests that, although recognizing the subjectivity of the patient is indeed crucial and potentially therapeutic, this very process of recognition also has the potential to be experienced by the patient as destructive if it is imbued with complacency or arrogance—that is to say, if the phenomenologist presumes to have captured in too definitive and totalizing a fashion the entire subjectivity of the patient. In such a case, it is the very subjectivity of the patient that would seem to be, in some sense, objectivized. Laing (1960) seems to have recognized the double-edged aspect of attempting to recognize or understand schizophrenic experience. While he argues that such understanding may well be of therapeutic value, he also insists that there always remains an underlying incomprehensibility of schizophrenic experience: The kernel of his schizophrenic’s experience of himself must remain incomprehensible to us. As long as we are sane and he is insane, it will remain so. But comprehension as an effort to reach and grasp him, while remaining within our own world and judging him by our own categories whereby he inevitably falls short, is not what the schizophrenic either wants or requires. (Laing, 1960) Levinas would generalize this point to all persons, noting that although empathic appreciation, by another person, of one’s own subjectivity may be a deep human need, one also needs to sense an appreciation by the knowing other, of one’s own unknowability—of what might be termed one’s own otherness to or for the other.


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The moral here is not, of course, that one should retreat to an external, purely behavioristic position; but that the phenomenological stance must contain a deep appreciation of its own limitations before the essential mystery inherent in the otherness of the other (particularly, of course, in the case of an “other” whose forms of experiences are especially unusual—as is the case with schizophrenia). Adam never overtly criticized the phenomenological model or approach. Still, his avoidance of sessions at times when the therapeutic relationship seemed “too close” or intimate might have indicated some anxious concern about the revelation of his own private dimension.

12 Recommendation to Clinicians This case demonstrates the potential value of concepts from phenomenological psychiatry in understanding and treating the early phase of schizophrenia, and also some potential dangers that may be inherent in a phenomenological approach. The notion of a disturbed basic sense of self, based on the ipseity-hyper-reflexivity model and the concept of ontological anxiety, formed the basis of the clinical formulation and treatment. These concepts can highlight for the clinician various points of vulnerability for the patient with schizophrenia. This highlighting may, in turn, inform the clinician’s understanding of the challenges the patient may face in interpersonal contact and immersed, nondetached engagement with daily life. The clinician needs to take care not to exacerbate these problems by “objectifying” the patient, stimulating excessive reflection, or encouraging interpersonal engagement that is overly intense. A manageable and rewarding homeostasis needs to be reached with these elements, which is a particular challenge given an underlying fragile basic sense of self. The therapeutic relationship may be particularly potent in this regard. The strategies described above, including encouraging a “second person” perspective and prominent use of the therapeutic relationship, are used in a wide range of therapies, including more traditional cognitive-behavior therapy. In the current case, use of these elements of therapy was guided by the phenomenological rationale that the primary disturbance that needed to be addressed was a disturbed basic sense of self. Declaration of Conflicting Interests The authors declared that they had no conflicts of interests with respect to their authorship or the publication of this article.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors. BN is supported by a Ronald Phillip Griffith Fellowship and a NARSAD Young Investigator Award.

Note 1. Laing (1960) used the term schizoid individual in a general sense to refer to the personality structure that underlies and which may intensify into schizophrenia, rather than in the stricter sense of the “schizoid personality disorder” in diagnostic manuals such as DSM-IV (American Psychiatric Association, 1994).

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Bios Barnaby Nelson is a senior research fellow and clinical psychologist at Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne. He conducts research into risk factors and intervention for patients in the prodromal and early phase of psychotic disorders. Louis A. Sass is professor of Clinical Psychology at Rutgers—the State University of New Jersey. He is the author of Madness and Modernism and The Paradoxes of Delusion, and of numerous articles on phenomenology, hermeneutics, and the schizophrenia-spectrum disorders.
