Psychosis Risk and Experience of the Self: Understanding the Individual Development of Psychosis as a Basic Self-disturbance 2022045758, 2022045759, 9780367651138, 9780367651145, 9781003127895

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‘This marvellous book shows us that going “back to basics” (the central role in psychiatry of conversation and close listening) can point the way forward for developing a more satisfactory understanding of psychosis and what to address in treatment. The content and writing style will appeal to a broad audience – clinicians, researchers, and interested general readers alike. This book is highly recommended’. —Professor Barnaby Nelson, Head of Ultra High Risk for Psychosis Program, Orygen, The University of Melbourne ‘This is an amazing cartography of the multiple shades and experiential layers that lie at the core of emerging psychosis, as well as an inspiring map for all those genuinely interested in the psychotherapy of schizophrenia. Over and above the in-depth clinical insights, Paul Møller offers something even more unique and rare in the contemporary literature landscape: a meditated distillate of clinical experience, interhuman curiosity, and therapeutic touch’. —Professor Andrea Raballo, MD, PHD, Professor of Psychiatry and Psychotherapy, Department of Biomedicine, University of Italian Switzerland, Lugano, Switzerland

PSYCHOSIS RISK AND EXPERIENCE OF THE SELF

Møller sheds light on the inner aspects of psychosis and psychosis risk, and its core experiential phenomena as a method of understanding the individual early psychosis development. The book details how such experiences might take shape in the human mind and how a better understanding achieved through detailed clinical conversations can lead to earlier detection and improved interventions. Møller also outlines the Subjectivity Model (also called Ipseity Disturbance Model) and presents a broad review of different treatment approaches and settings, in which work with disturbed self-experience could be integrated, including psychotherapy, in-patient milieu therapy, supportive treatments, psychoeducational family work, local networking, and medication. Psychosis Risk and Experience of the Self will prove essential for experienced and specialised clinicians as well as the more generally interested reader. Paul Møller, DrMedSci, is a consultant psychiatrist, senior researcher and former Research Director and Head of Department of Mental Health Research and Development for the Division of Mental Health and Addiction at Vestre Viken Hospital Trust, Norway.

THE INTERNATIONAL SOCIETY FOR PSYCHOLOGICAL AND SOCIAL APPROACHES TO PSYCHOSIS BOOK SERIES Series editor: Anna Lavis

Established over 50 years ago, the International Society for Psychological and Social Approaches to Psychosis (ISPS) has members in more than 20 countries. Central to its ethos is that the perspectives of people with lived experience of psychosis, their families and friends, are key to forging more inclusive understandings of, and therapeutic approaches to, psychosis. Over its history ISPS has pioneered a growing global recognition of the emotional, socio-cultural, environmental, and structural contexts that underpin the development of psychosis. It has recognised this as an embodied psycho-social experience that must be understood in relation to a person’s life history and circumstances. Evidencing a need for interventions in which listening and talking are key ingredients, this understanding has distinct therapeutic possibilities. To this end, ISPS embraces a wide spectrum of approaches, from psychodynamic, systemic, cognitive, and arts therapies, to need-adapted and dialogical approaches, family and group therapies and residential therapeutic communities. A further ambition of ISPS is to draw together diverse viewpoints on psychosis, fostering discussion and debate across the biomedical and social sciences, as well as humanities. This goal underpins international and national conferences and the journal Psychosis, as well as being key to this book series. The ISPS book series seeks to capture cutting edge developments in scholarship on psychosis, providing a forum in which authors with different lived and professional experiences can share their work. It showcases a variety of empirical focuses as well as experiential and disciplinary perspectives. The books thereby combine intellectual rigour with accessibility for readers across the ISPS community. We aim for the series to be a resource for mental health professionals, academics, policy makers, and for people whose interest in psychosis stems from personal or family experience. To support its aim of advancing scholarship in an inclusive and interdisciplinary way, the series benefits from the advice of an editorial board: Katherine Berry; Sandra Bucci; Marc Calmeyn; Caroline Cupitt; Pamela Fuller; Jim Geekie; Olympia Gianfrancesco; Lee Gunn; Kelley Irmen; Sumeet Jain; Nev Jones; David Kennard; Eleanor Longden; Tanya Luhrmann; Brian Martindale; Andrew Moskowitz; Michael O’Loughlin; Jim van Os; David Shiers. For more information about this book series visit www.routledge.com/The-InternationalSociety-for-Psychological-and-Social-Approaches-to-Psychosis/book-series/SE0734 For more information about ISPS, email [email protected] or visit our website, www.isps.org. For more information about the journal Psychosis visit www.isps.org/index.php/ publications/journal

PSYCHOSIS RISK AND EXPERIENCE OF THE SELF Understanding the Individual Development of Psychosis as a Basic Self-disturbance

Paul Møller

Designed cover image: Darrell Gulin, as rendered on Getty as the user who created this image. Courtesy of Getty Images. First published 2023 by Routledge 4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 605 Third Avenue, New York, NY 10158 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2023 Paul Møller The right of Paul Møller to be identified as author of this work has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Names: Møller, Paul, 1956– author. Title: Psychosis risk and experience of the self : understanding the individual   development of psychosis as a basic self-disturbance / Paul Møller. Description: Abingdon, Oxon ; New York, NY : Routledge, 2023. |   Series: The international society for psychological and social approaches   to psychosis | Includes bibliographical references and index. Identifiers: LCCN 2022045758 (print) | LCCN 2022045759 (ebook) |   ISBN 9780367651138 (hbk) | ISBN 9780367651145 (pbk) |   ISBN 9781003127895 (ebk) Subjects: LCSH: Psychoses—Diagnosis. | Schizophrenia—Diagnosis. Classification: LCC RC512 .M65 2023 (print) | LCC RC512 (ebook) |   DDC 616.89/8—dc23/eng/20221223 LC record available at https://lccn.loc.gov/2022045758 LC ebook record available at https://lccn.loc.gov/2022045759 ISBN: 978-0-367-65113-8 (hbk) ISBN: 978-0-367-65114-5 (pbk) ISBN: 978-1-003-12789-5 (ebk) DOI: 10.4324/9781003127895 Typeset in Times New Roman by Apex CoVantage, LLC

THIS BOOK IS DEDICATED TO THOSE WHO HAVE EXPERIENCED PSYCHOSIS, AND THOSE WHO LISTEN TO THEM.

CONTENTS

Prefacexi Acknowledgementsxii A central conversationxiv

Use of the term ‘schizophrenia’ in this book

  1 An initial aerial view of the field, then heading for the inside

1 6

  2 To understand is a universal human need

23

  3 The prodromal phenomena illuminate the core of existence – aiding the understanding of psychosis

37

  4 The problem of defining the prodromal phase

48

  5 The view of science determines the view of psychosis

56

 6 Subjectivity

64

  7 The self and basic self-disturbance

76

  8 Diagnostics, phenomenology, and the EASE manual in the field of psychosis risk

88

  9 The five domains of the EASE manual

95

10 The view of psychosis treatment among professionals and health authorities is changing

ix

106

C ontents

11 What about other models of understanding and therapeutic approaches to psychosis? Do they use subjectivity, selfexperience, or self-understanding as explicit concepts?

114

12 Self-disturbances as part of a wider treatment context

127

13 Conversation and phenomenology

133

14 Therapeutic effects and obstacles

141

15 Approaches and settings in treatment directed at basic self-disturbances

156

16 Outline of a pragmatic seven-step treatment module

174

17 Implementing the Subjectivity Model

189 196 199

Appendix Index

x

P R E FA C E

The main aim of this book is to inspire a renewed interest in working psychotherapeutically with schizophrenia and psychotic disorders, among clinicians and therapists from all backgrounds. Equally, I  hope that the book will serve as a source of information and deeper insight for clients and their families when trying to understand psychotic experiences and behaviour, thereby promoting genuine and positive communication within families. As a clinical researcher, I have had the privilege to participate in the scientific exploration of the scarcely investigated initial prodromal phase in schizophrenia, which is a puzzling and extremely challenging experiential area in which to navigate. Since the mid-1990s, there has been a surge of renewed scientific interest in the prodrome, and I realised at that time that this could provide an inroad into understanding the experiential phenomena of psychosis itself, as well as the relationship between these phenomena and the individual. Curiosity about how psychotic experiences can arise and develop, how they acquire their particular characteristics or ‘shape’ in consciousness, and how they can ultimately be understood is not reserved for researchers and therapists, but is also shared by many of the main persons themselves, and their families. It is my view that focusing systematically on clients’ self- and identity experience can address important scientific questions, and lead to a range of potential benefits in clinical work. My hope is also that, through deeper understanding, this book may provide some hope and comfort for affected families. The subject matter is by no means easy to convey, receive, understand, or digest, and therefore I have aimed, wherever possible, to present the material in a straightforward language that will be understood by a wide audience, from experienced and specialised clinicians to the more generally interested reader. Paul Møller

xi

ACKNOWLEDGEMENTS

First of all, I would like to express my deep gratitude to Professor Josef Parnas (Copenhagen, Denmark), for seminal meetings and collaboration with him, in the early 2000s, as an extremely insightful and dedicated psychiatrist and phenomenologist. During our preparation of the EASE manual, he opened doors for me to phenomenology as the most exciting and valuable scientific tool in the strive to understanding psychosis. I would like to thank psychiatrist, senior researcher, and Professor Jan Olav Johannessen (Stavanger, Norway), who in a decisive way encouraged me to start working with this book. An absolutely indispensable partner in the project has been the Norwegian–English translator and clinical psychologist John Andrew Holmes (Leeds, UK), who took care of the initial round of translating Norwegian texts on the topic and who has been involved in the innumerable subsequent adjustments and clarifications of the language. I must also thank the senior editor of the ISPS Book Series, medical anthropologist, and associate professor Anna Lavis (Birmingham, UK) for her thorough and thoughtful review of the script, and a manifold of important suggestions for adjustments and reorganisations of the material. The artworks used in this book, to illustrate some client experiences in a non-verbal way, are all made by the animation studio Animaskin (Oslo, Norway). Finally, a great hug to my close friends Asbjørn Stavenes, Ole-Jørgen Sagedal, Reidar Tyssen, and Thor-Steinar Grødal, for their encouraging and tireless faith in the significance of this project. Asker, Norway January, 2023

xii

Figure 1 Young boy, depicting a little indistinctly in the background, looks confusedly at two others who are talking animatedly together.

A C E N T R A L C O N V E R S AT I O N

Therapist (T): Y  ou told me that, when your difficulties started, you found it awfully difficult to keep up at school, and everything social was also difficult, interacting with people, even your closest friends and your family. But could you tell me a bit more about this, what this really feels like on the inside? Patient (P): It’s so difficult to put into words. It’s a bit like losing contact with yourself. Reality in a way seems a little distant. I become very isolated and think that everything seems different, everything seems somehow new and strange. T: Distant, different, new. Is it possible to say a little more about what is different and new? P: There’s something not quite right about me. All of life in a way gets turned upside down, nothing seems right, and nothing is meaningful to me. I’m thinking and worrying absolutely all the time, but not even thinking seems to work properly. I need to sort of consciously decide what to think. It’s obvious that I’m so different from everyone else. T: Do the things around you in the physical world seem different in any way? P: Not really, everything is sort of the same, but still everything feels different. It’s like I’ve been here a thousand times, and everything is the same, but still somehow changed. My surroundings seem distant. Everything is strange. T: So it’s the inner changes and this new feeling that result in it being so hard to function, at school and socially? P: That’s it. I can’t get anything done. I can’t find myself, I’m not even sure who I am any more, and I worry intensely about that. Always worrying and thinking about it. I can’t describe just how awful everything is. T: Does it seem to be the same from day to day and week to week, or does it change and develop over time?

xiv

A  central conversation

P:

T: P:

T:

P:

It’s definitely getting worse over time, slowly but surely over several months. I have this really strong feeling in my head that I’m somehow living new and differently. My head feels weird, it’s like there’s some weird suction in there. I get afraid of almost disappearing into myself, going into some kind of trance. It feels like the world around me is just an illusion. I wonder if I even exist. It’s incredibly difficult to explain. All the practical small details of everyday life, do they go on as normal? Dressing, washing, eating, sleeping? In a way, but everything is such an effort and difficult, nothing seems to work automatically anymore. I need to really concentrate even just to do the simplest of things. It’s like I don’t know what I’m supposed to do or what I should think about. Terribly restless, I feel like I don’t belong anywhere. I have a question that might sound a bit weird, but others have said some interesting things about it: would you say without hesitation that you feel like yourself and that you are a natural part of the world? It might sound a bit crazy when I say it, but to be honest I don’t even really understand what the world is any more. Everything seems artificial and unreal. And I don’t know who I am myself either. All my thoughts and worries have completely taken over my life and decide how I should see the world, namely like a meaningless and strange place where I can’t seem to find myself anymore.

xv

USE OF THE TERM ‘S C H I Z O P H R E N I A’ I N T H I S BOOK

As the current book’s main theme is the relationship between basic selfdisturbance (BSD) and the cluster of psychotic experiences and conditions belonging to the schizophrenia spectrum, I will first attempt to provide a brief discussion of the latter concept. In the context of this book, I considered consistently switching to the use of the term ‘psychosis’ instead of that of ‘schizophrenia’, but concluded that I wished to retain the concept, and then offer some reflections on it. The most important reason for my use of the term schizophrenia is that basic self-disturbance reflects (nonpsychotic) experiential phenomena which hyper-aggregate in, and can critically illuminate and deepen our understanding of the features of what is still termed the schizophrenia spectrum. The phenomena may even expand the discourse on whether to keep the designation or not.

National authorities in many countries insist that psychiatrists and psychologists use internationally recognised diagnoses in the field of mental health, such as in relation to psychotic disorders, including schizophrenia. However, the concept of schizophrenia is problematic and under increasing scrutiny, among professionals, non-professionals, and those with lived experience, in relation to its validity and legitimacy. Moreover, formal definitions and non-formal descriptions of schizophrenia, and the official manuals DSM and ICD, have been continually changed or revised since the concept was launched by Paul Eugen Bleuler in 1908. The current diagnostic criteria for schizophrenia and related psychotic disorders, especially in DSM-5 (APA, 2013) but also in ICD-11 (WHO, 2018), are to a large degree behaviourally oriented, primarily in order to strengthen the reliability of the diagnosis. It is a major weakness that these criteria to a very limited extent address the central and unique underlying experiential changes, now termed basic self-disturbance (BSD) in the research literature; this impedes both understanding, and the diagnostic precision and validity of psychotic disorders. In the quest to improve our understanding of psychotic disorders, a shift in focus from mostly DOI: 10.4324/9781003127895-1

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U se of the term ‘ schizophrenia ’ in this book

on external behaviour towards including characteristic experiences will bring us closer to the person with lived experience, whom I call ‘the main person’ in this book, and to the basic mental processes undergoing change. Phenomenologically oriented psychiatric research from the late 1990s onwards (see reviews: Henriksen et al., 2021; Nordgaard et al., 2021) has therefore brought new depth to the understanding and description of psychotic disorders and not least their preceding stages, particularly in relation to schizophrenia. There is little doubt among clinicians in the field that the collective term psychotic disorders covers a wide spectrum as regards to severity and specificity of symptom expression, from mild, transitory, and self-containing disturbances to highly severe, debilitating, and life-long disorders. It is this broad range of psychotic disorders that officially recognised diagnostic criteria attempt to reflect. Schizophrenia was for some time defined through what were taken to be essentially ‘pathognomonic’ criteria (i.e. specific to the condition), for example commenting and conversing auditory hallucinations and so-called bizarre delusions. A clear delimitation of such ‘pathognomonic’ criteria is however very challenging, if not impossible in many cases, and these criteria are in DSM-5 no longer considered specific (APA, 2013). The concept of anomalous self-experience (ASE), also called basic selfdisturbance (BSD) or self-disorder (SD), was introduced and defined through the publication of the phenomenological checklist Examination of Anomalous SelfExperience (EASE) (Parnas et al., 2005). This perspective represents a still too much neglected aspect of the psychopathology of psychosis, that is, the subjective experience. Since the early 2000s, many publications across the globe have reported a strong and consistent hyper-aggregation of these non-psychotic experiential phenomena, precisely in schizophrenia spectrum disorders (SSDs) (see review in Hensriksen et al., 2021: table 1, p. 1005). This hyper-aggregation is reported in (1) established at-risk mental states, irrespective of onset of psychosis, (2) schizotypal disorder, (3) conditions later converting to psychosis, and (4) in the overt psychotic phase. The phenomena are reported as being highly unpleasant and often almost impossible to verbalise (ineffable) for the main person, leading to a destructive influence on functioning for months or years before psychosis is evident. A person with either pre-psychotic experiences or fully developed psychosis will likely not spontaneously use the term ‘self-disturbance’. Still, this book will demonstrate that many do use expressions quite close to it. Here are some quotations, expressing the experience of not feeling like oneself: I am losing contact with myself; I have lost my entire self; I am not myself anymore; my inner self is disappearing, etc. (Møller & Husby, 2000; Parnas & Handest, 2003; Parnas et al., 2005). These statements suggest that affected persons do recognise and report the experiences that go under the term ‘self-disturbance’ in this book, and in the growing body of research literature, and that they appreciate and emphasise the importance of getting a language for them. Two recent reviews (Nordgaard et  al., 2021; Henriksen et  al., 2021) show that higher levels of BSD are strongly associated with (1) elevated risk of conversion from a clinical high-risk state (CHR) to psychosis, (2) more negative 2

U se of the term ‘ schizophrenia ’ in this book

prodromal symptoms (SIPS/SOPS), (3) more suicidality, (4) more social dysfunction, (5) longer duration of untreated psychosis, and therefore (6) a generally poorer course and prognosis (non-remission), even in cases where psychosis conversion does not occur. Several studies have replicated this, in showing that the level of BSD (= EASE total score) seems to consistently differentiate between schizophrenia (marked high levels; EASE total 20–25), schizotypal disorder (high levels; 15–20), other psychotic disorders (considerably lower; 10–15), bipolar disorders with psychosis (low levels; 5–10), non-psychotic mental disorders (very low levels; 4–8), and healthy controls (negligible occurrence; 0–1) (see Henriksen et al., 2021). In a timely coincidence with finalising this book, this first systematic review of empirical studies on SDs based on the EASE manual was published in Lancet Psychiatry (Henriksen et  al., 2021). The review gives a precise introduction to research findings on the major clinical characteristics of basic self-disturbances and may serve as a confirmatory backdrop to the choice to use the term schizophrenia in this book. I cite here from the review, with a few minor simplifying adjustments: In foundational texts on schizophrenia, the mental disorder was constitutively linked to a specific disintegration of subjectivity, often termed a self-disorder. However, further research on self-disorders generally faded into oblivion, and self-disorders were only recently rediscovered as notable psychopathological features of the schizophrenia spectrum, just nearly two decades ago (from 2000 onwards). Subsequently, the Examination of Anomalous Self-Experience (EASE) scale was constructed to allow systematic assessment of such (non-psychotic) self-disorders. The results of the present review consistently show (a) that self-disorders hyper-aggregate in schizophrenia spectrum disorders (SSDs) but not in other mental disorders (including other forms of psychosis); (b) that selfdisorders are found in individuals at a clinical risk of developing psychosis (particularly SSDs); (c) that self-disorders show a high degree of temporal stability; (d) that self-disorders predict the later development of SSDs; and (e) that self-disorders correlate with the canonical dimensions of the psychopathology of schizophrenia, particularly negative symptoms, impaired social functioning, and suicidality. At the turn of the millennium, self-disorders were rediscovered as core features of the schizophrenia spectrum. . . . Two explorative, phenomenologically informed studies of patients with schizophrenia spectrum disorders (Parnas et  al., 1998; Møller & Husby, 2000) reported complaints of profound and alarming, yet nearly ineffable, changes in selfexperience such as a failing sense of self-presence, feelings of not being truly present in the world, bodily self-alienation, and the permeability of ego-boundaries. A few years later, Sass and Parnas (2003) proposed the Ipseity Disturbance Model (IDM), arguing that the pathogenetic core 3

U se of the term ‘ schizophrenia ’ in this book

of schizophrenia is a disorder of the self. In 2005, the semi-structured psychometric instrument for a systematic, qualitative, and quantitative assessment of self-disorders was published, namely, the Examination of Anomalous Self-Experience (EASE) manual. Since then, empirical studies using the EASE manual have been done worldwide, exploring non-psychotic self-disorders and their association with other clinical variables, such as diagnostic outcomes and major symptom clusters (eg, positive, negative, and disorganised). Furthermore, self-disorders appear to be increasingly promising with intercepting the early developmental expressions of a schizophrenia spectrum vulnerability. Such a developmentally oriented perspective could be central for a new understanding of the pathogenesis of SSDs across childhood and adolescence, (i.e., before the emergence and consolidation of diagnostic symptoms). This knowledge could further have an effect in terms of refining current staging models of at-risk mental states for psychosis, since the presence of self-disorders might facilitate the timely differentiation of those at an increased risk of developing a schizophrenia spectrum psychosis, from others at a clinical high risk, seeking help. In summary, I conclude that the extensive and converging research findings on self-disturbances constitute central, ground-breaking, and fundamental evidence regarding clinically available phenomena, which seem strongly and quite selectively associated with schizophrenia spectrum disorders. Rather than adding to further stigmatisation, improved knowledge of self-disturbances and their relationship to SSDs, as shown in recent research, is in this book intended to contribute to the very opposite, namely a deeper scientific and clinical understanding of experiences in developing psychosis, increased empathy for the experiences of people living with a diagnosis of schizophrenia, and an improved ground for establishing a therapeutic alliance.

References American Psychiatric Association. (2013). DSM-5: Diagnostic and statistical manual of mental disorders (4th ed.). Arlington: American Psychiatric Association. Henriksen, M.G., Raballo, A., & Nordgaard, J. (2021). Self-disorders and psychopathology: A systematic review. The Lancet Psychiatry, 8(11), 1001–1012. Møller, P., & Husby, R. (2000). The initial prodrome in schizophrenia: Searching for naturalistic core dimensions of experience and behavior. Schizophrenia Bulletin, 26(1), 217–232. Nordgaard, J., Henriksen, M.G., Jansson, L., Handest, P., Møller, P., Rasmussen, A. R., . . .  & Parnas, J. (2021). Disordered selfhood in schizophrenia and the examination of anomalous self-experience: Accumulated evidence and experience. Psychopathology, 54(6), 275–281. Parnas, J., & Handest, P. (2003). Phenomenology of anomalous self-experience in early schizophrenia. Comprehensive Psychiatry, 44(2), 121–134.

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Parnas, J., Jansson, L., Sass, L.A., & Handest, P. (1998). Self-experience in the prodromal phases of schizophrenia: A  pilot study of first-admissions. Neurology Psychiatry and Brain Research, 6(2), 97–106. Parnas, J., Møller, P., Kircher, T., Thalbitzer, J., Jansson, L., Handest, P., & Zahavi, D. (2005). EASE: Examination of anomalous self-experience. Psychopathology, 38(5), 236. Sass, L.A., & Parnas, J. (2003). Schizophrenia, consciousness, and the self. Schizophrenia Bulletin, 29(3), 427–444. World Health Organization. (2018). ICD-11 for mortality and morbidity statistics (ICD11 MMS) 2018 version. https://icd.who.int/browse11/l-m/en.

5

1 AN INITIAL AERIAL VIEW OF T H E F I E L D, T H E N H E A D I N G F O R THE INSIDE

It was April in Berlin, the year 1908. A psychiatry congress was being held, and the audience quietened as Paul Eugen Bleuler, a 50-year-old Swiss psychiatrist and farmer’s son, began to speak. Little did he know that the new word he was to use publicly for the very first time that day would spread around the world and be in active use over 100 years later. The word would arouse lasting international interest and debate, and in certain circles also deep controversy. The word was schizophrenia. This first chapter provides an aerial view of the concept of schizophrenia, and then it will take you to the ‘inside’, to the core phenomena, the very experience of psychosis, particularly to the pre-psychotic stages, with a view to further understand more about how it is possible for such experiences to arise in the human consciousness.

The centre cannot hold: an orchestra without a conductor The scientific field concerning psychotic illnesses is associated with a great deal of general interest. People’s views on these conditions are often characterised by curiosity, concern, and, to a certain extent, fear. The field is awash with myths, and public knowledge about psychosis – particularly the diagnosis of schizophrenia – is relatively weak. There are two main reasons for this. First, there is no clear, comprehensive, or generally accepted understanding of these conditions. Furthermore, dissemination to the public of what knowledge exists is typically poor and mainly out of date. My attempt at presenting a supplementary model of understanding psychosis, and specifically, the experiential complex known as schizophrenia, to a large extent relies on a deep-diving, vertical exploration of what we call the self, very much influenced and supported by the science of phenomenology. It may therefore be pertinent to observe the field from great height first, before going down towards the ‘inside’ of these conditions, and their central mental phenomena, to look in more detail. 6

DOI: 10.4324/9781003127895-2

A n initial aerial view of the field

As already stated, it is not easy to find a proper way to strike a balance between the use of the terms psychosis and schizophrenia. In many instances, the term psychosis would be first choice. In general, there is a case for using psychosis when exploring experience, and for using schizophrenia when describing and discussing the diagnosis. However, there is of course a close connection between these experiences and the frame of theory and understanding, so this approach is probably too simple. As stated in the introductory section, using the term schizophrenia is justified in certain ways, and this is tied to the substantial empirical status of basic self-disturbances (BSD). It is now established that basic self-disturbances (BSDs) are both clinically and empirically found to be most pronounced, articulated, prototypical, and thus most relevant, in the schizophrenia spectrum diagnoses, not least in schizotypy (almost by definition, cf. the manual criteria). Understating this empirical evidence would impose a concealment or blurring of a central aspect of anomalous self-experience. Still, there are also features (items in the EASE manual) representing basic self-disturbances that are far less characteristic/ specific to the spectrum. So, the picture is complex, and there are indeed good reasons for being ‘diagnostically’ very reticent, especially in early pre-psychotic stages. Hopefully, these reflections and rules of caution may shed some light on this important and delicate conceptual issue. The history of the diagnosis of schizophrenia is curious, being short and long at the same time. The expression and manifestations of the disorder have never been presented in a clearly defined, objective, or unambiguous way, and therefore, it has not been possible to establish the condition as a stable and resilient object of research over time. Each period of research has worked within its own diagnostic tradition and definitions, which in successive periods have been repeatedly changed. One can possibly say that the definitions of schizophrenia have been just as variable and ambiguous as the condition itself. The history is therefore also complex, and difficult to present in a systematic way. Literature and other art forms, as well as historical documents, are full of descriptions and presentations of persons with disorganised behaviour, erratic speech, and incomprehensible experiences. Nevertheless, throughout history, these phenomena have been interpreted and understood in extremely different ways, from expressions of divinity or transcendental wisdom, to the very opposite, such as possession by the devil or evil spirits. Against this background, many would claim that psychosis has always existed but only in recent times been systematically described, that is, from the second half of the 19th century. At that time, the old concept of insanity was in the process of being roughly differentiated into four separate conditions: paranoia, dementia praecox (premature dementia or ‘youth stupor’), manic depressive disorder, and, in fact, epilepsy. The first three of these have since been replaced with new and more differentiated terms. Epilepsy has been transferred to the field of neurology. Let us start by asserting what most people currently agree about. The clinical phenomena which characterise what our diagnostic manuals still call schizophrenia are without doubt very real and challenging human conditions, causing 7

A n initial aerial view of the field

great suffering, and requiring understanding, care, and treatment. However, as mentioned earlier, there is increasing debate about whether these therapeutic and humanistic aims are dependent upon, or even served by, the continued use of the historical concept of schizophrenia, a concept largely based upon behaviourally oriented, more or less objectified diagnostic criteria. Influential voices from within the field (and outside) argue that the diagnosis as it is defined today has uncertain validity and that the concept/label should be left behind. It is of course impossible to remove these mental conditions by giving them a new name. Historically, it has been attempted to get rid of troublesome and stigmatising names by renaming (like what quite recently was called mental retardation or learning difficulties), but with limited success. On the other hand, there is a real need to work towards a better understanding of these conditions, by exploring deeper into their mysterious nature and the subjective experiences of those living through them, finding out more about the essential mental distortions involved and how we can provide improved understanding and help. Back to Berlin on 24 April  1908, as mentioned earlier, Paul Eugen Bleuler (1857–1939) used the word schizophrenia for the first time on that day, in a lecture to German psychiatrists – on the diagnosis and prognosis of dementia praecox (Moskowitz & Heim, 2011, p. 473). This was a newly created word deriving from the Greek words skhizein (split, divide) and phrén (reason, mind, soul), and therefore, directly translated, it means split mind. But the speaker Bleuler did not mean by this that the person or his or her personality was split into two. It is a widely held misconception that schizophrenia refers to a split personality. Bleuler was referring to the many central aspects (processes, functions) of human consciousness, such as thought, perception, feelings, impulses, movement and bodily awareness, and memory, and arguing that these no longer functioned in a coordinated and integrated fashion. In his 1908 talk, Bleuler said, ‘I believe that the tearing apart (“Zerreissung”) or splitting (“Spaltung”) of the psychic functions is a prominent symptom of the whole group’. Similarly, Emil Kraepelin (1856–1926) in his account of ‘dementia praecox’ (1896) wrote about psychic processes ‘losing their internal coherence’ and about ‘loss of inner unity’ of consciousness; the mind was like an orchestra without a conductor (see De Kock, 2020). Today, we use different terms; the concepts and theories are more detailed and sophisticated, but the essence is the same. The mind seems to disintegrate, in the sense that the various aspects of consciousness (categories of experience or intentionality) no longer function together in a unified way or appear to be coherent. The centre cannot hold, as Elyn Saks proclaimed on the front page of Time Magazine in 2007 (Saks, 2007). In addition – and this is of central significance – a person’s experiences no longer feel as if they are safely, and as a matter of course, tied to the individual: they seem to loosen, creating a very disturbing feeling of distance to one’s own self and mind (Sass & Parnas, 2003). In the more than 100-year period since 1908, there have been many attempts at defining and redefining the schizophrenia concept. The current diagnostic systems, ICD in Europe (International Classification of Diseases) and DSM in the 8

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USA (Diagnostic and Statistical Manual of Mental Disorders), have complex developmental histories. They started as statistical tools for the registration of causes of death at the end of the 19th century but were later expanded to also include the categorisation of injuries and diseases. The condition of schizophrenia has been a part of these revisions. As a recent reminder of the constant shifts in this field, the latest version of DSM (DSM-5, 2013) introduced major changes to the diagnostic criteria for schizophrenia, most importantly removing the ‘pathognomonic’ criteria. Despite the many historical changes in definition, the concept of schizophrenia seems by its very nature imprecise and problematic. However, this cluster of very distinctive altered human experiences exists, that are real and challenging, which deserve a continued effort to be better understood and treated. It is still a fact that precise connections between psychotic phenomena and different psychotic diagnoses are largely unsettled. In this situation, there are good grounds for researchers to engage in new ways of exploring psychosis from continually different perspectives and with new tools.

Heading for the inside This book is intended to take you to the ‘inside’, to the core phenomena, the very experience of psychosis, and to the early stages of psychotic disorders. The aim is to further understand how it is possible for such experiences to arise in the human mind, and how improved understanding can contribute to earlier and more targeted treatment. There is only one suitable instrument to systematically investigate these experiences from the inside: a mutually open, trusting, and genuinely engaged conversation. In the following, some core issues and concepts will be first clarified.

We have no comprehensive model to understand schizophrenia The group of diagnoses known as schizophrenia are the most elusive of all mental disorders. Despite over 100 years of intense research, we know little about the precise causes, and we have no comprehensive model to explain and understand these conditions. Neither do we have truly effective treatments, just a cluster of measures aimed at providing psychosocial support and calming symptoms, and relieving and calming medications. This book is about why, in this situation, it is especially important to focus on the development of a deepening understanding of psychosis, not just (mostly external) descriptions. Not least, this book concerns itself with what it means to understand, in this particular context. For those who develop a psychotic disorder, an understanding of the experience of psychosis is naturally the most important aspect. In addition to the personal comforting effects 9

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for those affected, and the usefulness for the family, a better understanding can also significantly contribute to professional assessment, diagnosis, and treatment, even though we may not understand the causes in detail.

Experiential phenomena can be investigated Experiences cannot be captured in biological samples or brain scans. Both general human experiences and the disturbed experiences in psychosis are fluid and transient, but they can nevertheless be investigated. For the person experiencing them, even unstable psychotic experiences often have a thematic core relating to something stable and characteristic, because they are always coloured by a unique and personal life-story. Decisive information about the experience can become available for clinicians through a well-designed and individually tailored conversation, a conversation based upon a familiarity with these strange or unusual phenomena. The nature of psychosis makes it therefore impossible, both for clinicians and for researchers, to avoid systematic investigations of the distorted experiences, if psychosis is to be understood. The most informative phase upon which our attention should be focused in order to understand the development of psychosis is the prodromal phase (or at-risk mental state), which precedes both first and later episodes of psychosis. Two chapters (Chapters 3 and 4) in this book are therefore concerned exclusively with this phase. It is in the prodromal phase that changes in experience arise and are most clearly apparent for the main person, that is, when the phenomena are in their formative phase. The first time the prodromal phase (the initial prodrome) manifests itself, that is, before a first episode of psychosis has ever appeared, it is usually most difficult to identify clinically. Clinical experience indicates that later episodes of psychosis will be preceded by a prodromal phase which has qualitative similarities to the initial prodrome, and the prodromal phenomena are therefore at least partly familiar and should be easier to recognise at an early stage. This pattern of qualitative similarity between initial and relapse prodromal phases is particularly helpful when forming personal crisis plans for the follow-up of persons with a psychotic disorder over time. Such plans are widely recommended and used today, for service users who have received treatment, with a view to preventing or reducing the severity of new episodes. The individual early prodromal phenomena are central to such secondary prevention measures.

Understanding is not explanation There is a major difference between the concepts of understanding and explanation. Understanding is about finding meaning in what is being experienced or studied, something which makes sense of the phenomena, with a conceptual coherence and logic. This contrasts with explanation, which focuses on causes, the large complex of causal factors that underlie the onset of the disorder. We are still a long way from precise explanations of why schizophrenia manifests in a 10

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particular individual, even though we do know many contributing causal factors, or more precisely risk factors. But it is perfectly possible, in the present, to understand in a meaningful way how the psychotic experience manifests and develops in the human mind, without paying any attention to the causes. Put more simply: we can to a certain degree say something about how the changes occur, but not why. Human beings have a basic need to understand the conditions and illnesses that we may be affected by. Understanding is closely related to feelings of security. We know little or nothing about the causes of very many physical diseases, but to be able to make sense of, that is, apply concepts, labels, and words, to the changes we experience, is of great importance for quality of life. This is often a significant part of treatment and care in the case of the many conditions where causes are unknown.

Schizophrenia versus psychosis Schizophrenia spectrum disorders are diagnostic categories with many forms, whose criteria and definitions, as mentioned, are widely discussed because of concerns in relation to both classification, validity, and stigma; I again refer to the earlier section, and the eloquent Kraepelin quotation orchestra without a conductor. The term schizophrenia has for many years carried a heavy burden of stigma and been almost exclusively associated with a poor prognosis. The picture today is far more optimistic and nuanced, and there is general agreement that both course and prognosis are just as diverse as the disorder itself. The term psychosis is an overarching and general term for the entire range of psychotic disorders, including the diagnosis of schizophrenia. Psychotic disorders range from (1) brief, reactive conditions that can quickly remedy themselves without treatment, through (2) disturbances with a relatively limited number of psychotic episodes over a few years, often with good treatment outcome, to (3) hugely debilitating, long-term illness, which necessitate major treatment interventions across much of the lifespan. Schizophrenia spectrum disorders usually belong to the final two of these categories, particularly the latter, and are among the most distinctive of the psychotic disorders. Bipolar disorder is also mentioned at certain points in this book, though only in the cases when psychotic symptoms are also present (bipolar psychosis). Since the beginning of the present century, the scientific community has been concerned with the identification of psychotic disorders as early as possible in their development. In the early pre-psychotic stages, however, these conditions are intrinsically unstable, and the different variants of pre-psychosis are not yet enough differentiated to be able to clarify which type is developing in a particular case. Not least judged by the diagnostic criteria in DSM-IV-TR (APA, 2000) and earlier versions, the psychotic conditions in the schizophrenia spectrum, in their most typical forms, are quite conspicuous and characteristic. They are usually the most challenging variants for the main person and for all those involved in treatment, not least because the complete and actual clinical picture cannot be seen until after a considerable time from the onset of the illness. 11

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Psychosis phenomena versus at-risk phenomena Likewise, in the clinical and research field of early detection and intervention for psychosis, the concept prodrome has been widely discussed and criticised (Nelson et  al., 2008), simply due to its unfortunate implication that psychosis will always follow. It comes from Greek and means something that runs (dromos) before (pro), that is, something preceding. It might therefore be taken to mean that this is a clinical state always followed by an episode of psychosis, which of course is not the case. On the contrary, this phase can last for weeks, months, or years, it can reverse and fade out, or it can swing back and forth. It can even be seen in the form of a stable, life-long condition, as in schizotypal disorder (ICD10; F21) (WHO, 1992), in which case it is not a prodrome in a strict sense, even though phenomenologically similar. Many schizotypal phenomena are basically the same as in a prodromal phase, and the consequences for functioning also. The prodromal phase can therefore develop into a psychotic disorder, but this is never certain. Experiences in the prodromal phase are different to the experiences in the psychotic phase, but the two phases are intricately connected and should be understood together. In this book, the prodromal phase and the psychotic phase are therefore sometimes discussed at one and the same time, referring to their common underlying phenomenological foundation. The basic psychopathological processes are the same, even though the phenomena being experienced are different.

The main source of knowledge about the mind Science creates knowledge, whereas clinicians and service users have experiences. Both knowledge and experience must be a part of the foundation when health services are developed. Nevertheless, researchers and clinicians must be fully aware that it is always real-life experience that is the main source of knowledge about the human mind and mental disorders. First, we must listen, then we can synthesise and develop theories and models, and finally treatment interventions can be tried out. The Subjectivity Model (or Ipseity Disturbance Model) of understanding psychosis presented in this book is consistently based on service users’ descriptions of themselves, that is, the first-personal perspective. Phenomenology is an indispensable scientific perspective behind this model.

Someone listen carefully to me! It is always the subjective, vividly real, and often painful experiences from real life that are the main source of knowledge about the human mind. These experiences are the raw data, which can be systematised, refined, and summarised 12

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into models, theories, understanding, and perhaps explanations. But first we must listen, attentively, thoroughly, and exhaustively, to the main persons who find themselves in a frightening pre-psychotic or psychotic inner landscape. A young person who was himself being assessed for a possible psychotic disorder said it in this way: Someone listen carefully to me! Really listen! In a general and basic sense, human beings have a deep-seated desire to understand. We have a strong need to know what and who we are, and to understand what is happening both within ourselves and in our surroundings. Theories are forms of understanding at a synthesised level. Sound and valid theory construction needs to take place as near as possible to the experiences under scrutiny, so that theories do not assume a life of their own, and over the course of time slip away unnoticeably from what is real and recognisable. Experiences are a kind of absolute reference value which we can and must fall back upon, even though they must be systematised into theories to become usable knowledge, not just for individual persons but also for groups of people. The scientific study of experience should therefore always consider using qualitative methods first, before quantitative. To optimally promote research progress and clinical innovation in mental health, the phenomenological first-personal aspects of normal psychology and psychopathology should initially be explored in detail, as exhaustive as possible, to ensure that basic elements involved are detected. These might easily be overlooked if one barely sticks to established conventional mental health measures and categories, through quantitative designs. To simplify, qualitative methods can often identify a fruitful initial main line of inquiry in a research field (see Møller & Husby, 2000; Feyaerts, 2021), whereas quantitative methods can later contribute to statistical measures; grading and precision, such as numbers, shares, and correlations; estimates of prevalence; incidence, etc. The reader may find some of the formulations, themes, and concepts used in this book a little philosophical. This is in a way unavoidable. In fact, it is a part of the message, because the field of phenomenology, to be exposed and discussed throughout the book, is, as a matter of fact, a major philosophical discipline (Zahavi, 2008, 2018). Stated simplified, phenomenology is in the present context the philosophical discipline investigating the first-personal perspective, how human experience is ‘structured’ in our consciousness to yield meaning or be meaningful, that is, what in the human consciousness contribute to make experiences meaningful. Phenomenology has for many years enriched other disciplines, like psychology and psychiatry, especially in continental Europe, and it would be fruitful to reintegrate philosophy and phenomenology into these fields. In this book, for didactic reasons, I have chosen to repeat and formulate the most central phenomenological-philosophical points several times, albeit from different angles, in different sections. I hope that this can make the message more accessible for professionals and others who are not familiar with phenomenology: ‘The more the nail has been hit on the head, the greater will be its value’. 13

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Phenomenology as an indispensable perspective in clinical research and practice I will now briefly provide a description of the unique position of phenomenology as a scientific basis for clinical research, clinical in-depth investigations, and psychotherapy in the field of psychosis. Phenomenology became one of the dominating branches of philosophy in the first half of the 1900s (Edmund Husserl, 1859–1938) and acquired significant influence on a number of other fields of philosophy (Zahavi, 2018). It became a cornerstone of the wider field of continental philosophy (one of the two main branches of philosophy), and has had, and still has, great significance for many scientific disciplines. Phenomenology is today the object of renewed interest, after being overshadowed in the second half of the 1900s when behaviourism took centre stage (behaviour vs. experience). One can speak now of a phenomenological renaissance (Parnas et al., 2008; Zahavi, 2018). Both as a theory and as a method, phenomenology has many different meanings and broad applications. On an overall and general level, phenomenology aims to help us to return to – make us aware of – the importance of the experiential world (what we can sense and experience directly) (Husserl, 1901; Zahavi, 2018). Experiences come before, and is a pre-condition for, all scientific conceptual construction and linguistic expression. This is a fundamentally logical principle, but nevertheless easy to lose out of sight. The scientist’s subjective experiences and senses are the allencompassing starting point of any scientific activity. First, we sense our surroundings: see, hear, and touch whatever is the object of investigation. Second, we reflect, analyse, and engage in the construction of theory. In the context of this book, sensing of the self (self-experience and self-awareness) is the part of the experiential world that we wish to emphasise, with support from phenomenology: All we know about humanity, the mind, mental disorders, and the surrounding world, all our scientific knowledge, arises originally from a first-person perspective, the I-perspective, whatever is being sensed by the subject. Without this perspective, science would be meaningless and irrelevant for us, we would not be able to make use of the knowledge, and it would not bear any significance. Scientific activity and the acquisition of knowledge are always dependent upon the scientist’s first-person and ‘pre-scientific’ experience of the world. All science must necessarily build upon a foundation of subjective experience. The founder of phenomenology, Edmund Husserl, based his theories on the principle discussed earlier: that the subjective always comes first, in any scientific field (Zahavi, 2018). He wanted to establish a universal platform to understand how human beings experience, understand, and find meaning. He wanted to create a kind of ‘first philosophy’ that all other scientific fields could base their activities 14

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on. The assumption is that we all live in a ‘stream’ of experiences, full of meaning, which over time builds our own personal life experience. The search for meaning is of central importance here. The central concepts stream of consciousness (see domain 1 in the EASE, Chapter 9) and intentionality derive from Husserl’s work (Sartre, 1970). Intentionality refers to the fact that all experiences, all consciousness, are directed at something, mainly objects in our surroundings, with the goal of finding meaning. This ‘directionality’ is a basic assumption when we talk of experiences as being the source of meaning: Phenomenology studies the structure and function of experiences and explores how experiences contribute to the creation of meaning, and the understanding of humanity and the world. Phenomenology, as the science of the subjective, is therefore both a method, which emphasises how central experience is for all scientific activity, and a theory (a philosophy), which addresses how meaning is created in consciousness. This book limits itself to that part of phenomenology that is concerned with these fundamental aspects of consciousness and experiences. Because phenomenology is a method and theory aiming to understand the subjective world, it is also a rich source of knowledge in the endeavour to establish a good therapeutic relationship; respect and interest for subjective phenomena are a guiding principle in all psychotherapy.

The mind can never be an object From around 1980, fears that theories may become detached and self-perpetuating in the field of mental health have led to diagnostic systems becoming increasingly theory-free and non-interpretive: they have become purely descriptive, with the apparent intention of being objective. As a result, this led to an inevitable paradox: something that is purely subjective, that is, mental phenomena, cannot be transformed into something objectively demonstrable. The human body’s physical attributes and behaviour can to large extent be objectified, but not the mind. In the latter case, we are totally dependent on developing the best possible assessment approaches – so-called proxies (approximations) – in the form of diagnostic criteria. A mental disorder is impossible to define precisely and unambiguously. Researchers therefore search for a limited number of valid (established) phenomena or symptoms which are particularly characteristic of the individual condition/diagnosis, and decide (in a very pragmatic way) that one must meet all or a selected few of these criteria, to be given the diagnosis. Several of the criteria can be common to different disorders, but an individual condition must have a specified combination of phenomena. One normally operates with one group of main criteria, one group of additional criteria, and finally exclusion criteria. In this way, many of the reservations or prerequisites (conditions) for this kind of diagnostic work can be met, as well as ensuring that a group of related mental disorders have 15

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enough common features that they can constitute a diagnosis or diagnostic group, even though two persons hardly ever have exactly the same picture of symptoms. Clearly, this is a less precise type of diagnostic system than for many somatic illnesses (not all, however), where an organ system on the one hand and an associated category of illness on the other hand are fully possible to link together. Looking a little closer at the aforementioned dilemma, the first natural questions when doing research on the mind become: (1) Do we listen properly and for long enough to the primary source (the person) so that we can capture the essential nature of these human experiences? The relevance of this question is quite obvious. (2) Can we, for the purpose of making models, find adequate and precise enough concepts and words to act as labels for the phenomena? Here, one should remember the mentioned point that models are never correct, but may still be useful (Box, 1976). And, most importantly, (3) do we continually contrast and compare these experiences with the models and theories which are emerging? This concern points to the need for circular movements in the processes of developing models. Based on decades of clinical and research experience in the field of psychosis, I would say there is a danger that, in the frame of recognised, existing models (cognitive, psychodynamic, or other perspectives), clinicians may be tempted to interpret or ‘explain’ clients’ experiential accounts too early and eagerly (Møller & Husby, 2000; Møller, 2001). Incorrect assumptions may follow, without checking out and referring to what the person actually means by what s/he says. These premature interpretations can assume a life of their own and in this way detract us from what is really meant (Sass & Parnas, 2003). For example, when a service user says s/he ‘feels dead’, this might not necessarily be an expression of a paralyzing desperation, exhaustion, and lack of energy, in a more consensual meaning. In the case of self-disturbances, it can imply an almost literal doubt about being alive, about one’s own factual existence, feeling ‘artificial’ and totally cut off from one’s own life (Parnas et al., 2005). Until researchers possibly discover some more specific ‘psychosis areas’ in the human brain, which is quite unlikely in the foreseeable future, experiences will inevitably remain ‘the gold standard’, even though they are subjective. It will therefore be useful and clinically relevant to increase our level of precision and sophistication in the study of pre-psychotic and psychotic experiences, which in turn will strengthen diagnostics – or we might rather prefer to say: strengthen ‘the phenomenological characteristics’ of psychosis.

Experiences precede behaviour Behaviour obviously gives rise to experiences. But in the case of developing psychosis, the first significant changes are experiential, according to common sense as well as clinical experience, and behaviour is mainly affected afterwards, as also demonstrated in my own in-depth studies (Møller & Husby, 2000; Møller, 2001). A large body of prodromal research, in itself, testify this general, all-over order of events, even though exceptions may occur. Despite this fact, diagnostic criteria are

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to a large degree developed as behaviourally oriented, so that they can be understood and used in the same way internationally, and preferably independent of theorisation. This is again an example of the relative dangers of objectivisation in the quest to operationalise diagnoses. The five main diagnostic criteria (domains) in the case of psychotic disorders demonstrate this (APA, 2013). Disorganised thinking (speech), grossly disorganised or abnormal motor behaviour, and the socalled negative symptoms are three clearly observable behavioural criteria, to be observed and assessed from the outside. But also the two final criteria, delusions and hallucinations (which of course are experientially based phenomena), when further specified in the manual, are mostly operationalised in terms of behavioural descriptions. In DSM-5, delusions are defined as ‘fixed beliefs that are not amenable to change in light of conflictive evidence’. Hallucinations are defined as ‘perception-like experiences that occur without an external stimulus . . . vivid and clear, with the full force and impact of normal perceptions, not under voluntary control . . . usually experienced as voices, perceived as distinct from the individual’s own thoughts’. The clinical rating too, of these two last types of phenomena, in accordance with mainstream symptom scales, like PANSS (Kay et al., 1987), is based to a great extent on the behavioural expression of the symptoms. Usually it is a requirement that psychotic delusions must have clear behavioural expressions to qualify for a diagnosis, and correspondingly one talks about ‘hallucinatory behaviour’. Furthermore, the focus in the criteria is generally on what the person is convinced of or perceives, not on how this can happen or is at all possible, which in a sense takes the focus away from understanding the phenomenon. This is to say a flat, referential, and non-interpretive description, which is also difficult to relate to, empathetically. This last point has consequences from a treatment perspective: a psychotic phenomenon needs, to a certain extent, to be ‘understood’ by both the client and the clinician, in the same way as for example anxiety and depression, something which is necessary for the clinician to be able to develop and express empathy. Psychosis and schizophrenia occupy a unique position, in the sense that their symptoms are not immediately understandable as everyday phenomena, as is the case with anxiety and depression.

Mind and experience challenge science What is unique – and obvious – about the mind is that it is completely immaterial and abstract, and therefore almost necessarily transient, constantly changeable, and ‘fluid’. There are no clear boundaries between the various aspects of the mind, mental phenomena, or symptoms of illness, and consequently not between diagnoses or mental conditions. This is an obvious premise in mental health, which to a large extent affects both clinical work and research. There is no organ of anxiety, of depression, or of psychosis, in the way that many organ systems can be

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differentiated in somatic medicine. All mental disorders have their seat in the same organ, the brain, which is thought to consists of around 100–200 billion nerve cells (however, most original articles have no references cited, see Herculano-Houzel, 2009), each nerve cell with tens of thousands of connections, organised in an overwhelmingly complex system of interconnections. This has far-reaching consequences for professional work in mental health, in assessment, treatment, and research. Both the acquisition of new knowledge (research) and the application of knowledge (clinical work and development) are characterised by this: mental events and phenomena are invisible and cannot be weighed, measured, or pictured in a precise way. This challenge is impossible for this scientific field to escape from. It needs to be met with constant innovation in methods and approach. In natural science research, one might get the impression that scientists often conceive the field of mental health as ‘too soft’, that is, without a sufficiently solid scientific foundation. These views are understandable but bear witness to a lack of recognition that the field has an intrinsic and unavoidable uniqueness, which challenges us to constantly develop our research methods. An interesting example of a recent innovation that allows us to delve at least a bit deeper into the mind as a ‘research object’ is smartphone-based app technology, with possibilities for continuous, intensive, and real-time monitoring of experiential qualities, for example through the Experience Sampling Method (ESM) (Palmier-Claus et al., 2012; Nelson et al., 2017; Dao et al., 2021). The method can be applied in several ways. In a research project in the specific field of basic self-disturbances (see Baklund et al., 2023), we first involved clients in full EASE interviews. Then the clients themselves selected what they considered the three most significant experiences of anomalous self-experience (ASE) (one such might be: ‘I doubt whether I really exist’). These three core experiences were loaded onto the specialised app that the participant had installed on their smartphone. The app notifies with multiple push notification at random points during the day/week/month that the ASE variants in question should be evaluated here and now, for example in terms of presence, intensity, and interference. In addition, the person can also in a quick and easy way register the social setting they are in at the time of registration (e.g. school, visiting someone, and training session) and which general feelings s/he has (sad, happy, irritated, unsure, etc.). Tasks like these are finished in only a few minutes and are completed by pressing ‘send’; thereafter, they are sent to a secure database for analysis. For example, ten registrations a day can be completed for a week, alternatively once a week for half a year. In this way, one can more precisely evaluate the stability of personal experiences over time, and correspondingly their significance for diagnostics and course of treatment. When using standard psychometric questionnaires, however, registration is usually completed retrospectively, for example symptoms that have arisen during the last weeks or months. Innovations such as these can be useful for improving the validity of diagnostic criteria, strengthening the validity and reliability of symptom measurements, and improving the understanding of the relationship between subjective and objective phenomena.

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Experience is at the centre of all therapy Innovative possibilities like this, for the improved study of experiences, will also have consequences for aspects of therapeutic work. If the therapeutic conversation early in the course of assessment and treatment aims at exploring and recognising distorted experiences, the conversation becomes more human, relevant, vital, and authentic. One is then talking about ‘the things themselves’ (die Sache selbst), as the founder of phenomenology Edmund Husserl (1859–1938) himself put it, that is, about what is a subjective and individually genuine lived experience (Logische Untersuchungen, 1901). The anomalous self-experiences seen during the development of psychosis should in other words occupy a central position in assessment and treatment. Psychotherapy research gives good reasons to believe that the personal acknowledgement of such powerful subjective states, through listening, responsiveness, and empathy, may benefit therapy (Watson et al., 2014; Hatcher, 2015), and exert a consolidating effect on the unstable and fragmented self: ‘You are in front of me, I look at you, what you are telling me is of immense importance’. (In other words: ‘You are real.’). Along the same lines, helping the main person to put into words and thus understand these phenomena can help towards positively ‘externalising’, and making accessible something which seemed to be internal and almost inaccessible (Møller & Husby, 2000; Sass & Parnas, 2003; Parnas et al., 2005). The person can in a sense experience to ‘lift out’ the phenomenon from the mind and make it more of an ‘object’ of direct conversational investigation, a phenomenon which can be sorted out, classified, labelled, and familiarised – and thus positively affected. When pre-psychotic phenomena in this way receive a name, a context, and a meaning, they become more available for conscious processing and influence, and moreover, less frightening. Finally, the fact that it is the person’s own words and phrases which are the foundation of the therapeutic cooperation and common understanding, and not the distancing terms of symptoms and diagnostic criteria, is a potentially powerful source of therapeutic alliance. The experiences are not being examined for their truthfulness, but their interpretation and understanding can be sheared, discussed, and adjusted.

References American Psychiatric Association. (2000). DSM-IV-TR: Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: American Psychiatric Association. American Psychiatric Association. (2013). DSM-5: Diagnostic and statistical manual of mental disorders (4th ed.). Arlington: American Psychiatric Association. Baklund, L., Røssberg, J.I., & Møller, P. (2023). Linguistic markers and basic selfdisturbances among adolescents at risk of psychosis. A qualitative study. EClinicalMedicine, 55, 101733. Box, G.E.P. (1976). Science and statistics. Journal of the American Statistical Association, 71(356), 791–799.

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Dao, K.P., De Cocker, K., Tong, H.L., Kocaballi, A.B., Chow, C., & Laranjo, L. (2021). Smartphone-delivered ecological momentary interventions based on ecological momentary assessments to promote health behaviors: Systematic review and adapted checklist for reporting ecological momentary assessment and intervention studies. JMIR mHealth and uHealth, 9(11), e22890. De Kock, L. (2020). ‘I think’ (the thoughts of others). The German tradition of apperceptionism and the intellectual history of schizophrenia. History of Psychiatry, 31(4), 387–404. Feyaerts, J., Kusters, W., Van Duppen, Z., Vanheule, S., Myin-Germeys, I., & Sass, L. (2021). Uncovering the realities of delusional experience in schizophrenia: A qualitative phenomenological study. Lancet Psychiatry, 8, 784–796. Hatcher, R.L. (2015). Interpersonal competencies: Responsiveness, technique, and training in psychotherapy. American Psychologist, 70(8), 747. Herculano-Houzel, S. (2009). The human brain in numbers: A linearly scaled-up primate brain. Frontiers in Human Neuroscience, 3, 31. Husserl, E. (1900–1901). Logische Untersuchungen II/2. New York: Routledge & Kegan Paul Ltd Kay, S.R., Fiszbein, A., & Opler, L.A. (1987). The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. Møller, P. (2001). Duration of untreated psychosis: Are we ignoring the mode of initial development? Psychopathology, 34(1), 8–14. Møller, P., & Husby, R. (2000). The initial prodrome in schizophrenia: Searching for naturalistic core dimensions of experience and behavior. Schizophrenia Bulletin, 26(1), 217–232. Moskowitz, A.,  & Heim, G. (2011). Eugen Bleuler’s dementia praecox or the group of schizophrenias (1911): A  centenary appreciation and reconsideration. Schizophrenia Bulletin, 37(3), 471–479. Nelson, B., McGorry, P.D., Wichers, M., Wigman, J.T., & Hartmann, J.A. (2017). Moving from static to dynamic models of the onset of mental disorder: A review. JAMA Psychiatry, 74(5), 528–534. Nelson, B., Yung, A.R., Bechdolf, A., & McGorry, P.D. (2008). The phenomenological critique and self-disturbance: Implications for ultra-high risk (“prodrome”) research. Schizophrenia Bulletin, 34(2), 381–392. Palmier‐Claus, J.E., Taylor, P.J., Gooding, P., Dunn, G., & Lewis, S.W. (2012). Affective variability predicts suicidal ideation in individuals at ultra‐high risk of developing psychosis: An experience sampling study. British Journal of Clinical Psychology, 51(1), 72–83. Parnas, J., Møller, P., Kircher, T., Thalbitzer, J., Jansson, L., Handest, P., & Zahavi, D. (2005). EASE: Examination of anomalous self-experience. Psychopathology, 38(5), 236. Parnas, J., Sass, L.A., & Zahavi, D. (2008). Recent developments in philosophy of psychopathology. Current Opinion in Psychiatry, 21(6), 578–584. Saks, Elyn R. (2007). The center cannot hold. A memoir of my schizophrenia. Boston, MA: Little Brown Book Group. ISBN 9781844081677. Sartre, J.P. (1970). Intentionality: A fundamental idea of Husserl’s phenomenology. Journal of the British Society for Phenomenology, 1(2), 4–5. Sass, L.A., & Parnas, J. (2003). Schizophrenia, consciousness, and the self. Schizophrenia Bulletin, 29(3), 427–444.

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Watson, J.C., Steckley, P.L., & McMullen, E.J. (2014). The role of empathy in promoting change. Psychotherapy Research, 24(3), 286–298. World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines (Vol. 1). Geneva: World Health Organization. Zahavi, D. (2008). Subjectivity and selfhood: Investigating the first-person perspective. Cambridge, MA: Bradford Books, and MIT Press. Zahavi, D. (2018). Phenomenology the basics. New York: Routledge.

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Figure 2 Young boy (standing in the background) scrutinises an ordinary chair (in the foreground) with a flat and distant gaze.

2 TO U N D E R S TA N D I S A UNIVERSAL HUMAN NEED

To understand is a deeply fundamental need of human beings. But what does understanding psychosis involve? What does it really mean ‘to understand psychosis’? What, precisely, is it that we want to understand? This is not something immediately obvious. When it comes to the main person – the person suffering from psychosis – it is natural to assume that it is the altered experiences of psychosis itself, those s/he must live with day in and day out, that first and foremost must be understood. The present chapter outlines some of the background exactly for this, the innate drive of humans to understand, and why this drive plays a very central role in the developmental process towards psychosis.

To understand is a basic human instinct ‘The noblest pleasure is the joy of understanding’, claimed the universal genius and renaissance scholar Leonardo da Vinci (1452–1519) (Bawden, 2021). He studied both the human body and the physical world, searching for fundamental laws governing the universe, over 500 years ago. ‘The desire to understand is as important as the need for safety’, writes the modern-day Norwegian novelist Karl Ove Knausgård in his book Spring (Knausgård, 2017) (in Norwegian). He was thinking of the desire to know and understand the forces underlying our feelings and actions. ‘The Nobel Prize is just a bonus, what drives us is understanding things we thought we couldn’t understand. Research is driven by the need to understand’, said the Norwegian Nobel Prize winners (2014) May-Britt and Edvard Moser when they explained how brain cells control the paths of memory in our brains (Lømo, 2014) (in Norwegian). ‘We are by nature scientists’, said the cosmologist, theoretical physicist, and genius Stephen Hawking (1942–2018) in one of his famous YouTube lectures (Hawking, 2007). DOI: 10.4324/9781003127895-3

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None of these scientists was thinking specifically of psychosis or schizophrenia, but these assertions apply to the same basic aspect of human nature, the need and desire, indeed almost the psychological drive or instinct, to understand, distinguish, sort, and categorise. Everything needs to be meaningful; otherwise, there is chaos. On a superficial and day-to-day level, we are all very different in our preference or need for order, understanding, and categorisation, but in the present context, we are addressing a much deeper level than this. We are discussing the fundamental conditions that make our existence in the world coherent and meaningful. This intrinsic need to understand is not something we make a conscious decision about, on a more surface level, such as when writers, artists, or scientists carry out their work. The need lies in our nature, in the very way consciousness is constructed: Human consciousness is the seat of all understanding. It has some basic ways of functioning, what might be referred to as a type of mental infrastructure, or architecture, providing its contents with a form, direction, and purpose (intentionality; Husserl, 1901). One of these functions is precisely the automatic, spontaneous, and constant search for meaning, or understanding, of all that is happening, within us and around us. Experiences constantly streaming through our consciousness are given, moreover must be given, meaning, as a failure to do so creates confusion. New, surprising, and confusing events are always given highest priority in our consciousness, which attempts to place them in a meaningful whole so that they can be understood.

Meaning, coping, and relationships The nature of consciousness is to seek meaning The two following sections refer much to qualitative client reports from the two Scandinavian phenomenologically inspired in-depth studies that initially triggered the reappearance and revival of the notion of disordered selfhood in schizophrenia, only two decades ago (Nordgaard et al, 2021; Parnas et al., 1998; Paras & Handest, 2003; Møller & Husby, 2000; Møller, 2000a; 2000b; 2001). Subsequently, we also made some unique clinical experiences from the application of these findings in a phenomenologically based psychosis assessment unit, investigating around 120 clients through eight years (see Chapter 15). Consciousness in psychosis must be understood in terms of the basic nature of normal consciousness. The endeavour to explore and understand more of psychotic consciousness has been deepened by studying classical texts on schizophrenia written by phenomenological psychiatrists, such as Eugene Minkowski and Wolfgang Blankeburg (see Nordgaard et al., 2021), who refer to the core feature as a profound disruption of the basic subject–world relationship. It has proved necessary to turn to phenomenological philosophy when investigating selfhood, subjectivity, and consciousness in schizophrenia (Zahavi & Parnas, 1998), to also enable clinicians to examine the inner world of afflicted individuals in a meaningful way. The very idea of basic self-disturbances in psychosis presented in this book leans fundamentally on phenomenological psychiatry and philosophy. 24

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To reiterate, consciousness is constantly and automatically searching for meaning, a process we do not need to actively initiate. Every person, or specifically every person’s consciousness, searches constantly for meaning and understanding, inside and outside of themselves. Every life-event must be understood. These then need to be stored, if they are not already stored, in our complete mental archive, something which gives human existence a constantly expanding foundation. Indeed, it might be seen as a characteristic of what it means to be conscious (Zahavi, 2018). The opposite of finding meaning is to be fundamentally unsure, confused, and unsafe, in the long term a highly destructive human state. Consciousness therefore prepares us to experience coherence and meaning in everything we are and do, a process running quietly in the background, seamlessly and continuously. On an interesting side-track, the Israeli-American sociologist Aaron Antonovsky (1923–1994) studied women who had survived concentration camps in the Second World War, identifying the psychological factors associated with survival. The wellrecognised findings from this study were that comprehensibility, manageability, and meaningfulness were decisive factors that gave people an energising ‘sense of coherence’ associated with positive health outcomes (Antonovsky, 1987). Later, in more generalised frames, he developed (several versions of) the sense-of-coherence (SOC) rating scale (Antonovsky, 1993) that have been validated for use in many different clinical and non-clinical settings. In other words, the inner sense of coherence (finding meaning) described determines the ability to give life direction, see ahead, and mobilise resources, which all seem intuitively related to a sound sense of self. Put differently, experiences that we can understand give us meaning. Next, to experience this meaning makes coping seem possible, and finally, the feeling of being able to cope (capable) can provide hope (and thus make survival more likely). All those are quite obvious and self-evident. The importance of understanding is that it, through the experience of meaning, may provide hope to surmount an otherwise overwhelming stream of experiences and challenges, not only in day-to-day existence but also when major life challenges occur. Not that everything will be coped with, but that there is a possibility which one can imagine and aim for. That is, everything we see, hear, feel, or think come to us in such a way that we can see a possibility of meeting and dealing with these experiences. The basic structure and function of our consciousness, therefore, is intrinsically both solution oriented and coping oriented. We do not always find solutions, but we can look for them in ways that we can deal with. The breakdown of relationships is observed first Though not conclusively researched in adults, it is widely held, in general, that good relationships with others are important sources of life quality and positive mental health (see Waters & Cummings, 2000). However, to establish and maintain good relationships is demanding, for all of us. This too needs to be coped with, and coping depends on our experiences of relationships being ‘intact’ and meaningful in their basic nature. Meetings between people are full of events that need to be interpreted and understood. If a person’s basic, general, pre-reflective 25

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way of experiencing is fundamentally distorted, as reported by persons in the prodromal phase of psychosis (Yung et al., 1996a; Møller & Husby, 2000), this basic change will of course quickly affect that person’s relationships. A major challenge in the treatment of psychosis is precisely that the decline in coping with relationships is so marked (Møller & Husby, 2000; Møller, 2001), and especially difficult for the main person to understand or to talk about (ineffability; not suited for verbal expression) (Sass & Parnas, 2003; Parnas & Handest, 2003). Because it is so difficult (and shameful) to express pre-psychotic and initial psychotic experiences verbally, a tense and destructive barrier to communication quickly arises, also within the family (Møller &Husby, 2000). Parents, siblings, and other persons close to the main person of course find it stressful and confusing not being able to understand the ongoing developments. As a result, a vicious circle may easily arise, where a conflict-laden and frustrating climate in the family can affect and worsen the main person’s emotional state and functioning, which for natural reasons in turn may increase the family’s stress. The result is a well-known (but also later critiqued) phenomenon from the research on schizophrenia in the 1970s and 1980s: the ‘expressed-emotions’ tradition (Vaughn & Leff, 1976). The main observation was that negative feelings internal to the family may have a negative impact on the state of the person with psychosis (and certain other disorders), and the course of the illness (Cechnicki et al., 2013; Wearden et al., 2000). These negatively expressed emotions most often arise from those who are most involved: parents, siblings, and the person experiencing psychosis him-/herself. It is therefore a therapeutic challenge to direct attention and effort systematically at reducing these negative spirals. In this approach, systematic psychoeducational family interventions (learning about and coping with mental illness) are a major treatment form in the overall treatment landscape (McFarlane, 2016). In recent years, such treatment, which includes teaching, information, and training for patients and families, has become a highly accredited treatment measure in international guidelines in this field (Kuipers, 2014; Galletly, 2016; Rodolico et al., 2022). To not offer family psychoeducation in schizophrenia and psychosis is now widely considered as professional misjudgement.

Stages in the early development of psychosis Understanding, meaning, coping, and relationships are four decisive and successive anchoring points in all healthy mental functioning. This also applies when we try to understand the development of psychosis. If we start with the final element in this sequence of events, then the stages of early psychosis development can be simplified as follows: the impairment of relationships derives from the impairment of coping, which in turn derives from the impairment of meaning formation, which, at the outset, derives from the impairment of basic self-understanding.

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The first thing, during psychosis development, that becomes outwardly visible is thus the impairment of relationships, most noticeably close relationships, but this failure is in fact the result of a lengthy, inner, and hidden subjective development, going right back to an impaired and disturbed self-experience and selfunderstanding. This impairment of relationships is painful and frustrating for the entire family, and to a large extent it is due to something incomprehensible and nameless, even for the main person. This unique form of relationship impairment is in turn an expression of a more ‘global’ breakdown in the capacity to understand oneself and to find meaning in daily interpersonal communication. Due to this fundamental breakdown of coping, relationships suffer immediately. This failure is due in turn to an even deeper disturbance of the structure or form of ordinary daily experiences and therefore their comprehensibility and meaningfulness. What is meant by a disturbance of the structure and form of common experiences will be discussed in the following.

What does it mean ‘to understand psychosis’? The understanding of psychosis is an undertaking with many possible interpretations: some shared by professionals, some by lay persons, and some by the very persons living through psychosis. Most types of researchers in the field of psychosis will assert that they strive to increase understanding too, when they study and analyse genetics, blood tests, medication, neo-natal medicine, effects of trauma and stress, infant development, environment, and life quality. In the same way, clinicians using various treatment approaches try to help their clients’ understanding of his or her mental disorder. Most people in the general population, however, know very little about psychosis and schizophrenia, so that almost any available information will be helpful towards understanding these disorders. For the person suffering from a psychotic disorder, the question of understanding becomes more acute. Comprehending the incomprehensible, the psychotic experiences themselves, is an almost overwhelming necessity. The background to their questions, when approaching health services seeking help, is the daily, personal experiences interfering with their lives and reducing their quality of life. Psychotic experiences are regularly confusing and painful; they can overwhelm and almost bring life to a standstill (Saks, 2007). When such experiences are continuously present in a person’s life, they are both powerfully salient and all-encompassing. In these circumstances, the experiences control the individual rather than the other way around. Understanding helps to transform something internal, hidden, and frightening into something accessible, more open, and less dangerous. The internal phenomena become in a sense ‘lifted out of the mind’, available for sharing,

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sorting, and naming and in that way creating a calming distance towards them. When psychosis phenomena are designated and placed in a framework that gives new meaning, they are more available for psychotherapy, for sharing, processing, and working with. Possibilities are thus created for treatment directed specifically at the devastating experiential phenomena. The two in-depth empirical studies mentioned earlier, and several other reports (see Stanghellini & Fusar-Poli, 2012; Parnas & Henriksen, 2016), as well as clinical experience, have learned us that many clients have desperate difficulties to express verbally their need for help with something so unusual and peculiar as alienation, feelings of unreality, and a fragmentation of meaning. Equally challenging, or worse, was not being believed when they told of hearing voices, psychotic delusions, and other similar phenomena. And contrastingly, they have told of the sense of relief when they were finally taken seriously, at their word, almost literally, when they related their ‘incomprehensible’ experiences and received help to find words and ideas to conceive the inconceivable. Words and language are decisive tools in the struggle with psychological pain, for therapists and for clients. This partial sense of release too, by putting words to troublesome, frightening, and seemingly ineffable feelings, is a recurring therapeutic experience. This is perhaps particularly relevant in the field of psychosis, where the paucity of words often is so marked.

The Subjectivity Model (or Ipseity Disturbance Model) The purpose of this book is to present the model of understanding the phenomenology of psychosis, and, as a crucial part of this, the understanding of the early developmental phases of psychosis, based on disturbed subjectivity and altered self-experience – the Subjectivity Model. The model and its related concepts are intended to be neither exhaustive nor ‘correct’, because by necessity, they represent a single limited approach, a sample of certain perspectives in a greater picture, albeit important ones not provided elsewhere. Though neither exhaustive nor ‘correct’, the model has nevertheless proved to be usable and useful in clinical practice (see Chapter 17) and offers an illuminating and expanded understanding, on levels different from the standard approaches. In principle, the model is compatible with all other existing models, and it is supported by recent developments in clinical and cognitive neuroscience and the study of consciousness (e.g. on self-consciousness and sense of agency) (see Lou, 2012; Ebisch & Gallese, 2015). What is subjectivity? As stated, the very idea of basic self-disturbances in psychosis leans on both classical and contemporary phenomenological psychiatry and philosophy. The core 28

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concept of the model presented in this book is subjectivity, which is discussed in greater detail in the remaining chapters of the book (particularly Chapter 7), but which I will briefly present already here. The concept of subjectivity can have several meanings and apply to several scientific disciplines. In this book, however, one specification of the concept is highly important: in the present context, we are not talking about being a subject in the usual sense of the word, that is, being autonomous, independent, etc. What we are referring to here is what it specifically means to experience oneself as a subject (self-experience), and what aspects of our consciousness are pre-conditions for this experience (Zahavi & Parnas, 1998; Zahavi, 2008, 2018). Subjectivity is a supporting ‘structural component’ of human consciousness which is configured and developed throughout the lifespan, and which supports the most fundamental aspects of a person’s sense of identity. Identity means ‘the same’, in this sense being the same as myself, which results in an experience of being myself. Subjectivity thus represents the many interacting and complex mechanisms of the mind, which results in us feeling like unique individuals, being only like ourselves: ‘I am myself’. Subjectivity probably represents the deepest aspect of consciousness that can be reached in dialogue, somewhat indirectly, using clinical methods. Still, it is by nature implicit and ‘silent’, being an in-built part of every experience, all of which have a content and a form. This form, or structure, is a way or mode (modus) in which the relevant experience manifests itself for me, namely as mine. This experience of mineness is seen as provided by subjectivity. These and other aspects of subjectivity will be explored more deeply later. What is a model? As the main theme of this book is to propose a model of understanding, it is appropriate to pause and consider what a model is and, equally importantly, what it cannot be. A model is a simplified representation of something, typically a physical entity or a person, also possibly of a suggested structure, a system, or related events. The scientific field which perhaps more than any other has developed models that can represent the relationships between events and the laws found in nature is the field of statistics. A popular professor of statistics, George Box, is the originator of an often-quoted aphorism concerning the limitations and potentials of models, which he summarises in this way: ‘All models are wrong, but some are useful’. This aphorism was first quoted in an article in the Journal of the American Statistical Association (Box, 1976). Here are some of his reflections on the theme:

All models are wrong, but some are useful Since all models are wrong, the scientist cannot obtain a ‘correct’ one, by excessive elaboration. On the contrary, he should seek an economical

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description of natural phenomena. Just as the ability to devise simple but evocative models is the signature of the great scientist, so overelaboration and over-parameterisation are often the mark of mediocrity. It would be very remarkable if any system existing in the real world could be exactly represented by any simple model. However, cunningly chosen parsimonious models often do provide remarkably useful approximations. For such a model, there is no need to ask the question ‘Is the model true?’ If truth is to be the whole truth, the answer must be no. The only question of interest is: ‘Is the model illuminating and useful?’ As all models are wrong, the practical question is: How wrong do they have to be to not be useful? The most that can be expected from any model is that it can supply a useful approximation to reality (George E.P. Box, 1976–1978).

Aspects of the Subjectivity Model With these wise words concerning the limitations of models in mind, the Subjectivity Model will be presented. It is meant to represent a limited but illuminating aspect of the complex mechanisms in the development of psychosis phenomena. The presentation of the model is built up throughout the course of the entire book. Several aspects of the model will be specifically and more deeply addressed several times, to make the picture gradually become clearer. Specific chapters therefore present and discuss the different aspects of the model, briefly summarised thus: (1) what are the primary sources of knowledge; (2) what is understanding taken to mean in the present context; (3) on the prodromal phase (wherein the phenomena can best be studied); (4) the different conceptions of the prodromal phase in different academic traditions; (5) the significance of scientific culture for our understanding; (6) the contents of the key concepts of the self and subjectivity; (7) a discussion of the concept of psychosis treatment; (8) the unique possibilities of the conversation, and (9) how the model can result in treatment measures specifically aimed at basic self-disturbances. Each of these aspects shed explanatory light on each other and on the entire picture, and many years of teaching have told me that the aspects should be presented from different angles in order to capture gradually more of the holistic nature of the model. I wish to start with a three-step ‘conceptual ladder’, containing three supporting concepts that represent developmental ‘stages’, which are didactically useful in drawing a basic, simplified, and reductionist (but useful) outline of prodromal and psychosis phenomena. The three concepts are self-experience, self-understanding, and self-disturbance. It should be emphasised that the experiential phenomena we are discussing here are possible, not definite, prodromal phenomena for psychosis. As mentioned earlier, psychotic illness does not necessarily follow a (presumed) prodromal phase. And some of the prodromal phenomena are also present 30

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in other conditions. In other words, A can lead to B, but not necessarily, and A can lead to C or D, or to nothing at all. This will be further discussed. Self-experience: a spontaneous, non-thematic basic experience of the self Self-experience (sense of self) is our immediate, spontaneous, holistic, non-thematic experience of ourselves at any given moment, here and now. In principle, it is not governed by the will or by conscious thought, but is a passive, ‘unrefined’, and global basic awareness of our inner core: the self (self-awareness, sense of self, self-experience). A person’s self-experience is impossible to describe exhaustively; its scope is endlessly wide-ranging, almost infinitely complex. It is a kind of continuous sensing of the self, a background process that can perhaps be compared with the new-born child’s naïve impressions of itself and the outer world, before momentary experiences are generalised into complex experiences, and these experiences in the long run manifest as growing psychological forms and structures. Self-experience is in this sense the sum of all sensations and awareness taking place in ourselves. Though by nature implicit and automatic, we can become aware of it to some extent by closing ourselves off to the world and turning our attention freely and openly inwards. In a way, self-experience is at one and the same time both everything and nothing: everything, because it implies an all-encompassing and unbounded attentiveness towards the entire scope of our consciousness, and nothing, because it is unspecific and non-thematic in nature and essentially has no ‘content’ other than that we are aware of ourselves and our existence. Evidently, the state of self-experience is intuitively difficult to grasp, but it is still important to be aware of. It is decisive for our overarching understanding of psychosis because alteration of self-experience reflects part of the basis of the development of prodromal phenomena, and the eventual psychotic phenomena which (may) follow. Self-understanding: a conscious and deliberate attribution of meaning Self-understanding can be regarded as a parallel-running and continuous further development of self-experience. It involves a personal, rational, cognitive processing and understanding (providing meaning; cognitive attribution), as a part of mental development and growth. Through the lifespan, our ‘dynamic’ selfexperience is constantly being assigned with meaning and significance which is personal and private. Put simply and schematically: ‘I feel in this particular way (that is, self-experience), and I understand this as an expression of this particular quality (that is, self-understanding)’. In this way, our life events begin to tie together over time and acquire an intrinsic meaning and logic. They become predictable, reassuring and gradually forming our identity. New experiences are constantly arriving, becoming part of a constantly changing (still non-thematic) 31

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self-experience, creating in turn a new basis for a self-understanding in seamless constant development. This is a process whereby our dynamic, spontaneous self-experience is constantly assimilating new life events and experiences which become concrete themes in our conscious lives. The resulting self-understanding will consist of the sum of all relevant meanings and wishes; the order, structure, and direction in our lives; our relationships, positions, roles, and possibilities – in other words, everything about the individual. In this way, self-understanding constitutes a large part of our total conscious, cognitive, and emotional sense of identity. Self-understanding and our sense of identity are closely related core phenomena in this phenomenological model. We are referring to how a narrative identity is built throughout the lifespan. Theme after theme, aspect after aspect are accumulated in our self-understanding. Everything is tied to the self, as ours, i.e., it becomes a part of the self. These are psycho-physical (integrated mental and bodily) fundamental processes which establish and develop a feeling of ownership of everything we experience. It is also how our sense of having a core is constituted, in that everything that is tied to the self feels to be centred on an ‘existential centre of gravity’. It is this feeling of having a reassuring core, that for many persons diagnosed with schizophrenia is reported to be significantly twisted, or impaired (The centre cannot hold; Saks, 2007). Along the same line, they can also experience that it is impossible to understand what it means to have a core, due to the previously mentioned ineffability. Admittedly, it is not possible for anyone to really ‘understand’ what it means to have a core, but we normally have an intuitive understanding of what this means. When asked ‘Do you feel like you have a central core?’, most people would spontaneously reply affirmatively, though explaining further what this means would probably be difficult to elaborate upon. Self-disturbance: a search for an alternative (inappropriate) self-understanding As stated, the model presented rests upon the phenomenon which phenomenology and consciousness research call subjectivity (Zahavi, 2018). This structural part of our consciousness is responsible for the so-called first-personal perspective, in other words, the basis of the experience of being a subject, to feel like a singular, stable, and recognisable centre of one’s own life. If and when this subjectivity is affected by a disturbance/weakening/distortion, whatever the cause, this will immediately make an impression on our natural, spontaneous, non-thematic self-experience (step 1). Initially, this takes the form of a vague and almost imperceptible feeling of alienation and unreality, an almost dreamlike feeling. This feeling can apply to myself as a person, what I see, hear, and touch around me, bodily perceptions, or other types of experiences. This is a critical and decisive point in the mental development that may follow on to psychotic experiences. This feeling of being vaguely alienated, unreal, distant, strange, closed off, or ‘mechanical’ results quite quickly in consciousness searching for alternative 32

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meaning and understanding (step 2) of the new condition, of myself. Here, the basic principle of human consciousness comes into play: that it constantly searches for meaning, by its very nature. To understand oneself and one’s situation is developmentally necessary for survival. Several client stories describe how this confusion can rapidly become very destructive if no new form of understanding is developed. This understanding might well be irrational, but nevertheless can represent a point of anchorage that limits the confusion. In summary, the dynamics of this process can be understood as follows: when subjectivity is disturbed, self-experience is affected first, then self-understanding, then in turn various forms of self-disturbances can gradually develop, which represent potent phenomena that may become a part of the development of psychosis. These new ideas and assumptions that the individual develops about him-/herself are initially far from convictions, but rather shaky and vague beliefs or so-called ‘as if’ phenomena. They are often expressed with words, such as ‘I wonder if’, ‘It feels like’, or ‘It’s as if’. In clinical assessment, it is important to note these formulations (and take notes) as accurately as possible, as a guide to judging just how much influence and control the experience has on the person. It is here we find the division between psychotic and non-psychotic: the division between (mainly) stable conviction and an unstable ‘as if’. From self-disturbance to psychosis Attributions, or the meaning the experience acquires for the individual and that constitutes the core of self-disturbances, may over time consolidate and increase in intensity and personal conviction. They can thereby acquire a degree of psychosis if they remain irrational and are increasingly rigid. It is these negative processes which need to be detected as early as possible in treatment, in that way opening for constructive and corrective therapeutic processes. But we must again remember that some individual variations of certain self-disturbances may also be present in other forms of mental disorder, such as dissociation, panic disorders, major depression, and severe personality disorders, but the surrounding context is usually clarifying as to which condition is present.

References Antonovsky, A. (1987). Unraveling the mystery of health: How people manage stress and stay well. Washington, DC: Jossey-Bass. Antonovsky, A. (1993). The structure and properties of the sense of coherence scale. Social Science & Medicine, 36(6), 725–733. Bawden, D. (2021). The noblest pleasure: Theories of understanding in the information sciences. In Theory development in the information sciences (pp.  283–299). Austin: University of Texas Press. Box, G.E.P. (1976). Science and statistics. Journal of the American Statistical Association, 71(356), 791–799.

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Cechnicki, A., Bielańska, A., Hanuszkiewicz, I., & Daren, A. (2013). The predictive validity of expressed emotions (EE) in schizophrenia. A 20-year prospective study. Journal of Psychiatric Research, 47(2), 208–214. Ebisch, S.J., & Gallese, V. (2015). A neuroscientific perspective on the nature of altered self-other relationships in schizophrenia. Journal of Consciousness Studies, 22(1–2), 220–240. Galletly, C., Castle, D., Dark, F., Humberstone, V., Jablensky, A., Killackey, E., . . . & Tran, N. (2016). Royal Australian and New Zealand college of psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Australian & New Zealand Journal of Psychiatry, 50(5), 410–472. Hawking, S.W. (2007, March 13). Hawking discusses the origin of the universe (Oppenheimer Lecture). UC Berkeley. YouTube. Husserl, E. (1900–1901). Logische Untersuchungen II/2. New York: Routledge & Kegan Paul Ltd. Knausgård, K.O. (2017). Om våren. Oslo: Oktober Forlag. Kuipers, E., Yesufu-Udechuku, A., Taylor, C., & Kendall, T. (2014). Management of psychosis and schizophrenia in adults: Summary of updated NICE guidance. BMJ, 348. Lømo, T. (2014). Nobelprisen i fysiologi eller medisin 2014 (Nobel Prize in Physiology or Medicine 2014). Tidsskrift for Den norske legeforening, 134, 2232. Lou, H.C. (2012). Paradigm shift in consciousness research: The child’s self‐awareness and abnormalities in autism, ADHD and schizophrenia. Acta Paediatrica, 101(2), 112–119. McFarlane, W.R. (2016). Family interventions for schizophrenia and the psychoses: A review. Family Process, 55(3), 460–482. Møller, P. (2000a). The phenomenology of the Initial Prodrome and Untreated Psychosis in First-episode Schizophrenia: An Exploratory Naturalistic Case Study (Doctoral dissertation). Ullevaal University Hospital, University of Oslo and Diakonhjemmet Hospital, Oslo (National Library of Norway). www.nb.no/nbsok/nb/529751f97933a06b30ee14bd 4b710320?lang=no#0 Møller, P. (2000b). First-episode schizophrenia: Do grandiosity, disorganization, and acute initial development reduce duration of untreated psychosis? An exploratory naturalistic case study. Comprehensive Psychiatry, 41(3), 184–190. Møller, P. (2001). Duration of untreated psychosis: Are we ignoring the mode of initial development? Psychopathology, 34(1), 8–14. Møller, P., & Husby, R. (2000). The initial prodrome in schizophrenia: Searching for naturalistic core dimensions of experience and behavior. Schizophrenia Bulletin, 26(1), 217–232. Nordgaard, J., Henriksen, M.G., Jansson, L., Handest, P., Møller, P., Rasmussen, A.R., . . . & Parnas, J. (2021). Disordered selfhood in schizophrenia and the examination of anomalous self-experience: Accumulated evidence and experience. Psychopathology, 54(6), 275–281. Parnas, J., & Handest, P. (2003). Phenomenology of anomalous self-experience in early schizophrenia. Comprehensive Psychiatry, 44(2), 121–134. Parnas, J., & Henriksen, M.G. (2016). Mysticism and schizophrenia: A phenomenological exploration of the structure of consciousness in the schizophrenia spectrum disorders. Consciousness and Cognition, 43, 75–88. Parnas, J., Jansson, L., Sass, L.A., & Handest, P. (1998). Self-experience in the prodromal phases of schizophrenia: A  pilot study of first-admissions. Neurology Psychiatry and Brain Research, 6(2), 97–106.

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Rodolico, A., Bighelli, I., Avanzato, C., Concerto, C., Cutrufelli, P., Mineo, L., . . . & Leucht, S. (2022). Family interventions for relapse prevention in schizophrenia: A systematic review and network meta-analysis. The Lancet Psychiatry, 9(3), 211–221. Saks, E.R. (2007). The center cannot hold. A memoir of my schizophrenia. Boston, MA: Little Brown Book Group. Sass, L.A., & Parnas, J. (2003). Schizophrenia, consciousness, and the self. Schizophrenia Bulletin, 29(3), 427–444. Stanghellini, G., & Fusar-Poli, P. (2012). The vulnerability to schizophrenia mainstream research paradigms and phenomenological directions. Current Pharmaceutical Design, 18(4), 338–345. Vaughn, C.E., & Leff, J.P. (1976). The influence of family and social factors on the course of psychiatric illness: A comparison of schizophrenic and depressed neurotic patients. The British Journal of Psychiatry, 129(2), 125–137. Waters, E., & Cummings, E.M. (2000). A secure base from which to explore close relationships. Child Development, 71(1), 164–172. Wearden, A.J., Tarrier, N., Barrowclough, C., Zastowny, T.R., & Rahill, A.A. (2000). A review of expressed emotion research in health care. Clinical Psychology Review, 20(5), 633–666. Yung, A.R., & McGorry, P.D. (1996a). The initial prodrome in psychosis: Descriptive and qualitative aspects. Australian and New Zealand Journal of Psychiatry, 30(5), 587–599. Zahavi, D. (2008).  Subjectivity and selfhood: Investigating the first-person perspective. Cambridge, MA: Bradford Books, and MIT Press. Zahavi, D. (2018). Phenomenology the basics. New York: Routledge. Zahavi, D.,  & Parnas, J. (1998). Phenomenal consciousness and self-awareness: A phenomenological critique of representational theory. Journal of Consciousness Studies, 5(5–6), 687–705.

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Figure 3 A man’s torso, dressed in a dark t-shirt, the centre of his chest is stylistically marked as a round and lighter coloured field, intended to illustrate the person’s ‘core’.

3 THE PRODROMAL PHENOMENA ILLUMINATE THE CORE OF EXISTENCE – AIDING THE UNDERSTANDING OF PSYCHOSIS

This chapter and the next one highlight different facets of the initial prodrome of psychosis. The at-risk period – the prodromal phase – with its endless variations of altered experiences is the best starting point to understand the origins of the clinical phenomena characterising the early stages of psychosis, particularly schizophrenia. Most of the experiential features in the prodromal phase arise from a protracted and deeply disturbed experience of the self – one’s body, mind, and identity – and consequently a disturbed experience of the surrounding world. No psychotic phenomena seem to be exempted from this starting phase, which provides this scientific field and those who work in mental health service with a golden opportunity to gain an improved understanding and instigate earlier intervention.

The existential core experience of the prodrome: losing oneself Concepts like the self, self-awareness, and subjectivity are still slightly foreign in our common (conventional) understanding of psychosis and schizophrenia, but they are necessary if we are to understand, rather than just describe, the clinical phenomena in schizophrenia and in the prodromal phase. Over 100 years before the branch of psychology known as self psychology (Kohut & Wolf, 1978) took shape in the 1960s (Heinz Kohut, 1913–1981), Søren Kierkegaard, the founder of existentialism (1813–1855), wrote: The greatest hazard of all, losing the self, can occur very quietly in the world, as if it were nothing at all. No other loss can occur so quietly; any other loss – an arm, a leg, five dollars, a wife, etc. – is sure to be noticed. (The sickness unto death, 1849) DOI: 10.4324/9781003127895-4

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Kierkegaard explained the human self as a relation (i.e. the body–mind entity) which relates itself to itself (i.e. reflects about the relation). He specifies that it is not the relation (the body–mind entity) in itself, but the aspect of this relation that it reflects about itself which constitutes the self. Today, this rather complex description corresponds closely to the concept of self-awareness, and it is important to distinguish this from concepts such as self-confidence and self-esteem. Self-awareness refers to our awareness of, and our ability to reflect on, our own existence and our own self, which is the essence of being human. This highly developed ability to reflect on one’s own existence is regarded as a uniquely human quality, distinguishing us from all other living beings. Accordingly, one of the prodromal phase’s core experiences is typically expressed by many persons afflicted with schizophrenia or the prodome in this way: ‘I have lost myself’ or ‘I don’t know who I am’ (Møller & Husby, 2000, p. 222; Parnas et al., 2005, EASE item 2.1), representing a fundamentally impaired self-experience or self-awareness.

Subjectivity: a foundation stone of human existence – and of the prodrome Subjectivity has been described as a foundation stone of the human psyche, and therefore our existence (see Chapter 2; What is subjectivity?). Intact subjectivity is a constituent and essential part of all natural, ordinary human consciousness and experience. The scientific understanding of psychotic consciousness outlined in this book is linked to general theories of consciousness. The so-called problem of consciousness – how can objective, physical, neurophysiological processes give rise to a completely abstract, mental consciousness? – still constitutes one of the greatest challenges for modern science (Crick et al., 1995). It has also been called ‘the hard problem’ (Chalmers, 2007), which science has barely any real grip on understanding. Despite this, research on human consciousness has revealed some useful findings. Together with neuroscience, existential philosophy, phenomenology, and other disciplines, research on consciousness has once again, since the turn of the millennium, placed subjectivity as a phenomenon of consciousness on the scientific agenda (Zahavi, 2008), even behaviourists now recognise that subjectivity must be a part of any satisfactory theory of consciousness. In the 21st century, this has now become one of the central tenets in theories of consciousness. Various scientific, artistic, and cultural expressions over the past 150  years have referred to and described persons with schizophrenia. In a strikingly consistent way, it has been demonstrated that basic self-experience and self-awareness (sense of self) are often strongly and protractedly disturbed in these conditions (see Sass, 1992). Furthermore, these changes already seem to be evident in the preceding and often lengthy prodromal phase. But this prodromal disturbance of the normal way in which consciousness functions is not primarily manifested

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as ‘light’ versions of regular psychosis phenomena, but as non-psychotic characteristically altered ways of experiencing. Both phenomenologically oriented psychiatric research and research on consciousness highlight that subjectivity is a foundation stone of all human self-reflection and existential awareness (see Sass & Parnas, 2003); psychiatric phenomenology describes the experiential consequences of disturbed subjectivity, while research on consciousness discusses subjectivity mainly as a normal phenomenon (Zahavi & Parnas, 1998).

The prodromal phase: new clinical phenomena – new research directions The concepts ‘prodrome’ or ‘prodromal phase’ were in the early 2000s identified as ethically, clinically, and scientifically problematic, and many argued that these concepts should be discarded (see Nelson et  al., 2008). Prodrome means precursor: something is therefore expected to come afterwards – in this case a psychotic disorder. The concept of the prodrome, therefore, seems to imply a kind of ‘prediction’, without sufficient empirical evidence, we have namely not found prodromal symptoms which are truly specific for psychosis. Over time, different concepts have been launched regarding new terms for pre-psychotic risk states, for example the concepts of ‘at-risk mental state’ (Yung et al., 2005), ‘clinical high risk’ (CHR) (Addington et al., 2011), ‘ultra-high risk’ (UHR) (Yung & Nelson, 2013), and hypo-psychosis (Reading & Birchwood, 2005). No concepts of risk, however, can possibly be detached from the condition for which they constitute a risk. Furthermore, the concept of a prodrome for psychosis is well established in the literature and is unlikely to disappear anytime soon, though the limitations of the concept should always be clearly stated and kept in mind. In clinical assessment, it will be appropriate to talk of the prodrome and prodromal phenomena, psychosis risk, and risk phenomena where the development of psychosis is suspected and possible. The dilemmas connected to the prodrome are further underlined due to the current ambition to move the early detection endeavour to the area of child and adolescent services. At such an early age, at-risk mental states for psychosis, as well as for other mental states, must be interpreted with even greater caution: these can be associated with several possible developmental paths, not only towards psychosis (Ghazan-shahi et al., 2009). These phenomena will therefore in children and young persons often be more unstable and unspecific, and in many cases may disappear. In 1994, the fourth major revision of the American diagnostic manual (DSM-IV) was published (APA, 1994). Here, the list of prodromal phenomena in schizophrenia in the previous version (DSM-III-R, 1987) was removed due to uncertain empirical evidence. As a result, the landscape opened up for a new basic exploration of the prodromal phase, and this area of research took off internationally (McGlashan, 1998). A few years earlier, I had myself just started a doctoral research project on the prodromal phase. I was lucky to find myself

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among a relatively small, international group of researchers re-addressing this exciting field. Most researchers chose reiterative quantitative approaches, studying prodromal phenomena which had been described previously, usually as pale or weak versions of regular psychotic phenomena (Miller et al., 1999; Yung et al., 2005). For my study, I chose an in-depth, qualitative approach (Møller, 2000a). Two markedly diverging perspectives were taken by researchers on the prodromal phase from the year 2000 onwards. These are more closely addressed in the next chapter. Just shortly here: simply speaking, the main dividing line lies between (1) those assuming that prodromal phenomena and psychosis phenomena are highly similar in expression but different in intensity (Anglo-American tradition), and (2) those assuming that prodromal phenomena are qualitatively different from psychosis phenomena (European continental tradition). This marked division between two research traditions manifests itself as clear differences regarding which prodromal phenomena are seen to be most central and useful for early detection, how definitions should be termed, and in relation to the very way the dynamics and development of psychosis, and schizophrenia specifically, should be understood. This dichotomy, therefore, will be referred to and built upon in several chapters of this book. In 1995, I regarded a qualitative exploratory approach as the most expedient, when this research field was to be thoroughly re-addressed for the first time since 1958, a view in retrospect supported by a high and growing citation frequency (600 as per February 2023 in Google Scholar) of the study (Møller & Husby, 2000) (>600 as per March 2023 in Google Scholar). A comparable, concurrent, and fully independent qualitative study from Denmark, also inspired by the German Basic Symptoms concept, resulted in quite similar findings of prodromal phenomena (Parnas et al., 1998). These two Scandinavian studies sparked a new line of inquiry and the establishment of the Subjectivity Model (or Ipseity Disturbance Model) of understanding psychosis phenomena, based on altered self-experience and the phenomenological concept of subjectivity. Central to establishing the model was also the construction of the clinical check-list EASE (Examination of Anomalous Self-Experience) (Parnas et al., 2005), which is now available in 11 languages and which has led to an increasing wave of subsequent studies on self-disturbances internationally (see Nordgaard et al., 2021; Henriksen et a., 2021). What was new and different in the initial study mentioned, notably when it comes to the psychosis prodrome, was, quite simply, asking open-ended questions in this way: ‘How would you yourself – with your own words – describe the kinds of changes you experienced in the weeks, months and years before you were admitted to hospital for the first time (with a diagnosis of schizophrenia)?’ The experiential features that emerged were indeed dissimilar to (attenuated) classical psychotic phenomena, and were of a completely different nature to the phenomena associated with other common mental disorders, such as depression and anxiety. These truly unexpected answers to my questions completely changed my view of psychosis, and in particular schizophrenia.

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Core experiences emerged The surprising and extremely unusual experiential phenomena which emerged during the interviews were described by almost every person interviewed, independent of each other: a profound and deeply painful existential confusion, which developed well before the psychosis was manifest. They reported marked and pervasive changes in their own experience of themselves, of people around them, and of the world, and not least marked changes in their areas of interest.

Fully developed psychotic symptoms represent the end stages of a protracted development, whereas significant prodromal features precede, signal, and form the basis of these end-stage phenomena. Still, the prodromal phenomena had received strikingly little attention before the turn of the millennium. One of the most significant experiences from my research project on the prodrome (except the symptoms themselves) was that the in-depth conversations with participants constituted a unique and effective ‘instrument’ (the conversation as a microscope; see Møller, 2011), eventually leading the way to understanding more of the core phenomena and the underlying processes in the development of schizophrenia. This phenomenologically inspired form of conversation will therefore be the subject of Chapter 12 in this book.

The background for my in-depth study of the initial prodrome My first challenges as a doctor in psychiatry in the early 1980s were meeting clients with the most severe mental disorders, especially schizophrenia, bipolar disorder with psychosis, and severe personality disorders. Two things made a deep impression on me in these early years. Firstly, a deep fascination regarding the human mystery and challenge of schizophrenia. How was it possible for clients to be convinced about such strange, incomprehensible, and almost impossible beliefs about themselves and others? Furthermore, an equally deep frustration that there was no unified and agreed scientific understanding of the clinical phenomena of this elusive disorder, that is, the extremely unusual experiences recounted by these persons. It felt uncomfortable working professionally with such great human suffering without understanding much of the core phenomena. The treatment of those most severely affected consisted mainly of listening and containing – taking on board – their irrational beliefs, trying to ‘reality orientate’, as well as administering anti-psychotic medication, which had a limited effect and considerable side effects. There were practically no useful or illuminating descriptions of the underlying psychopathology of these conditions in textbooks, scientific journals, or among

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supervisors and experienced colleagues. How could it be that these psychotic phenomena manifested in precisely the way they did? The concept of schizophrenia was 100 years old; nevertheless, clinicians and scientists had still not agreed upon a common and universally recognised understanding of the central phenomena. This made a deep impression and woke my curiosity. After ten years working clinically, I therefore began my research work. Using a qualitative approach, I systematically studied the prodromal phase preceding the onset of psychosis in young people, just after their very first episode of a DSM-IV defined schizophrenia. The findings resulted in my radically different professional orientation to the field. After Conrad’s (1958) legendary three-phase model for the development of psychosis – Trema (confusion), Apophany (incorrect attribution), and Apocalypsis (full-blown psychotic break-down) – and up to the turn of the millennium, there were internationally no in-depth studies of the prodromal phase, without the use of pre-defined scales. Therefore, I  undertook a qualitative, explorative study (Møller, 2000b), at that time in fact without knowledge of the classical continental phenomenological tradition. The study describes naturalistic prodromal phenomena, in the sense that they were to be identified and described exactly as they occurred and were reported, without being forced into any kind of scientific framework or established concepts. The main findings (Table 1) turned out to directly confirm the classical literature. Furthermore, the two core dimensions we suggested were almost precisely the same as the two fundamental aspects of the later Ipesity Disturbance Model, and overlapping the disturbances of Table 1 Naturalistic core dimensions of initial prodromal experience and behaviour – from the Norwegian in-depth study (Møller & Husby, 2000). Eight naturalistic dimensions of prodromal experience * 1) Disturbance of perception of self (Anomalous SelfExperience)

* 2) Extreme preoccupation with and withdrawal to overvalued ideas (Hyper-reflection)

3) Neurotic-like disturbances

4) Disturbances of formal thought

5) Attenuated delusional ideas or perceptions

6) Disturbance of mental/inner control

7) Disturbance of simple perception

8) Secondary coping/ relieving responses

Four naturalistic dimensions of prodromal behaviour 1) Quit school, university or job, or major school truancy

2) Marked and lasting observable shifts of interests

3) Marked and lasting social passivity, withdrawal or isolation, or extreme social avoidance

4) Marked and lasting change in general global appearance/ behaviour

* The two prodromal types of experience suggested as tentative core dimensions.

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subjectivity that Parnas and his colleagues (1998) found in the concurrent, independent study in Denmark. The publication of this study became the starting point for me, of a fruitful collaboration with the world-leading phenomenologist and psychiatrist Josef Parnas’ research group at the University of Copenhagen and the Center for Subjectivity Research in Copenhagen. Over a five-year period, the cooperation resulted in the construction of the EASE manual, a checklist for the explicit and systematic study of self-disturbances (Parnas et al., 2005). The manual receives growing interest and is widely and increasingly used and cited internationally. These events also triggered the founding of the Subjectivity Model (or Ipseity Disturbance Model), as a new branch of the continental experientially oriented tradition. During the years we constructed the EASE, I realised to my surprise that classical texts existed, describing many of these phenomena (see Parnas, 2011), but mostly written in German or French. This literature was at that time (the 1990s) mostly unknown in my home country of Norway, where the professional, scientific, and linguistic tradition was Anglo-American oriented. The classical reports are better known more recently, not least because German researchers in psychiatry now also publish in English.

The onset phase is always important to the understanding of disorders It is reasonable to suggest that the very earliest changes in experience in the case of different mental disorders may possibly reflect core characteristics of a particular condition, and may thus carry more central information regarding the causes and development of the disorder than later behavioural changes. In general, and for obvious reasons, the person’s own insight, motivation to seek help, and ability to participate in treatment will, at least for many, be better before psychotic features have appeared. When more rigid and overwhelming psychotic beliefs have begun to take hold, the person’s insight and desire to seek help and treatment are usually weakened. Early conversations with the client in the prodromal phase are a good starting point for developing the person’s insight and building a therapeutic alliance. Focusing on subjective experiences in these conversations is also consistent with ‘the art of helping’, according to Kierkegaard (1859), which always involves ‘starting from where the person in fact is’, namely his or her current experience. Considering the entire path of the disorder, prodromal experiences may provide significant and important clinical information, lying at an ‘intermediate’ level, between the (largely unknown) biological foundations of the condition on the one hand, and the highly salient psychotic symptoms and behavioural consequences on the other. The prodromal stage is difficult to define precisely also in terms of duration. In principle, this phase lasts from the first clearly noticed, relevant, lasting change in experience or behaviour until the first stable symptom of psychosis manifests itself (Yung & McGorry, 1996). Given the previously stated fact that such phenomena 43

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in adolescence are unstable, transient, and sensitive to several influences, the estimated duration of the initial prodrome in many cases will be highly uncertain. It will be almost impossible to ascertain the start of this phase precisely, as this will be done retrospectively. The end point of the prodromal phase will also depend on the definition of psychosis used. Consequently, the duration of the prodromal phase found in research reports covers a wide range, from days and weeks to years and even more than a decade, with a median duration in several studies of around one year and a mean duration of two to three years (see Møller & Husby, 2000). Based upon the concept of Basic Symptoms, a German study has estimated the average length of the prodromal phase to be approximately five years (Häfner, 2000). To sum up this chapter, the concepts of the self, self-awareness, and subjectivity have been further underlined as necessary to understand the essential clinical expressions of schizophrenia and the initial prodrome, strikingly illustrated by one of the most prevalent client quotations; I have lost myself. Subjectivity, as essential to all natural human consciousness and experience, is thus essential also to understand the severe distortions taking place in the prodrome. Central conceptual difficulties of the prodrome have been discussed. The important point in the discussion of scientific division between Anglo-American and Continental European research approaches lies not in subtle details. Of most significance is that the two perspectives are deeply dissimilar, one being strongly behaviourally oriented, describing the individual mainly from the outside, the other being experientially oriented, investigating the individual from within. Both are used today, and this dividing line characterises the leading edge of the research on the prodromal phase. The research on the prodrome has been vigorous for over 20 years, but still the accuracy regarding the prediction of psychosis is extremely limited. The division also entails decisive differences regarding which prodromal phenomena should be considered the most useful for early detection. I  considered qualitative and exploratory approaches as the most expedient to guide prodromal research, when this field was to be ‘revisited’ at the turn of the millennium, after several decades of research paucity.

References Addington, J., Cornblatt, B. A., Cadenhead, K.S., Cannon, T.D., McGlashan, T.H., Perkins, D. O., . . . & Heinssen, R. (2011). At clinical high risk for psychosis: Outcome for nonconverters. American Journal of Psychiatry, 168(8), 800–805. American Psychiatric Association. (1987). DSM-III-R: Diagnostic and statistical manual of mental disorders (3rd ed., Revised). Washington, DC: APA. American Psychiatric Association. (1994). DSM-IV: Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: APA. Chalmers, D. (2007). The hard problem of consciousness. The Blackwell Companion to Consciousness, 225–235. Conrad, K. (1958). Die Beginnende Schizophrenie: Versuch einer Gestaltanalyse des Wahns. Stuttgart: Georg Thieme Verlag.

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Crick, F., & Koch, C. (1995). Why neuroscience may be able to explain consciousness. Scientific American, 273(6), 84–85. Ghazan-shahi, S., Roberts, N., & Parker, K. (2009). Stability/change of DSM diagnoses among children and adolescents assessed at a university hospital: A cross-sectional cohort study. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 18(4), 287. Häfner, H. (2000). Onset and early course as determinants of the further course of schizophrenia. Acta Psychiatrica Scandinavica. Supplementum, 407, 44. Henriksen, M.G., Raballo, A., & Nordgaard, J. (2021). Self-disorders and psychopathology: A systematic review. The Lancet Psychiatry, 8(11), 1001–1012. Kierkegaard, S. (1859). Synspunktet for Min Forfatter-Virksomhed: En Ligefrem Meddelelse. Rapport til Historien (The Viewpoint of My Author Business: A Straightforward Message. Report to History). Copenhagen: Reitzel. Kohut, H.,  & Wolf, E.S. (1978). The disorders of the self and their treatment: An outline. International Journal of Psycho-Analysis, 59, 413–425. McGlashan, T.H. (1998). Early detection and intervention of schizophrenia: Rationale and research. The British Journal of Psychiatry, 172(S33), 3–6. Miller, T.J., McGlashan, T.H., Woods, S.W., Stein, K., Driesen, N., Corcoran, C.M., . . . & Davidson, L. (1999). Symptom assessment in schizophrenic prodromal states. Psychiatric Quarterly, 70(4), 273–287. Møller, P. (2000a). First-episode schizophrenia: Do grandiosity, disorganization, and acute initial development reduce duration of untreated psychosis? An exploratory naturalistic case study. Comprehensive Psychiatry, 41(3), 184–190. Møller, P. (2000b). The Phenomenology of the Initial Prodrome and Untreated Psychosis in First-episode Schizophrenia: An Exploratory Naturalistic Case Study (Doctoral dissertation). Ullevaal University Hospital, University of Oslo and Diakonhjemmet Hospital, Oslo (National Library of Norway). www.nb.no/nbsok/nb/529751f97933a06b30ee1 4bd4b710320?lang=no#0 Møller, P. (2011). The conversation as a microscope – The experiential dimension in schizophrenia. In Mind gap – Eighteen research portraits. Oslo: Norwegian Museum of Science and Technology. Møller, P., & Husby, R. (2000). The initial prodrome in schizophrenia: Searching for naturalistic core dimensions of experience and behavior. Schizophrenia Bulletin, 26(1), 217–232. Nelson, B., Yung, A.R., Bechdolf, A., & McGorry, P.D. (2008). The phenomenological critique and self-disturbance: Implications for ultra-high risk (“prodrome”) research. Schizophrenia Bulletin, 34(2), 381–392. Nordgaard, J., Henriksen, M.G., Jansson, L., Handest, P., Møller, P., Rasmussen, A.R., . . . & Parnas, J. (2021). Disordered selfhood in schizophrenia and the examination of anomalous self-experience: Accumulated evidence and experience. Psychopathology, 54(6), 275–281. Parnas, J. (2011). A disappearing heritage: The clinical core of schizophrenia. Schizophrenia Bulletin, 37(6), 1121–1130. Parnas, J., Jansson, L., Sass, L.A., & Handest, P. (1998). Self-experience in the prodromal phases of schizophrenia: A  pilot study of first-admissions.  Neurology Psychiatry and Brain Research, 6(2), 97–106. Parnas, J., Møller, P., Kircher, T., Thalbitzer, J., Jansson, L., Handest, P., & Zahavi, D. (2005). EASE: Examination of anomalous self-experience. Psychopathology, 38(5), 236.

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Reading, B., & Birchwood, M. (2005). Early intervention in psychosis. Disease Management & Health Outcomes, 13(1), 53–63. Sass, L.A. (1992). Madness and modernism: Insanity in the light of modern art, literature, and thought. New York: Basic Books. Sass, L.A., & Parnas, J. (2003). Schizophrenia, consciousness, and the self. Schizophrenia Bulletin, 29(3), 427–444. Yung, A.R.,  & McGorry, P.D. (1996b). The prodromal phase of first-episode psychosis: Past and current conceptualizations. Schizophrenia Bulletin, 22(2), 353–370. Yung, A.R., & Nelson, B. (2013). The ultra-high risk concept – A review. The Canadian Journal of Psychiatry, 58(1), 5–12. Yung, A.R., Yung, A.R., Pan Yuen, H., Mcgorry, P.D., Phillips, L.J., Kelly, D., . . . & Buckby, J. (2005). Mapping the onset of psychosis: The comprehensive assessment of at-risk mental states. Australian & New Zealand Journal of Psychiatry, 39(11–12), 964–971. Zahavi, D. (2008).  Subjectivity and selfhood: Investigating the first-person perspective. Cambridge, MA: Bradford Books, and MIT Press. Zahavi, D.,  & Parnas, J. (1998). Phenomenal consciousness and self-awareness: A phenomenological critique of representational theory.  Journal of Consciousness Studies, 5(5–6), 687–705.

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Figure 4 In a darkly coloured and secluded atmosphere, people rush around in a city, and a young lonely man in the foreground looks anxiously over his shoulder with a depressed facial expression.

4 THE PROBLEM OF DEFINING THE PRODROMAL PHASE

As briefly introduced in the previous chapter, the attempts to operationalise criteria for the prodromal phase have entailed a significant division between two main scientific approaches. This will be further explored now. On one side of the division, we have the Anglo-American behaviourally oriented tradition, where the phenomena and definitions often indicate a later detection, close to the onset of psychosis. On the other side is the Continental, experientially oriented tradition, which assumes that prodromal phenomena can be detected at a much earlier, pre-psychotic stage. Not surprisingly, it has been challenging to achieve a global consensus as to which definition is the more clinically useful. However, there has been some progress recently, aimed at combining the two perspectives.

Psychopathology is the systematic description and understanding of the manifestations of mental disorders in human experience and behaviour. The psychopathology of the prodromal period of psychosis is still largely unresolved. Because schizophrenia, the prodrome as well as the full-blown syndrome, also does not have any specific or measurable biological markers at the individual level, it is only experience and behaviour of the person concerned that can be the basis of identification and diagnosis. Moreover, since there is limited agreement on the psychopathological content of the prodrome, the prodromal phenomena and concepts currently recognised in the two scientific traditions are still quite distinct. The conventional Anglo-American perspective chose to define prodromal phenomena mainly in terms of ‘psychosis light’ or ‘forme fruste’, that is, psychosis-like experiences (PLEs), almost a forerunning shadow of ordinary psychotic phenomena. One overt example from the SIPS instrument (Miller et a., 2003) is the prodromal entity attenuated positive symptom syndrome (APS), by far the most prevalent among the three entities investigated in empirical studies. This tradition thus assumes that the prodromal phenomena are fairly like the psychotic phenomena, only weaker or less prominent (sub-threshold). The continental European 48

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phenomenological-philosophical perspective, which quite consistently investigated self-reported subjective experiences, like the Basic Symptom concept (Gross, 1986; Schultze-Lutter et al., 2007; Schultze-Lutter, 2009), drawing on client reports from classical psychiatric texts as well as more recent qualitative studies. In the following, the two perspectives are presented in some more detail.

The prodromal phase in the Anglo-American scientific tradition When the list of prodromal symptoms in the third, revised version of DSM (DSMIII-R, 1987) was not carried over to the following version (DSM IV, 1994), due to a lack of scientific evidence, the prodromal phase had to be newly operationalised, that is, defined with its own criteria. The classical, behaviourally oriented positive and negative symptoms of psychosis were largely used as a template for this task. In this tradition, the prodromal phase is now described as three types of psychosis risk syndromes (Table 2) (syndrome refers to a group of symptoms). The syndromes are identified by means of the symptom scales SIPS/SOPS (Miller et al., 1999, 2003) and CAARMS (Yung et al., 2005), which however are only to a limited degree founded on basic clinical research in psychopathology. (Basic research here implies that the fundamental characteristics of mental phenomena in various mental disorders are empirically and directly investigated in detail, qualitatively and quantitatively.) The SIPS/SOPS scales occupy instead a pragmatic position, by defining prodromal symptoms mainly as weak (attenuated positive symptoms syndrome – APSS) or short-lived (brief intermittent psychotic symptoms syndrome – BIPS) versions of typical psychosis symptoms. The conventional division into three types of psychotic symptoms (positive, negative, and disorganised) is therefore in the DSM and SIPS/SOPS tradition also an organising principle for the definition and understanding of the prodromal phase. An exception to this is type 3 (genetic risk and deterioration syndrome – GRDS), which is defined based on genetic risk (familial occurrence) in addition to significant loss of function. This latter type has, however, in clinical studies proved to be very rare. This long-leading operationalisation of the prodromal phase, initially developed in American (Miller et al., 2003) and Australian (Yung et al., 2005) research communities, has increasingly demonstrated significant weaknesses when tested out clinically (Hartmann, 2016; Raballo & Poletti, 2022). Particularly, a very low proportion (15–20%, and decreasing over time) of individuals that meet the criteria for being in a prodromal phase (ultra-high risk; UHR) go on to develop psychosis (Addington et al., 2011), all the way down to a transition rate of 8% in 288 individuals over 1–2 years (Morrison et al., 2012). Evidently, two out of the three types of prodromal syndromes identified in this tradition (see Table 2) (Yung & Nelson, 2013) have a high degree of proximity to psychosis onset in time, and likewise similarity to psychosis in content. A central point here is that the preventive potential of identifying prodromal phenomena by means of these criteria will be limited, due to their being largely 49

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Table 2  Psychosis risk syndromes (three types) from the Anglo-American tradition. Used in the instruments SIPS/SOPS and CAARMS (albeit somewhat different definitions in detail). Brief intermittent psychotic symptoms syndrome (BIPS)

Attenuated positive symptoms syndrome (APSS)

Genetic risk and deterioration syndrome (GRDS)

Def.: brief intermittent psychotic symptoms: In SIPS: started previous three months. At least several minutes daily, at least once per month. In CAARMS: < 1 week. Loss of function previous year.

Def.: weaker symptoms than BIPS, but sufficient severity and frequency: In SIPS: start or worsening previous year. In CAARMS: loss of function previous year.

SIPS/SOPS: grade 6 on one of P1–P5.

SIPS/SOPS: grade 3–5 on one of P1–P5.

Def.: genetic risk plus loss of function: Psychotic disorder in first degree relative, or schizotypal disorder in the patient, plus GAF down > 30 in previous month compared to highest level previous year. See definitions of affective and nonaffective psychotic disorders, schizotypal disorder, and GAF categories.

CAARMS = comprehensive assessment of at-risk mental states; SIPS = structured interview for psychosis risk syndromes; SOPS  =  scale of psychosis risk symptoms; P1−P5  =  symptom no. 1–5 of positive symptoms in SOPS/SIPS.

behavioural, and a possible onset of psychosis is thus likely to be quite close, if it occurs. Moreover, many persons with prodromes defined in this way may have already experienced psychosis, possibly several times, but not yet stably. Likewise, and not the least, the lack of fundamental clinical-phenomenological research base limits this perspective’s contribution to enhancing the understanding of psychosis development.

The prodromal phase in the continental European scientific tradition In contrast to the aforementioned perspective, European scientific psychiatric communities have a history of more than 100 years of basic clinical research in psychopathology (see Henriksen et al., 2021). A research culture such as this is a necessary condition to allow the identification of valid clinical phenomena in the prodromal phase of psychosis. This research tradition, in addition to describing well-known, non-specific phenomena which are also parts of the prodrome (anxiety, depression, anger, compulsions, withdrawal, sleep disturbances, cognitive difficulties, and panic) (Klosterkötter et  al., 2008) has also revealed far more characteristic disturbances of self-experience and subjectivity (Sass, 1988, 2021). They describe prodromal phenomena which appear very early and which 50

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are not obviously similar to typical psychosis phenomena (Schultze-Lutter et al., 2007; Parnas et al., 2005). These prodromal phenomena are also not organised according to the conventional positive-negative distinction, but rather involve the wide spectrum of altered self-experience, to be discussed throughout this book. There are many other sources too, supporting this scientific perspective, classical and more recent. Empirical studies, clinical practice, works of fiction, literature, art, and thought have described the main theme of the prodrome and psychosis as being feelings of long-lasting and destructive alienation, unreality, and disintegration of meaning (see Sass, 1992). A seminal and very early contribution to this European tradition came from the acclaimed German psychiatrist, philosopher, and phenomenologist Karl Jaspers (1883–1969), who in 1913 published the first systematic and phenomenologically based description of mental disorders and their features, including schizophrenia, in the textbook Allgemeine Psychopathologie. The book has later been revised several times (Jaspers, 1997), and is uniquely ambitious in its detailed descriptions of many psychological phenomena and disorders, not least psychotic disorders. Phenomenologically oriented researchers later supplemented Jaspers’ detailed clinical descriptions with existential philosophical and phenomenological research and theorisation on consciousness. Two distinctive examples are the Polish-French Eugene Minkowski (1885–1972), particularly known for his concept ‘loss of vital contact with reality’ (see Urfer, 2001) and the German Wolfgang Blankenburg (1928–2002) for the concept ‘loss of common sense’, that is, weakened automatic understanding of the obvious (see Mishara, 2001). Basic experiential conceptions and perspectives like these, alongside with self-awareness and subjectivity, have, through these and other authors, gained an even stronger position in the investigation of the subjective dimensions of schizophrenia and the prodrome. Building further on these European classical contributions, Gross, Huber, and colleagues in Germany worked systematically on the subjective psychopathology of schizophrenia and the prodrome, eventually launching the concept of basic symptoms, emphasising the intimate connection between the two developmental stages. They operationalised this concept through ‘Bonner Skala für die Beurteilung von Basissymptomen’ (1986), or the ‘Bonn Scale for the Assessment of Basic Symptoms’ (BSABS) (Gross, 1986). The concept has been central in German research on schizophrenia and the prodrome during most of the postwar period. From the same group, Klosterkötter and colleagues (2001), through the Cologne Early Recognition Study, have identified distinct but overlapping ‘risk syndromes’ (groups of basic symptoms) which have a high predictive value for the later development of psychosis. Schultze-Lutter and colleagues (2007) systematised these findings further and developed the Schizophrenia Proneness Instrument, adult version; SPI-A. As part of this work, two risk syndromes, named COPER and COGDIS (see text box), have been shown to stand up well statistically regarding the prediction of conversion to psychosis within 1–2  years. In practice, COGDIS is regarded as the most precise risk instrument. 51

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Two psychosis risk syndromes (COPER and COGDIS) based on the German basic symptoms tradition (Schultze-Lutter et al., 2007). The first five phenomena are part of both syndromes.

Cognitive perceptual basic symptoms (COPER) – At least one of the following ten basic symptoms, at least weekly for the previous three months and at least one year since the first sign: (1) Thought interference, (2) thought blockages, (3) disturbance of receptive speech, (4) thought pressure, (5) unstable ideas of self-reference, (6) thought perseveration, (7) decreased ability to discriminate between ideas and perceptions, (8) derealisation, (9) visual perception disturbances, and (10) acoustic percept ion disturbances.

Cognitive disorders (COGDIS) At least two of the following nine basic symptoms, at least weekly for the previous three months (no requirement of at least one year since first sign): (1) Thought interference, (2) thought blockages, (3) disturbance of receptive speech, (4) thought pressure, (5) unstable ideas of self-reference, (6) inability to divide attention, (7) disturbance of expressive speech, (8) disturbance of abstract thinking, and (9) captivation of attention by details of the visual field (‘spellbinding’). Later, a child and youth version (SPI-CY) (Schultze-Lutter  & Koch, 2010) has also been made. Both the adult and the child and youth versions are semistructured interviews, and the CY version covers four dimensions (adynamia, perceptual disturbances, neuroticism, and thought/motor disturbances). Finally, the basic symptoms research milieus to a certain extent also have operated with two ‘temporally different’ types of prodromal symptoms, one appearing particularly early in the development (early/distal prodromes), and another type emerging much later, that is, close to the emergence of psychosis (late/proximal prodromes) (Klosterkötter et al., 1997). The EASE and the Subjectivity Model relate primarily to the former (early prodromes).

References Addington, J., Cornblatt, B.A., Cadenhead, K.S., Cannon, T.D., McGlashan, T.H., Perkins, D. O., . . . & Heinssen, R. (2011). At clinical high risk for psychosis: Outcome for nonconverters. American Journal of Psychiatry, 168(8), 800–805.

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American Psychiatric Association. (1987). DSM-III-R: Diagnostic and statistical manual of mental disorders (3rd ed., Revised). Washington, DC: APA. American Psychiatric Association. (1994). DSM-IV: Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: APA. Gross, G. (1986). The Bonn scale for the assessment of basic symptoms. In C. Shagass, R.C. Josiassen, W.H. Bridger, K.J. Weiss, D. Stoff, & G.M. Simpson (Eds.), Biological psychiatry 1985. New York: Elsevier, pp. 1142−1144. Hartmann, J.A., Yuen, H.P., McGorry, P.D., Yung, A.R., Lin, A., Wood, S.J., . . . & Nelson, B. (2016). Declining transition rates to psychotic disorder in “ultra-high risk” clients: Investigation of a dilution effect. Schizophrenia Research, 170(1), 130–136. Henriksen, M.G., Raballo, A., & Nordgaard, J. (2021). Self-disorders and psychopathology: A systematic review. The Lancet Psychiatry, 8(11), 1001–1012. Jaspers, K. (1997). General psychopathology (Vol. 2). Baltimore, MD: The Johns Hopkins University Press. Klosterkötter, J., Hellmich, M., Steinmeyer, E.M., & Schultze-Lutter, F. (2001). Diagnosing schizophrenia in the initial prodromal phase. Archives of General Psychiatry, 58(2), 158–164. Klosterkötter, J., Schultze‐Lutter, F., Gross, G., Huber, G.,  & Steinmeyer, E.M. (1997). Early self‐experienced neuropsychological deficits and subsequent schizophrenic diseases: An 8‐year average follow‐up prospective study. Acta Psychiatrica Scandinavica, 95(5), 396–404. Klosterkötter, J., Schultze-Lutter, F., & Ruhrmann, S. (2008). Kraepelin and psychotic prodromal conditions. European Archives of Psychiatry and Clinical Neuroscience, 258(2), 74–84. Miller, T.J., McGlashan, T.H., Rosen, J.L., Cadenhead, K., Ventura, J., McFarlane, W., . . . & Woods, S.W. (2003). Prodromal assessment with the structured interview for prodromal syndromes and the scale of prodromal symptoms: Predictive validity, interrater reliability, and training to reliability. Schizophrenia Bulletin, 29(4), 703–715. Miller, T.J., McGlashan, T.H., Woods, S.W., Stein, K., Driesen, N., Corcoran, C.M., . . . & Davidson, L. (1999). Symptom assessment in schizophrenic prodromal states. Psychiatric Quarterly, 70(4), 273–287. Mishara, A.L. (2001). On Wolfgang Blankenburg, common sense, and schizophrenia. Philosophy, Psychiatry, & Psychology, 8(4), 317–322. Morrison, A.P., French, P., Stewart, S.L., Birchwood, M., Fowler, D., Gumley, A.I., . . . & Dunn, G. (2012). Early detection and intervention evaluation for people at risk of psychosis: Multisite randomised controlled trial. BMJ, 344, e2233. Parnas, J., Møller, P., Kircher, T., Thalbitzer, J., Jansson, L., Handest, P., & Zahavi, D. (2005). EASE: Examination of anomalous self-experience. Psychopathology, 38(5), 236. Raballo, A., & Poletti, M. (2022). Overlooking the transition elephant in the ultra-high-risk room: Are we missing functional equivalents of transition to psychosis? Psychological Medicine, 52(1), 184–187. Sass, L. (2021). Everywhere and nowhere: Reflections on phenomenology as impossible and indispensable (in Psychology and Psychiatry). Critical Inquiry, 47(3), 544–564. Sass, L.A. (1988). The land of unreality: On the phenomenology of the schizophrenic break. New Ideas in Psychology, 6(2), 223–242. Sass, L.A. (1992). Madness and modernism: Insanity in the light of modern art, literature, and thought. New York: Basic Books.

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Schultze-Lutter, F. (2009). Subjective symptoms of schizophrenia in research and the clinic: The basic symptom concept. Schizophrenia Bulletin, 35(1), 5–8. Schultze-Lutter, F., Addington, J., Ruhrmann, S., & Klosterkötter, J. (2007). Schizophrenia proneness instrument, adult version (SPI-A). Rome: Giovanni Fioriti. Schultze-Lutter, F.,  & Koch, E. (2010).  Schizophrenia proneness instrument: Child and youth version (SPI-CY) (p. 98). Rome: Fioriti. Urfer, A. (2001). Phenomenology and psychopathology of schizophrenia: The views of Eugene Minkowski. Philosophy, Psychiatry, & Psychology, 8(4), 279–289. Yung, A.R., & Nelson, B. (2013). The ultra-high risk concept – A review. The Canadian Journal of Psychiatry, 58(1), 5–12. Yung, A.R., Yung, A.R., Pan Yuen, H., Mcgorry, P.D., Phillips, L.J., Kelly, D., . . . & Buckby, J. (2005). Mapping the onset of psychosis: the comprehensive assessment of at-risk mental states. Australian & New Zealand Journal of Psychiatry,  39(11–12), 964–971.

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Figure 5 First image (of two): a person looks, from a distance, slightly puzzled at a teacup and a teabag. Second image: The person picks up the teacup, holds it upside down, and obviously does not understand how the things are connected.

5 THE VIEW OF SCIENCE DETERMINES THE VIEW OF PSYCHOSIS

The two diverging scientific approaches, which arose during the 20th century, to investigating and understanding the prodromal phase, clearly has implications for today’s research and clinical practice in the whole field of psychosis. It is precisely these differences that for a long time highlighted the general difference between the American DSM-system (more criteriabased) and the European ICD-system (more based on clinical descriptions). In Anglo-American-oriented countries, the former perspective, with its emphasis on objectivity and operationalisation, has been dominant in the post-war period due to the scientific and educational influences by the USA. This may now be in the process of changing, because of an emerging desire for collaboration and approach between the two traditions.

The earliest scientific perspectives on the central aspects of schizophrenia In continental European research communities, from the beginning of the 20th century and up to the launching of the ICD-9 by WHO in 1977 (see Kramer et al., 1979), there was considerable agreement among central classical thinkers about altered experience of the ‘self’ being a core or primary aspect of schizophrenia (for a brief historical overview, see Henriksen et al., 2021). Positive psychotic symptoms such as hallucinations and delusions were, however, regarded as secondary phenomena. This European perspective was increasingly ignored or neglected in Anglo-American psychiatric research, and quite few showed a scientific interest in it, often asserting that the self-experience phenomena cannot be operationalised, described, and measured reliably and precise enough (too soft business). As a consequence, from ICD-9 onwards, the positive symptoms of psychosis largely overtook as primary diagnostic criteria of psychosis and schizophrenia in the ICD system, as it did in the DSM-III (APA, 1980).

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Returning, then, to the subjective psychopathology of schizophrenia, this literature has thus existed for over 100 years (see Parnas, 2011), inspired by philosophical traditions, especially phenomenology (Sass, 2021) and existential philosophy (Jaspers, 1997; Fuchs et  al., 2013; Häfner, 2015). Within this perspective, in-depth understanding and detailed descriptions of the first-personal perspective and subjective phenomena of psychosis have had a central position. Phenomenology seeks, among other things, to understand how human consciousness functions, that is, the process whereby our perceptions, thoughts, feelings, and movements become something meaningful for us, and form a coherent and comprehensible whole (Zahavi, 2018; Sass, 2021). Within this endeavour, the classical psychiatric texts have described, albeit with different conceptual nuances, strikingly similar experiential changes that the participants in my prodromal study told about, such as extreme perplexity about one’s own existence, identity, and the taken-for-granted conditions of the world.

The wave of operationalism The publication of DSM-III (APA, 1980) stimulated a marked increment of the use of precisely operationalised diagnostic criteria for mental disorders, motivated by the need for a unitary and unifying base for nosological clarity, etiological research, and international consensus. This important turning point was strongly highlighted by the influential US psychiatrist and researcher Nancy C. Andreasen: Since the publication of DSM-III in 1980, there has been a steady decline in the teaching of careful clinical evaluation . . . that is enriched by a good general knowledge of psychopathology. Students are taught to memorise DSM rather than to learn complexities from the great psychopathologists of the past. By 2005, the decline has become so severe that it could be referred to as ‘the death of phenomenology in the United States’. (Andreasen, 2007) At the same time, Anglo-American psychiatric research also became influenced by American authorities’ demands for objective documentation of the precise content and effect of clinical activity and interventions, due to the call for improved financial management in health services, and not least the management of the rights of clients in relation to insurance companies (see Andreasen, 2007). Such empirical documentation is of course expected to be made available mainly by objective measurements, through gold standard methods such as randomised controlled trials (Cumpston et al., 2019). This authoritative focus on measurability and cost-effectiveness of interventions inevitably reinforce the wave of operationalism in the sciences of psychiatry and psychology. In the search for this type of measurability, a greater part of the field of psychiatry has emphasised the need for ‘translation’ of subjective phenomena into something measurable and almost objective. Aspects of behaviour have thus assumed a central role, because they can

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more easily be operationalised and defined. In the field of psychosis, instruments for the measurement of symptoms have thus become characterised by symptoms being evaluated and graded as much as possible through the effects they have on behaviour. This improves the reliability of measurement of an instrument; people at different locations, cultures, and points in time will thereby be able to measure a phenomenon with the same result. However, the validity (actually measuring the phenomenon the instrument claims to measure) could be weakened.

A pervasive scientific watershed This objective-subjective contrast in our view and understanding of scientific knowledge, where operationalisation constitutes a form of watershed, still permeates the entire field of psychosis. The differences are significant and clear, and reflect marked shifts between (1) the objective and the subjective dimensions, (2) the operationalised and the descriptive, (3) behaviour and experience, (4) quantitative and qualitative research methods, and finally (5) between proximal (psychosisnear) and distal (further away from the onset of psychosis) concepts of the psychosis prodrome. In Scandinavia, the former – objectivity and operationalisation – have generally dominated in the entire post-war period, as we have been strongly tied to the US research tradition. But this is now hopefully in a commencing process of being changed, in that research communities in the two traditions have more contact and work more together (Andreasen, 2007; Thompson, 2016).

Scientific culture has influenced the current understanding of psychosis Today’s criteria for psychosis in ICD and DSM – that is, the psychosis signs and symptoms – do not necessarily reflect the most fundamental and central disturbances in psychotic disorders. As shown, it was recognised already in the early 1900s that schizophrenia disturbs fundamental elements of human selfhood, experience, and identity. In a closer look, this has been implicitly ascertained even in the two mentioned diagnostic systems, but strangely only in the introductory descriptive comments to schizophrenia. First, in ICD-10: The disturbance involves the most basic functions that give the normal person a feeling of individuality, uniqueness, and self-direction. (WHO, 1992, p. 86) Second, in DSM-IV-TR (text revision): Psychotic symptoms are not necessarily the most central features in these disorders. (American Psychiatric Association, 2000, p. 297) 58

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In these sentences, we do find, implicitly, some of the central characteristics of psychotic disorders described, and they could in my opinion have been exemplified more closely and appended as an essential descriptive reference to the manual criteria. Disturbed individuality, uniqueness, and self-direction (ICD-10) clearly go straight to the core of self-experience, self-awareness, and subjectivity. That psychotic symptoms are not necessarily the most central features in these disorders (DSM) is in the same way a clear indication that some other underlying changes are more important, as a background for the psychotic phenomena. It is not difficult to see that self-disturbances readily fit in with such descriptions, and it reveals that such phenomena have not gone unrecognised. At the same time, both diagnostic systems still define schizophrenia through mainly behaviourally oriented criteria: hallucinatory behaviour, delusions, broad and observable disturbances of behaviour and language, and negative symptoms.

Consequences for clinical practice In daily clinical practice, this situation has resulted in clinicians spending much of their time used on diagnostics looking for what seem to be ‘clear and concise’ diagnostic criteria, while the decisive phenomena relating to evaluations of ‘individuality, uniqueness, and self-direction’ are left more or less untouched. For clinicians, the diagnostic criteria may over time assume an unfortunate and erroneous status as seemingly precise, correct, and exhaustive representations of the disorder. The disorder is in danger of becoming ‘identical’ with the criteria, and one overlooks that the criteria are merely a selection of the disorder’s more explicit and behavioural features. The diagnostic criteria, used in such an inappropriate way, meet quite understandable needs of clinicians to be able to identify psychotic disorders in a reliable and clear way. However, using the criteria in this way may in fact limit the opportunities for exploring and discovering the true nature of the disorder. In addition, with a lack of focus on the individual client’s experience, the clinician might ignore central aspects of his or her condition, leading to underdiagnosis. The discrepancy between the accepted definition on the one hand (conventional psychotic symptoms) and the fundamental subjective aspects on the other (disturbed subjectivity) have over time led to obvious clinical consequences. When the focus among professionals is continually held on a set of reductionistic criteria, this will be at the expense of a deeper understanding of the fundamental human phenomena, and possibly also at the expense of genuine therapeutic encounters.

Subjective aspects of psychosis are not trivial In my experience from psychosis research and clinical practice, since the mid1990s, the lived experience, subjective perspectives, narratives (life stories), and phenomenologically based approaches have slowly received increased attention and priority. Due to sustained demand and pressure from service users and the 59

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survivor movement, health authorities in a growing number of countries have emphasised that one of the most under-utilised sources of knowledge in mental health services is the client. Moreover, the validity of psychosis diagnoses and mental health diagnostics in general has long been under pressure both from within and outside the field (Jablensky, 2016). This is brilliantly illustrated and compared to another complex natural phenomenon by Wittgenstein: [T]he classifications made by philosophers and psychologists are as if one were to classify clouds by their shape. (Wittgenstein, 1980) The metaphor is apt: clouds have fuzzy boundaries, tend to merge imperceptibly, and drift, being carried by invisible air currents. Observation and measurement of their movement predict, within a margin of error, the weather, yet the inner physical and chemical structures of clouds are hidden to the naked eye (Jablensky, 2016). These current trends support a renewed attention on subjective phenomena, also in the case of psychotic disorders. However, it needs to be stated clearly that the subjective phenomena discussed in this book do not refer to the obvious necessity of greater service user involvement and an empathetic, client-centred approach. The subjective as a scientific field, fundamentally linked to consciousness, refers to complex and elusive phenomena, which are pre-reflexive, pre-verbal, and precognitive. The Subjectivity Model presented in this book addresses the ‘infrastructure’ of consciousness, as a necessary condition for intact self-experience and self-awareness. In certain contexts, however, it seems that the scientific study of subjective phenomena is trivialised and banalised. This may simply be because of limited knowledge, or that one has not fully realised what the deepest levels of the experience of identity truly represent. A lack of awareness regarding this can lead to indeed unfortunate scientific misunderstandings. This book aims to present an understanding of subjective phenomena in psychosis, with the intent to bringing more clarity to this particularly elusive field.

Science is about doing things once again: re-searching, re-specting, re-thinking, and re-labelling The research process involves several sub-processes, and this is particularly the case in under-investigated fields. First, research literally means to search once again, that is, re-search. Second, the concept of respect is highly relevant to research too. The researcher needs to have respect for the yet unsettled phenomena in question, in the sense that one must be both able and willing to examine carefully, thoroughly, and honestly one more time, or several times, it means in fact to look at a phenomenon once again, that is, ‘re-spect’. Third, the researcher must think about and analyse the observed or reported phenomena once again, that is, re-think. Finally, developing new models and new starting points often 60

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involves re-labelling, that is, giving new and informative names to the phenomena studied that support conceptual clarity. If an area of research is currently weakly or inadequately described, it is important that researchers take the necessary steps back and make a restart from that point in development where well-confirmed knowledge ends. To find an appropriate direction and general line of approach to a new research area in mental health, it will be useful, if not exigent, to start with qualitative investigations, and in our particular field, it will mean a phenomenological approach. This will ensure that one searches for the right type of phenomena from the very start, and that the researcher finds him-/herself in the right area in which to search. If one continues building upon what are in fact uncertain or possibly even fallacious initial assumptions, then the research might easily be led astray. The psychiatrist and philosopher (phenomenologist) Karl Jaspers (1883–1969) said this about philosophy’s search for knowledge and wisdom, indeed relevant for our field: It is the search for the truth, not possession of the truth, which is the way of philosophy. Its questions are more relevant than its answers, and every answer becomes a new question. (Jaspers, 1951) In summary, it is essential in under-investigated areas, such as the initial psychotic prodrome, to search openly for the phenomena once again, often with new methods. We must then inspect and examine the phenomena repeatedly, and we must think and analyse again, in open-minded ways. Finally, as a result of these processes, we can create new models, possibly giving the phenomena new, more precise and meaningful names too. Open-minded processes like these are dependent upon the ability to put to one side existing knowledge that is incomplete or uncertain, what phenomenologists refer to as ‘bracketing’ (Sass, 2021). Researchers must have courage and be able to cope with going off the beaten track. This will maximise the likelihood of making new discoveries and scientific progress. The next two chapters will offer an introduction to the concepts of subjectivity, the self, and basic self-disturbance. The three phenomena are closely intertwined, and together underlie the Subjectivity Model.

Reference American Psychiatric Association. (1980). DSM-III: Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: APA. American Psychiatric Association. (2000). DSM-IV-TR: Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: APA. Andreasen, N.C. (2007). DSM and the death of phenomenology in America: An example of unintended consequences. Schizophrenia Bulletin, 33(1), 108–112. Cumpston, M., Li, T., Page, M.J., Chandler, J., Welch, V.A., Higgins, J.P., & Thomas, J. (2019). Updated guidance for trusted systematic reviews: A new edition of the Cochrane

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handbook for systematic reviews of interventions. Cochrane Database of Systematic Reviews, 10, ED000142. Fuchs, T., Breyer, T., & Mundt, C. (Eds.). (2013). Karl Jaspers’ philosophy and psychopathology. Berlin: Springer Science & Business Media. Häfner, H. (2015). Descriptive psychopathology, phenomenology, and the legacy of Karl Jaspers. Dialogues in Clinical Neuroscience, 17(1), 19. Henriksen, M.G., Raballo, A., & Nordgaard, J. (2021). Self-disorders and psychopathology: A systematic review. The Lancet Psychiatry, 8(11), 1001–1012. Jablensky, A. (2016). Psychiatric classifications: Validity and utility.  World Psychiatry, 15(1), 26–31. Jaspers, K. (1951). Way to wisdom: An introduction to philosophy as translated by Ralph Mannheim (Chapter  1, What is Philosophy? 2003, p.  12). Baltimore: Johns Hopkins University Press. Jaspers, K. (1997). General psychopathology (Vol. 2). Baltimore: Johns Hopkins University Press. Kramer, M., Sartorius, N., Jablensky, A., & Gulbinat, W. (1979). The ICD-9 classification of mental disorders: A review of its development and contents. Acta Psychiatrica Scandinavica, 59(3), 241–262. Parnas, J. (2011). A disappearing heritage: The clinical core of schizophrenia. Schizophrenia Bulletin, 37(6), 1121–1130. Sass, L. (2021). Everywhere and nowhere: Reflections on phenomenology as impossible and indispensable (in psychology and psychiatry). Critical Inquiry, 47(3), 544–564. Thompson, A., Marwaha, S., & Broome, M.R. (2016). At-risk mental state for psychosis: Identification and current treatment approaches. BJPsych Advances, 22(3), 186–193. Wittgenstein, L. (1980). Philosophical remarks. Chicago: University of Chicago Press. World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization. Zahavi, D. (2018). Phenomenology the basics. New York: Routledge.

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Figure 6 A young person in a train compartment anxiously examines his own reflection in the train window.

6 SUBJECTIVITY

In order to understand certain aspects of human consciousness, it can be illuminating to distinguish between form and content. In a phenomenological perspective, consciousness can be regarded as having a ‘content’ consisting of just one thing: experiences, that is, subjective phenomena such as thoughts, feelings, perceptions, bodily sensations, movements, memories, impulses, pain, and sensations. Moreover, consciousness must have a ‘form’, that is, structural aspects, functional forms, and ways of displaying the contents of consciousness. Subjectivity is understood as one such structural aspect, giving consciousness an anchorage and a direction. Because subjectivity underlies basic functions intimately tied to daily experience, disturbances of subjectivity, most clearly in the case of schizophrenia spectrum disorders, can have major consequences for a person’s way of experiencing. In this chapter, the diverse ‘functions’ of subjectivity and its characteristics are the main focuses.

For the sake of coherence, I will briefly repeat a ‘definition’ of subjectivity, as it should be understood in the context of this book. We are here not talking about being a subject in the usual sense of the word, that is, being autonomous, independent, etc., but rather about what it specifically means to experience oneself as a subject (self-experience), and what aspects of our consciousness are preconditions for this specific experience (Zahavi  & Parnas, 1998; Zahavi, 2008, 2018). Subjectivity is a ‘structural’ component of human consciousness which supports the most fundamental aspects of a person’s sense of identity. Identity means being the same as myself, which results in an experience of being myself. Subjectivity thus represents complex mechanisms of the mind which results in us feeling like unique individuals, being only like ourselves: ‘I am myself’. Subjectivity probably represents the deepest aspect of consciousness that can be reached in a clinical dialogue, albeit indirectly. It is in itself by nature implicit and ‘silent’, being an in-built part of every experience, all of which have a content and a form. 64

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This form, or structure, is a way or mode (modus) in which all experiences manifest itself for me, namely as mine. This experience of mine-ness is seen as provided by subjectivity. These and other aspects of subjectivity will be explored further in this chapter.

Schizophrenia and subjectivity disturbances shed light on normality Our human mind, or consciousness, ‘reveals itself’ to us all the time, by making us aware of ourselves, our existence, and our environment. In other words, consciousness provides us with self-awareness (Zahavi & Parnas, 1998; Zahavi, 2008). Consciousness as such, however, is extremely difficult to access in order to undertake precise scientific examination. Significantly, crucial aspects of consciousness, such as subjectivity, never reveal themselves to us directly, only indirectly. When intact, subjectivity nevertheless ensures that our experiences are formed and function in an adequate way. Perhaps the most important thing that consciousness ensures is that we feel like ourselves, that we experience control over our own selves, and that everything we experience feels anchored in a stable way to ourselves (see client quotations in box, Chapter 7). At first glance, these points may seem obvious, or even trivial, but notably only in the sense that very few of us ever need to address or think about these deep issues, located at the pre-reflective level. Put differently, we do not know what we have (and need) before we lose it. Under normal conditions, it is as if consciousness ‘just works’ and goes on and on. – a bit like a car full of petrol and a fully functional engine, or like a plant with light, air, and water in plentiful supply, or a person breathing, with fresh air and the correct blend of nitrogen and oxygen. Such is the human mind when subjectivity is intact. Conversely, when subjectivity is compromised, as is claimed to be the case in incipient or fully developed schizophrenia, the disturbance sheds unexpected light on normality, revealing to the person ‘what s/he had, before it was lost’. In reports from phenomenological research (Parnas et al., 1998; Møller & Husby, 2000; Parnas & Handest, 2003), and indeed from clinical work, clients recounting the time just before and during the onset of the psychotic episode have provided us with a clear reminder of the immense significance for all human beings of intact self-awareness, and of being centred in one’s own self. Naturally, it follows from this that the costs of severe alterations in subjectivity are overwhelming.

Body and mind are intertwined The body is at once a physical object that can be touched and felt, but also something abstract and mental which is experienced and lived from within. Normally, we have a sense of psychophysical unity and coherence, a normal interplay, or oscillation of the body as ‘lived from within’ as a non-spatial subject or soul and of the body as a spatial and physical object. In other words, our bodily experience 65

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is neither of an object nor of a pure subject. It is simultaneously both. These bodily experiential aspects have a central position in the phenomenological domain of embodiment (Zahavi, 2018). Clearly, one cannot say that it is the body itself that ‘experiences’ the body. On the contrary, all experience has its seat in consciousness. In other words, it is the mind that also experiences the body, in the sense that bodily experiences are formed and take place in consciousness. It is difficult to imagine a body without a mind or a mind without a body from an experiential perspective, and it seems reasonable to view the body and mind as completely and mutually intertwined. In the same way as I never normally ask questions about whether I own my mental experiences, it is intuitively obvious that my bodily experiences are also mine, and that they are also subjective. So, it is the aspect of consciousness known as subjectivity that underlies this, ensuring that both my physical and mental experiences are mine. It is also the case that the experience of psychophysical unity, is an experience at the pre-reflexive level: it is something we do not need to think about, we just grasp it automatically and intuitively (Fuchs & Schlimme, 2009).

Subjectivity – the basic element of the self So, we do not always know what we have until we have lost it, and this certainly applies in the case of subjectivity. Subjectivity might be called the basic ‘element’ of the self and our experiences. An element, in the chemical sense of the word, is a unique and pure substance, and a building block of other more complex substances. Subjectivity is of course not a chemical element, and neither is it located in a specific area of the brain. The concept of subjectivity represents complex mechanisms in our mind, which result in us being able to experience ourselves as unique subjects, individuals like no other. The word identity is ultimately derived from the Latin word ‘idem’, which means ‘the same, sameness, oneness, state of being the same’ (etymonline.com). In the present context of self-experience, this sameness refers to being the same as myself, what it is that makes me myself. Subjectivity is therefore like a mental ‘infrastructure’ that underlies some of the most fundamental aspects of our sense of identity. Taking a practical step to the side for a moment, in the case of clinical assessment and treatment, it is of great practical value that mental phenomena (self-experience) at such a deep level can be made (indirectly) accessible during clinical examination (e.g. through a conversational interview guided by the manual Examination of anomalous self-experiences [EASE]). Altered subjectivity is indirectly accessible, for clients and therapists, through normal experiences changing their basic character. These phenomena have great clinical utility, especially for the early identification of the prodrome of psychosis, and are a result of self-disturbances being experienced so vividly by those affected that they can be reported and described in considerable detail. They lend themselves to exploration in conversation, and eventually they may well assume clear behavioural consequences, after a period of time. 66

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Where does subjectivity come from? To considerably simplify, we might say that subjectivity arises through our continual interaction with the physical and social world, from our first day of life (Zahavi, 2008, 2014). Our body and mind gradually become suffused and intertwined with ‘selfhood’ or ipseity. This provides the person with a feeling of a coherent and unifying core, of being oneself, feeling present, and of being the owner of one’s experiences – which in turn give rise to a basic experience of identity and vitality. Every intact/normal experience therefore consists of (1) a thematic content, that is, a particular thought or feeling, and (2) a form or ‘structure’, that is, a way (modus) that the thought or feeling in question manifests itself for me, including it being mine. This feeling of intact subjectivity is therefore implicit, something which in everyday life does not enter conscious attention: it is silent, self-evident, and taken for granted.

Compromised subjectivity results in a compromised sense of identity If subjectivity is disturbed, weakened, or distorted, our basic, spontaneous selfexperience or selfhood is immediately affected: we then experience ourselves as gradually being altered into something alien, strange, somehow unreal, and to an extent unrecognisable. The consequences of this type of implicit disturbance show up explicitly and are expressed by the individual through utterances such as ‘I have lost my feelings, entailing loss of myself, making me another person’; ‘I tried to find out who I was by scrutinising my photos, notes and diaries’; ‘I totally lost myself, and had to remind me about who I was’; ‘something inside me had turned unhumane’; I had a scaring feeling of being unreal, changed, and hazy’. (Møller & Husby, 2000). When subjectivity is compromised in this way, we (i.e. our consciousness) will automatically, by our very nature (intentionality, Husserl, 1901), begin to search for new understanding and meaning in what is now a changed perception of ourselves. The person will strive to assign the new, alien self-experience a private, personal, and inappropriate meaning (à Campo et  al., 1998; Møller & Husby, 2000, pp. 223, 225). This may obviously be the start of a changed and disturbed conscious self-understanding, and potentially a further source of development of psychotic delusions about oneself and the world around. In this way, over time, a self-disturbance may develop, based on an incorrect interpretation of the disturbed underlying self-experience. These ‘steps’ of development were laid out in Chapter 2: (1) from disturbed non-thematic selfexperience, via (2) disturbed conscious self-understanding, possibly leading to (3) basic self-disturbances, and eventually (4) the psychotic conviction. Subjectivity is a hidden intrinsic component of every experience: when you see, hear, move, think, feel, or touch something, you are instantly and automatically aware that the experience is yours. This ‘mine-ness’ is an in-built part of the experience itself (Cermolacce et al., 2007; Zahavi, 2008). The individual sensory 67

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act on the one hand and subjectivity on the other hand are functionally intertwined and as a coherent whole give rise to interpretations of our daily experiences, which normally seem intact and recognisable. The sensory event provides me with a meaningful visual impression, an understandable sound, or a recognisable touch sensation, and I feel this as mine, something happening within me. If subjectivity is affected by a disturbing process, the sensory impression loses its integration (with subjectivity) and may be characterised by a certain distance, foreignness, and unrecognisability, seeming a little dreamlike and not quite understandable. Moreover, the sensory impression might also assume an anonymous quality: ‘Are these really my thoughts that are in my head? Is it really me experiencing this?’ Once again, it must be emphasised that questions such as these are not of a trivial variety. In a more mundane context, we may all ask these types of question in a metaphorical way, for example in stressful or demanding situations. In the context of psychosis, however, these experiences of compromised mine-ness are much more literal, involving an uncertainty on a profound level, not just in relation to the specific experience, but even in relation to one’s own sense of reality and existence (Panas & Handest, 2003). All severity degrees of unstable, disturbed, or distorted subjectivity are found in psychosis: from the mild, limited, and transient to the severe, wide ranging, and long term. The disturbance can affect a few or many types of mental and bodily experiences (more or less clearly demarcated), such as sight, hearing, smell, taste, touch, thought, feelings, movements, or bodily sensations. Other mental disorders, psychotic and non-psychotic, can also display elements of distortions of subjectivity (see Henriksen et al., 2021). But here they are mostly either limited in time, as in the case of panic attacks, or in a personal context where the basic nature of the disturbance usually is quite clear. This can happen for example in dissociative disorders, major depression, or acute, critical, and perhaps lifethreatening catastrophic events or situations, characterised by overwhelming and severe anxiety.

Prototypical disturbances of subjectivity In the case of schizophrenia spectrum disorders and it’s prodromes, basic self-disturbances are at the centre of these conditions, in the forefront of the clinical picture. All over, the features are quite stable and trait-like, but in some persons, they may slowly worsen, whereas in others slowly decreasing over time. The disturbance usually involve several phenomena or types of experience. The more characteristic (prototypical) the phenomenon, the higher the risk of psychosis. Put differently, more prominent, trait-like, long-lasting, escalating, wide-ranging, and prototypical disturbances of subjectivity mean that there is a higher risk that the disturbance is part of the development of schizophrenia.

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Six basic functions of subjectivity in human consciousness The role of subjectivity for the normal formation of experience is difficult to present in a straightforward way. It is useful to maintain both a dimensional perspective (that mental phenomena exist in different degrees, not just either/or), and, for didactical reasons, a categorical perspective (i.e. distinguishing between more or less differentiated entities of phenomena). In the following, six fundamental ‘existential functions’ normally provided by subjectivity in human consciousness are suggested and outlined, together with examples of corresponding anomalies or disturbances, that is, self-disturbances. A division like this, into ‘functions’, serves a purpose slightly different from the EASE manual’s (Parnas et al., 2005) classification into five domains (see Chapter 8). ‘Existential functions’ are in any case a pragmatic construction, a pedagogic tool by which to even better illuminate how ‘deep down’ in consciousness these changes take place. The domain classification in the EASE manual is however organised according to established (and more detailed) subjective psychopathological aspects, and aims therefore to be conceptually consistent with this field of study. Classification in terms of ‘existential functions’ of consciousness illuminates the roles of subjectivity from a slightly different perspective, and is intended to highlight broader and more general ‘functions’, which is perhaps also more recognisable in ordinary everyday terms and language.

Feeling like oneself Feeling like oneself is one basic and normal function of subjectivity. If subjectivity is intact, this feeling is taken for granted and not consciously thought about. In other words, this can be described as a ‘silent’ and intrinsic part of self-experience. Persons with schizophrenia may not be able to spontaneously confirm that they ‘feel like themselves’, or some may even feel that they no longer know what it is to be oneself: ‘I have completely lost myself’. It is obvious that this feeling will affect all sides of life in a highly daunting way. Client quotations, based on research and clinic, related to disturbances of this particular ‘existential function’ are listed in Chapter 7.

Feeling whole, coherent, and having a core Our normal, intuitive feeling of having a core is also intricately connected to the feeling of being oneself. This feeling provides an experience of having a unifying centre, of being whole and coherent, a function that also includes bodily experiences and bodily sensations. Having a core is important for normal bodily experience (corporeality), and for a feeling of integration, that is, that the body and mind are completely and inextricably intertwined (Merleau-Ponty, 1945; Fuchs & Schlimme, 2009; and see Parnas et al., 2013 [‘inner and outer’]). Disturbed subjectivity can manifest itself as a feeling that the different parts of the body do not 69

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seem to work or fit together, that they change size, get interchanged, or do not belong to the same person. Some also feel that internal organs or the brain are removed or destroyed.

Client (and research participant) quotations: the experience of not having a unifying core (Møller & Husby, 2000; Møller, 2000b, 2001. Consent to publish obtained. This applies to all samples of quotations in this book) • • • • • • •

It’s as if my inner core has disappeared It feels like my left and right lower arm have changed places It’s like parts of my body don’t belong to each other, as if my head is just stuck on to the rest I don’t understand what’s happened to one of my legs, it doesn’t feel like mine Sometimes when I look at my arms and my hands, it feels like they are not mine It’s difficult for me to understand that it is me inside this body The centre cannot hold (Saks, 2007)

A feeling of presence (in phenomenology: primary presence) Another category of pre-reflective experience (i.e., that we are not normally conscious of) is the feeling of being mentally and physically present. Phenomenologists refer to this as primary presence (see Parnas & Handest, 2003), which is the experience of being able to feel a general, natural, and unproblematic belongingness to, or a feeling of being present in, one’s own body, one’s own mind, and the physical world in which we are situated. This phenomenon can be difficult to grasp, again because it is usually one of life’s ‘obvious’ facts. When severely disturbed, it can give rise to a feeling of deep restlessness and displacement, a painful feeling of not belonging anywhere, a pervasive unease about one’s very existence.

Client/participant quotations: the experience of not feeling present • • •

I’m not a part of this world I feel painfully cut off from the world I don’t really feel as if I’m here

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• • • • • •

The world around me is just an illusion I can’t decide whether I should sit or stand I don’t understand what the world is, it’s become a meaningless place, where I can’t find a place for myself I feel like I have become disconnected to other people I no longer know where I should be or what I should do I have to constantly find out and analyse where I’m supposed to be

A feeling of owning one’s experiences A disturbance of the feeling of owning one’s experiences can lead to a strong sense of doubt about where an experience really arises, belongs, or takes place. One dramatic example of this type of disturbance is when one’s thoughts no longer fully and completely feel like one’s own but assume a distant and foreign quality. Both the content and the relevancy do not feel quite right, as if the thoughts come from, or are steered by, something or someone else. This sense of (almost literal) anonymity can of course apply to all other types of experiences, including feelings, perceptions, touch, and movement, and it is easy to imagine that such distortions of the things we normally take for granted in our mental lives lead to detrimental consequences for our sense of identity. As can easily be imagined, disturbed ownership to one’s thoughts can further develop into the classical psychotic idea that ‘someone has put thoughts into my head’. This formulation (and experience) is one of the most well-known and discussed examples of psychotic ideation in psychiatric practice and academic literature (Sass, 1994). For this reason, this phenomenon – conviction of thought insertion – has for more than 100 years been regarded as a relatively certain sign of schizophrenia (i.e., pathognomonic).

Client/participant quotations: the experience of not owning one’s experiences • • • • •

In a very strange way, thinking is just going on inside of me – it feels like it’s not me thinking the thoughts in my head The head starts thinking by itself I have a strong sense of grief deep within me that I can’t understand, because it’s as if it’s not my own grief Wants and needs are not a part of me anymore, I can’t even think about tomorrow I’m not sure if it is me who is looking at the picture, or if it’s the picture looking at me

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Feeling alive and vital Another area of our mental life which is dependent upon intact subjectivity is the feeling of being alive and vital. That feeling too can be severely disturbed and has been expressed by many clients (and research participants) as feeling dead, mechanical, machine-like, like a robot or feeling ‘off-stage’ in one’s own life. This implies that life seems flat, one-dimensional, and artificial. A person can recognise and, in a sense, understand that s/he is physically alive (can move around, etc.), but that this does not feel fully true. The natural feelings of vitality may well be dependent precisely upon the experiential qualities discussed in this chapter being intact: that we feel like ourselves, that we feel whole and integrated, physically and mentally present, and the natural centre and owner of our own mental and physical lives. When several of these qualities become significantly compromised, the normal feeling of depth to our existence will naturally be affected, as expressed by a client. ‘I can remember that I felt like a robot when I was a child. So much that I actually tried to make robot sounds too’. In a fully developed psychotic state, it can be the case that the person may think that s/he is actually dead, or has ceased to exist.

Client/participant quotations: the experience of not feeling alive and vital • • • • • •

I know I’m not dead, but it feels like I’m dead People are human beings, and me too, but I don’t feel human I feel like a tree, as if I’m made of wood Sometimes I don’t know whether I’m dead or alive I’m so pale, sometimes I stand and look in the mirror, does this mean that I’m dead? I touch myself on my face and feel numb. Am I dead?

Understanding the obvious Subjectivity makes it also possible to develop and maintain the natural and automatic ability to understand the obvious things in life, such as intuitively taking for granted that the wind makes the trees move and that the light comes on when you press the switch. In phenomenology, this ability is called common sense (Blankenburg, 1969; Mishara, 2001), but in the current context, it has a different and more specific meaning than just the popular meaning ‘behaving sensibly’. This disturbance refers to the basic understanding of several obvious facts about the world, facts that we have come to understand through a lifetime of experience. We understand in the space of a second the connection between certain events in time and space and have no need to analyse and reflect over these things every time. We know that the light will come on when we press the switch, and that it is the wind making the trees move. 72

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We know that the wheels on a moving car must rotate, and that children make crying sounds when they fall and hurt themselves. In the early development of psychosis, such obvious connections in the world gradually become less obvious and apparent; they can become strange and unfamiliar and, in some cases, totally incomprehensible. This can, even in mild cases, naturally be extremely frightening and cause much suffering and dysfunction in the form of endless brooding (hyperreflection) over events that one previously never needed thinking about.

Client/participant quotations: the experience of not understanding the obvious •

When I see a bonfire burning, I don’t understand why the flames are on top of the wood. • Everything seems new, different, artificial, weird, and ‘unlikely’. • Something has happened that has made me unable to understand anything. • I think about conversations for weeks on end. • Life has been turned upside down, nothing makes sense. • I don’t understand anything, everything has become meaningless and inexplicable. • Everything has turned to nothing. • I can look at my legs, a branch, a piece of furniture, a car – but it’s like the legs aren’t my own, and the things aren’t the same, unrecognisable, meaningless. This chapter has provided an introduction to the concept of subjectivity. Subjectivity’s most important normal ‘existential functions’ or manifestations, together with corresponding functional disturbances, have been briefly discussed and exemplified through multiple client quotations. The next chapter deals with core concepts of the self, and how we learn that we are ‘ourselves’, reflecting the very deepest layers of our self-experience, and how this may be severely altered, resulting in basic self-disturbances.

References à Campo, J., Frederikx, M., Nijman, H.,  & Merckelbach, H. (1998). Schizophrenia and changes in physical appearance. Journal of Clinical Psychiatry, 59(4), 197. Blankenburg, W. (1969). Approach to the psychopathology of common sense. Confinia Psychiatrica. Borderland of Psychiatry. Grenzgebiete der Psychiatrie. Les Confins de la Psychiatrie, 12(2), 144–163. Cermolacce, M., Naudin, J., & Parnas, J. (2007). The “minimal self” in psychopathology: Re-examining the self-disorders in the schizophrenia spectrum. Consciousness and Cognition, 16(3), 703–714.

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Fuchs, T.,  & Schlimme, J.E. (2009). Embodiment and psychopathology: A phenomenological perspective. Current Opinion in Psychiatry, 22(6), 570–575. Henriksen, M.G., Raballo, A., & Nordgaard, J. (2021). Self-disorders and psychopathology: A systematic review. The Lancet Psychiatry, 8(11), 1001–1012. Husserl, E. (1900–1901). Logische Untersuchungen II/2. New York: Routledge & Kegan Paul Ltd. Merleau-Ponty M. (1945). Phénoménologie de la perception. Paris: Gallimard. Mishara, A.L. (2001). On Wolfgang Blankenburg, common sense, and schizophrenia. Philosophy, Psychiatry, & Psychology, 8(4), 317–322. Møller, P. (2000b). First-episode schizophrenia: Do grandiosity, disorganization, and acute initial development reduce duration of untreated psychosis? An exploratory naturalistic case study. Comprehensive Psychiatry, 41(3), 184–190. Møller, P. (2001). Duration of untreated psychosis: Are we ignoring the mode of initial development? Psychopathology, 34(1), 8–14. Møller, P., & Husby, R. (2000). The initial prodrome in schizophrenia: Searching for naturalistic core dimensions of experience and behavior. Schizophrenia Bulletin, 26(1), 217–232. Parnas, J., & Handest, P. (2003). Phenomenology of anomalous self-experience in early schizophrenia. Comprehensive Psychiatry, 44(2), 121–134. Parnas, J., Jansson, L., Sass, L.A., & Handest, P. (1998). Self-experience in the prodromal phases of schizophrenia: A  pilot study of first-admissions.  Neurology Psychiatry and Brain Research, 6(2), 97–106. Parnas, J., Møller, P., Kircher, T., Thalbitzer, J., Jansson, L., Handest, P., & Zahavi, D. (2005). EASE: Examination of anomalous self-experience. Psychopathology, 38(5), 236. Parnas, J., Sass, L.A., & Zahavi, D. (2013). Rediscovering psychopathology: The epistemology and phenomenology of the psychiatric object. Schizophrenia Bulletin,  39(2), 270–277. Saks, Elyn R. (2007). The center cannot hold. A memoir of my schizophrenia. Boston, MA: Little Brown Book Group. Sass, L.A. (1994).  The paradoxes of delusion: Wittgenstein. schreber, and the schizophrenic mind. Ithaca, NY, London: Cornell University Press. Zahavi, D. (2008).  Subjectivity and selfhood: Investigating the first-person perspective. Cambridge, MA: Bradford Books, and MIT Press. Zahavi, D. (2014). Self and other: Exploring subjectivity, empathy, and shame. Oxford: Oxford University Press. Zahavi, D. (2018). Phenomenology the basics. New York: Routledge. Zahavi, D.,  & Parnas, J. (1998). Phenomenal consciousness and self-awareness: A phenomenological critique of representational theory. Journal of Consciousness Studies, 5(5–6), 687–705.

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Figure 7 Two people sitting at a table, with all colours muted as if there is a barrier. In the foreground, with ordinary colours, another person looks at the two, his hands on the table, supposedly feeling isolated and left out.

7 THE SELF AND BASIC S E L F-D I S T U R B A N C E

With yet another small turn of view, but towards the same case complex, we shall now have the concept of the self at the centre. Why such a strong focus on the self and basic self-disturbance in the understanding of psychosis and schizophrenia? Let us listen to the persons ‘wearing the shoes’, when they talk about the time when the disorder was in the early pre-onset period. In that period, there are few words they refer to more than this one: ‘myself’. The recognition of this fact has paved the way for revived phenomenologically oriented research lines on early psychosis phenomena. The core of severe psychotic disorders turns out to be about the core of the individual, his or her very existence – about the self – what in fact makes us feel ‘ourselves’. It is these aspects of self-awareness that are fundamentally altered, and emerge during the pre-psychotic stages of schizophrenia.

How do we become ourselves? Human existence and development are characterised by what might be seen as a dualism. We are fundamentally socially dependent (though some philosophers disagree), but at the same time, we are totally separate individuals. Put differently: we are dependent on others to become ourselves (Kohut, 1977; Baker & Baker, 1987). We form and re-form ourselves continually, not in isolation, but through countless meetings with others and the surrounding world. In the first part of our lives, this process is largely tied to our closest relations, our parents. Through these meetings, we must assume that subjectivity gradually forms and is established (Zahavi, 2008, 2018): we learn – through looks and facial expressions, words and sounds, touch and movements – that the other person is ‘out there’ and I am ‘in here’. I learn that it is only me that is in here, as myself. Slowly but surely, I increasingly manage to distinguish between what is me and mine on the one side, and what is you and yours on the other. We learn that we

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are individuals, separate, unique. We learn, at a pre-conceptual level, that we are ourselves. My experience is that I am myself, and that I am the only person who is precisely me. Without a stable and secure automatic feeling of being myself, I will slide into a state characterised by increasing unreality and alienation. All these points may seem trivial and obvious, yet they reflect the very deepest layers of our self-experience and sense of identity – which serve to prevent total existential chaos.

The existential self and Kierkegaard That the self is at the core of what it means to be human is apparent in an important philosophical passage in the famous book The Sickness Unto Death written by Søren Kierkegaard in 1849. In the introductory paragraph, he puts forward an explanation of the essence of a human being:

What is a human being? ‘The human being is spirit. But what is spirit? Spirit is the self. But what is the self? The self is a relation that relates itself to itself, or is the relation’s relating itself to itself in the relation; the self is not the relation but is the relation’s relating itself to itself. A human being is a synthesis of the infinite and the finite, of the temporal and the eternal, of freedom and necessity, in short, a synthesis. A synthesis is a relation between two. . . . Thus under the qualification of the psychical, the relation between the psychical and the physical is a relation. If, however, the relation relates itself to itself, this relation is the positive third, and this is the self’. Søren Kierkegaard, in The Sickness Unto Death, 1849

Kierkegaard’s interpretation of the self may sound long-winded, but it is important and can be clarified and simplified: he takes as his starting point what he calls a relation, namely the psycho-physical synthesis that exists between body and mind. What he understands to be the self is the process that is occurring when a human being relates to and reflects upon its own self (as a synthesis of body and mind) and its own existence. Today, the researchers of consciousness would refer to this as self-awareness, understood as the self being aware of itself. In close accordance with Kierkegaard, the founder of existential philosophy, we could thus define the self in these terms: the self is our (body-and-mind) reflection over ourselves and our existence. And here lies the important point in the context of this book: it is the preconditions underlying such normal or sound self-reflection that are altered in basic self-disturbances.

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The self in self psychology As mentioned earlier, the most renowned branch of psychology which uses the self as a central pivot of understanding is self psychology, which was developed in the 1960s, 1970s, and 1980s by the Austrian-American psychiatrist and psychoanalyst Heinz Kohut (for an overview, see Baker & Baker, 1987). As a branch of psychoanalysis, it was a modernisation breaking with classical Freudian psychoanalysis. It focuses on a person’s emotional struggles with themes such as identity, meaning, ideals, and, crucially, their self-experience. The theory describes in detail the different phases a human being must go through to develop a self, either a mature and well-adjusted self or a less mature or immature self. It describes the conditions which are necessary, and the needs that must be met in specific phases of childhood and adolescence to avoid deficient or skewed development. Self psychology places a decisive emphasis on a dynamic and longitudinal conceptualisation of the development of the self, and it has also developed corresponding therapeutic interventions that target the various problems relating to deficient or skewed self development.

The self in art If we step for a moment outside of our own scientific field, we will see that ‘the self’ is also very central in many areas of art, particularly the visual arts and literature. This further confirms the status of the self as one of the most important themes of human existence, and art can bring important nuances and contrasts to our understanding of the self, through in-depth studies of individual works. The Norwegian novelist Karl Ove Knausgård has for example told about how Edvard Munch’s ambition was to paint the story of the self. Artists such as Munch and others, in the same way as poets, are in a unique position to express what is almost inexpressible in any other way about human life, about the inner and deepest core of our existence, that can only be perceived outside of our ordinary, more direct forms of verbal communication. It is practically impossible to find fitting words or descriptions to the facial expressions in many of Munch’s works, simply because they express so much and so broadly about the human condition. Phenomenology refers to the term ‘ineffability’, meaning ‘not suitable for verbal expression’. This is clearly the essence of poetry and other types of art: they are unique and alternative channels for conveying what cannot be expressed in ordinary, everyday language and words. The Swedish poet Gustav Fröding (1860–1911) had interesting descriptions of his own psychotic disorder in a letter to his sister Cecilie in August 1894 (my parentheses and italics): I am not so bothered by my visions (hallucinations) and fantasies (delusions) now, but they certainly have been interesting, and perhaps I could put them to good use someday when my faculties return. It is true as 78

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you say that I am to blame for my own loneliness, but occasionally I do miss socializing with others, and I try to be like them, but usually fail. It is as if we are from different races and do not understand each other. I have occasionally wondered whether it is about differences in ability – where sometimes it is I who is superior and sometimes it is them – but it is not the case, it is about a fundamental difference in nature, having nothing to do with superiority or inferiority. I am from the moon or Jupiter and have arrived here by a misunderstanding, and here I am regarded as a changeling, and I feel very much like one myself. If one is relatively well, this feeling of alienation does not mean so much – one is a tourist and can have some fun and games with all the things one sees, and which one regards as absurd. One can collect various types of personalities and ways of living from the human flora of this foreign land, finding everything interesting and scientifically valuable. Then he writes the following on the more acute psychotic phase in a letter to his friend Mauritz Hellberg in September of the same year. The strange expression ‘transcendalised’ at the start of the text is a very unusual formulation and is an interesting and illustrative way of describing sliding into a psychosis. ‘Transcend’ is about crossing a boundary and can be used in a concrete (physical) sense or an abstract (mental) sense. I transcendalised to such an extreme level . . . in my attempts to understand myself, and in so doing I travelled almost totally out of material existence. Something as desperate as my struggles to understand the relationship of the soul to the body, or the individual self’s relationship to the rest of the world, I had never experienced earlier. It was quite illuminating, but not always enjoyable or pleasant, and the delusions began to totally overwhelming me. The whole thing was very destructive, because that old, evil spirit, who always denied me and always mocked me, was too strong. Fröding’s words and formulations from 1894 are almost blueprints of several of this book’s examples of self-disturbances. He experiences inner changes that are so strong that he feels like a different race to everyone else, as well as feeling an almost total barrier to understanding himself and the world. He writes about fundamental differences in nature – which is indeed a powerful expression – as if he was from a different planet, and that he has himself arrived here by mistake. He calls the experience a feeling of alienation and that everyone else comes from the ‘human flora’ of a foreign land. When he tried to understand himself, he almost travelled out of material existence. He suggests that endless reflections and worries took over. He tried to work out the relationship between the soul and the body, the individual ‘self’s’ relationship to the world, and writes that it was the most difficult thing he had experienced. This is an erudite and illuminating account of the 79

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psychotic experience, a condition that seems to have had a similar and universal nature throughout history. It is this timeless, subjective ‘pattern’ of disturbances which reflects the essence of the Subjectivity Model. Fröding’s expression, ‘from different planets’, is unlikely to be taken literally (unless being in a psychotic phase), but probably expresses in any case something much stronger than a common metaphor; the metaphor is not merely a metaphor. Psychosis patients’ relationship to the use of metaphors is in itself an important issue in clinical work, which I will return to when discussing interviewing techniques and the EASE instrument (Chapters 8 and 9).

The self in phenomenology From phenomenological psychiatry and philosophy, there are numerous published descriptions of the concepts of self and self-disturbances, related to schizophrenia and psychosis. Not surprisingly, none is short and simple. I will here draw on a couple of illuminating descriptions that extract essential elements of the phenomenological self. Nelson et al. (2014) summarises: There are many different meanings and controversies surrounding the notion of the ‘self’ (Parnas et  al., 2013). These controversies mainly concern its ontology or ultimate reality status, for example, as a kind of ‘substance’, object, or process. The experiential, subjective notion of the self (the sense of self) is, however, widely acknowledged, both in the analytic philosophy of mind (Dainton, 2008) and in phenomenology (Zahavi, 2008). The level of the experiential self is typically proposed as the ‘minimal’ self, also referred to as ‘basic’ or ‘core’ self or as ‘ipseity’. This is a pre-reflective, tacit level of selfhood. It refers to the implicit first-person quality of consciousness, that is, the implicit awareness that all experience articulates itself in first person perspective as ‘my’ experience. In other words, all conscious acts are intrinsically (at the same time) self-conscious (Janzen, 2008), a feature sometimes designated as ‘self-affection’. ‘Minimal’ or ‘core’ self constitutes the foundational level of selfhood on which other levels of selfhood are built (Zahavi, 2008; Janzen, 2008; Parnas, 2003). Nordgaard et al. (2021) provide a parallel and complementary description: The contemporary concept of self-disorders refers to a disturbed structure of phenomenal consciousness, that is, to a disturbed sense of the experiential or minimal self (Zahavi, 2014). Thus, the ‘self’ that is proposed to be disturbed in schizophrenia is a very basic experiential sense of self, that is, more specifically, the very first-personal structure of experience. . . . Experiences are given to the subject of experience 80

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in a way in which they are not given to anybody else, namely, firstpersonally. This first-personal given-ness, which persists through temporal change and across different modalities of consciousness (e.g. perception, imagination, and thinking), imbues the experience with an inchoate sense of singularity, individuation, or a basic sense of selfpresence (experiential self, minimal self, or ipseity) (Parnas & Henriksen, 2016). This intimate, fundamental sense of self-presence is given prior to self-reflection and knowledge. Usually, I do not need to reflect upon who it might be that experiences this or that, entertains these thoughts or emotions, or moves my body. Typically, such questions never arise, because the answer is already pre-reflectively given (Henriksen & Nordgaard, 2014) – it is, so to say, woven into the fabric of the experience itself; the experience is given for-me. Phenomenologically speaking, this basic experience of being a self is intrinsically bound together with an automatic, pre-reflective immersion in the world. The minimal self is a ‘structural’ feature of phenomenal consciousness that is operative in all experiences, for example, experiences of oneself, others, and the world. Adding to these not quite easily accessible theoretical accounts, there are also some entailing clinical, more explicit aspects that may serve to further clarify and delimit this phenomenologically inspired concept of self. First, there is no decisive emphasis on the longitudinal, developmental perspective over the lifespan, like in self psychology (Sass & Parnas, 2003). This is not because aspects of developmental psychology are seen to be less important, but because the phenotypical (clinically manifested) development of psychosis typically occurs over a limited time period, often in the late teens or in the early 20s. Second, and notably not as a plain consequence of the previous point, the phenomenological concept of the self emphasises the immediate, momentary nature of the sense of self, or self-experience, what is experienced here and now, in every current moment, continuously over time. Moreover, in the case of self-disturbances, the emerging distortions of this global, non-thematic, tacit self-experience is often (but not always) manifested clinically as a rather pronounced ‘developmental break’. Seen from self psychology, change in self-experience usually is spoken about as a certain dynamic, in relation to the longer course: the deficient and immature self is something resulting from a long developmental pathway, over large parts of the lifespan. Self-disturbances in psychosis, however, usually emerge over a period of weeks or months (but may even be years), and often directly triggered by exceedingly difficult or stressful life events or life situation. The disturbances are also often appearing during the period when the brain shows a developmental spurt, that is, in puberty. It is usually possible to locate in time an (approximate) onset, a clinically recognisable ‘break’ in the person’s development. This is not so much the case if self psychology would describe the ‘beginning’ of the manifestations of an immature self. Third, as outlined earlier, and most importantly 81

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in clinic, phenomenology is concerned with levels of the self and identity experiences that are completely inaccessible to direct conscious introspection. They concern the very feeling of existing, of being alive and ‘human’, and of being the subject and owner of one’s experiences. Contrastingly, in mental disorders classified as for example personality disorders or neurotic disorders, there can be great pain involved in feelings such as identity confusion, insecurity, shame, and inadequacy, but this suffering is in principle available for conscious reflection. The experience of losing oneself, however, at the basic level of subjectivity, represents a much more profound and ‘structural’ disturbance of human self-experience. Needless to say, this may have great impact on treatment.

Sense of identity: conscious and unconscious levels Finally, the aforementioned theoretical and clinical accounts of the self may alternatively also be explicated in terms of levels of ‘identity feeling’. Namely, our experience of identity (or self) can be described and understood as existing on different consciousness levels (Zandersen & Parnas, 2019; Parnas & Henriksen, 2019; Henriksen et al., 2021). In the following, levels of ‘identity feeling’ will be described, which may be didactically useful to see more clearly at which level the self-disturbances occur in psychosis and schizophrenia. It will obviously have appeared by now that the automatic and unproblematic feeling of being oneself is a basic, first-personal pre-condition for an ordinary, harmonious human life. This feeling appears to represent the deepest level of the sense of identity, and normally we are not explicitly conscious of or talk about this level, and we take it fully and completely for granted. From this deepest level, we can move ‘upwards’ and describe identity levels which are increasingly open, accessible, and ‘superficial’. Let’s start, however, with the highest level, and work down. Sense of identity – the narrative level: conscious everyday identity This is the most accessible and communicable level, which in summary includes the entire ‘CV’ of our personal life. In everyday interactions, this is where we tell each other such things as what we do for a living, about our interests, skills, education, and experience, where we have travelled, our likes and preferences, plans and dreams for the future, and memories of events and mileposts in the past. In summary, this level is about all aspects of what is mainly conscious in our life. It is those sides of our sense of identity that we are fully aware of on a daily basis and carry with us, know well, and usually share with others. This is the level that most people recognise as their ‘common sense identity’. Many people for example say such things as ‘my job and my interests are important parts of my identity’. From this main everyday level, it is possible to move somewhat further ‘down’ and identify narrative phenomena that are a little less readily accessible, and that we are not prepared to share with everybody. Here we may find phenomena such as personality traits, behavioural tendencies, and vulnerabilities that regulate our ways of 82

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interacting with others. For example, in the face of personal criticism or frustration, we might show tendencies to withdrawal, self-criticism, or suspicion, or alternatively tendencies to get offensive, angry, sarcastic, or intellectualising. Such tendencies are also a part of our view of ourselves, our sense of identity, but they are somewhat less conscious and explicit. However, they are aspects of our functioning that can quite readily become objects of more conscious attention, for example in psychotherapy. Sense of identity – the reflexive level: I am the same over time Further ‘down’, we may speak of a level that supports the indeed important feeling of being the same person over time, in a quite basic sense. Naturally, we are in a certain respect constantly changing over the course of our lifetimes because of constant new events and experiences. However, these changes are fairly slow, small, and shallow, and we largely experience that we are still the same person ‘deep down’ today, as we were 5, 25, or even 45 years ago. We can call this a reflexive level of sense of identity, a level we can consciously experience and reflect over, even if it is quite global and non-thematic. Even though this level is, to some extent, accessible to introspection, it is at the same time a relatively deep lying part of the sense of identity. We can reach an awareness of being the same person over time through active self-reflection: we can recognise a kind of nonspecific feeling of possessing an inner constancy. Sense of identity – the pre-reflexive level: I am myself From what we have now discussed, we can see that our experience of who we are, that is, our experience or sense of identity, is dependent upon (1) thousands of trivial, everyday details regarding our inner and outer life events, as well as our personality traits, and (2) the fundamental feeling of being the same person, stably over a longer period of time. Nevertheless, there remains (3) an even deeper identity level, much more difficult to become aware of because it is wordless, invisible, implicit, and silent. This level of the minimal or core self is the level of consciousness where subjectivity ‘operates’, which takes care of indispensable functions of mental life, outlined in the previous chapters. Subjectivity makes sure that we feel like ‘ourselves’, that we perceive a ‘core’, that we feel whole and coherent (physically and mentally), that we feel present (in our mind, body and world), and that we own our experiences, that is, that my experiences in fact happen in me, and are generated by me. According to the Subjectivity Model, it is at this deepest identity level basic self-disturbances in pre-psychosis and psychosis are operating. When attempting to understand the model, in my experience, not going sufficiently ‘deep down’ may easily result in fundamentally misconceiving the issues. Other seemingly parallel models of selfhood have been proposed, however building primarily on the level of the narrative self (Mishara et al., 2014) or on the dialogical aspect of selfhood (Lysaker & Lysaker, 2010). 83

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It is imperative to underline that when mental health clinicians work with and talk of identity alterations in psychosis, it is easy to think about the higher, more accessible, and more ‘superficial’ levels. If so, we will fail to understand the essential dynamics of the basic self-disturbance. These profound disturbances will have destructive consequences for all aforementioned levels: one can then begin to doubt whether one is the same person from time to time, or become fundamentally unsure whether one’s past life events (narrative), or events from day to day, really have happened. According to what is outlined, forces of change operating between the levels of identity mainly work ‘upwards’, not ‘downwards’. There is of course a continuous and seamless transition between the levels (encompassing self-experience as well as self-reflection), but the higher the level of identity, the greater availability for reflection, and the deeper the level of identity, the less opportunity for explicit reflection.

Disturbed sense of identity: losing oneself We have seen how humans experience identity and learn that we are ‘ourselves’, even prior to words and concepts. Chapter 3, on the content of the prodromal phase, began with a discussion of a central experience that persons with schizophrenia very often tell about, namely, the experience of ‘losing oneself’. Thus, the self, sense of self, and self-experience are indispensable concepts in the Subjectivity Model, if we are to understand these phenomena. This point emerges quite clearly from what the main persons consistently tell us when they try to describe the most prominent and troublesome aspects of the prodrome and early psychosis (‘I have lost myself’ or ‘I don’t know who I am’, etc.) (Parnas et  al., 1998; Møller & Husby, 2000, p. 222; Parnas &Handest, 2003). It is striking how pervasively the words I, me, myself, oneself, ourselves, himself, herself, the self, etc. are used by clients to describe the prodrome. Similar descriptions and experiences are also reported in fully developed psychosis (e.g. Haug et al., 2012; see Henriksen et al., 2021), but then the total symptom picture is often overshadowed and dominated by the more salient psychotic phenomena. The psychotic symptoms represent further developments of conscious interpretations of the changes of ‘the self’, but even though they are conscious, they are often irrational. Therefore, when it comes to treatment, it is the road back, from the (present) irrational psychotic interpretations to the (previous) pre-psychotic ‘as if’ experiences, that needs to be investigated and pursued, put on words, and understood. Persons who are possibly developing psychosis (being in the prodromal phase) clearly express something happening deep within, something touching the very centre of what it is to be human. At a cliché level of presentation, the clients formulate their experiences as seemingly quite unspecific complaints, as already shown: ‘I do not know how to live’, ‘I do not fit to the world, ‘I’m not myself’, etc. These expressions, however, conceal profound transformations in the way s/he experiences her-/himself and the world, changes that can only be disclosed after more intense psychopathological investigation beyond this surface level of presentation (Parnas et al., 1998). This is also reflected in the almost insurmountable difficulties 84

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to verbalise the changes (Møller & Husby, 2000), and it underscores the importance of learning from the many informative and revealing quotations from clients and research participants, that form the basis for the Subjectivity Model. Whereas intricate philosophical-phenomenological descriptions can sometimes get a little lost, the occasionally almost poetic (but accurate) words expressed by clients can be a fantastic aid to communication. Some client quotations follow, as a concluding exposition of this chapter, self-transformations representing the centre of the Subjectivity Model:

Client quotations: the experience of not feeling like oneself (Møller & Husby, 2000; Møller, 2000b, 2001). (Consent to publish obtained) • • • • • • • • • •

I am losing contact with myself It feels like my own core is missing I have lost my entire self I am not myself any more I am myself, but I cannot find myself Something has ripped my personality out of me Something inside me has become unhuman (non-human) I don’t understand who I am any more I have become a spectator to my own life My inner self is disappearing

This chapter has dealt with some different self concepts, and how we learn that we are individuals, separate, unique, that is, how we learn, at a pre-conceptual level, that we are ourselves. This reflects the very deepest layers of our selfexperience and sense of identity, which may be altered in schizophrenia. In the following chapters, these phenomena of self-disturbance will be linked to various practical, clinical contexts. First, clinical assessment and evaluation are discussed, and thereafter various treatment approaches, aimed at self-disturbances, will be presented.

References Baker, H.S., & Baker, M.N. (1987). Heinz Kohut’s self psychology: An overview. American Journal of Psychiatry, 144(1), 1–9. Dainton, B. (2008). The phenomenal self. Oxford: Oxford University Press. Haug, E., Lien, L., Raballo, A., Bratlien, U., Øie, M., Andreassen, O. A., . . . & Møller, P. (2012). Selective aggregation of self-disorders in first-treatment DSM-IV schizophrenia spectrum disorders. The Journal of nervous and mental disease, 200(7), 632–636. Henriksen, M.G., & Nordgaard, J. (2014). Schizophrenia as a disorder of the self. Journal of Psychopathology, 20, 435–441.

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Henriksen, M.G., Raballo, A., & Nordgaard, J. (2021). Self-disorders and psychopathology: A systematic review. The Lancet Psychiatry, 8(11), 1001–1012. Janzen, G. (2008). The reflexive nature of consciousness (Vol. 72). Amsterdam: John Benjamins Publishing. Kohut, H. (1977). The restoration of the self. New York: International Universities Press. Lysaker, P.H.,  & Lysaker, J.T. (2010). Schizophrenia and alterations in self-experience: A comparison of 6 perspectives. Schizophrenia Bulletin, 36(2), 331–340. Mishara, A.L., Lysaker, P.H.,  & Schwartz, M.A. (2014). Self-disturbances in schizophrenia: History, phenomenology, and relevant findings from research on metacognition. Schizophrenia Bulletin, 40(1), 5–12. Møller, P., & Husby, R. (2000). The initial prodromal in schizophrenia: Searching for naturalistic core dimensions of experience and behavior. Schizophrenia Bulletin, 26(1), 217–232. Møller, P. (2000b). First-episode schizophrenia: Do grandiosity, disorganization, and acuteinitial development reduce duration of untreated psychosis? An exploratory naturalisticcase study. Comprehensive Psychiatry, 41 (3), 184–190. Møller, P. (2001). Duration of untreated psychosis: Are we ignoring the mode of initialdevelopment? Psychopathology, 34 (1), 8–14. Nelson, B., Parnas, J., & Sass, L.A. (2014). Disturbance of minimal self (ipseity) in schizophrenia: Clarification and current status. Schizophrenia Bulletin, 40(3), 479–482. Nordgaard, J., Henriksen, M.G., Jansson, L., Handest, P., Møller, P., Rasmussen, A.R., . . . & Parnas, J. (2021). Disordered selfhood in schizophrenia and the examination of anomalous self-experience: Accumulated evidence and experience. Psychopathology, 54(6), 275–281. Parnas, J. (2003). Self and schizophrenia: A phenomenological perspective. In T. Kircher, A.S. David, & A. David (Eds.), The self in neuroscience and psychiatry. Cambridge: Cambridge University Press, pp. 217–241. Parnas, J., & Handest, P. (2003). Phenomenology of anomalous self-experience in early schizophrenia. Comprehensive Psychiatry, 44(2), 121–134. Parnas, J., & Henriksen, M.G. (2016). Mysticism and schizophrenia: A phenomenological exploration of the structure of consciousness in the schizophrenia spectrum disorders. Consciousness and Cognition, 43, 75–88. Parnas, J.,  & Henriksen, M.G. (2019). Selfhood and its disorders. In G. Stanghellini, M. Broome, A. Raballo, A.V. Fernandez, P. Fusar-Poli, & R. Rosfort (Eds.), The Oxford handbook of phenomenological psychopathology. USA: Oxford University Press, pp. 465–474. Parnas, J., Jansson, L., Sass, L.A., & Handest, P. (1998). Self-experience in the prodromal phases of schizophrenia: A  pilot study of first-admissions.  Neurology Psychiatry and Brain Research, 6(2), 97–106. Parnas, J., Sass, L.A., & Zahavi, D. (2013). Rediscovering psychopathology: The epistemology and phenomenology of the psychiatric object. Schizophrenia Bulletin, 39(2), 270–277. Sass, L.A., & Parnas, J. (2003). Schizophrenia, consciousness, and the self. Schizophrenia Bulletin, 29(3), 427–444. Zahavi, D. (2008).  Subjectivity and selfhood: Investigating the first-person perspective. Cambridge, MA: Bradford Books, and MIT Press. Zahavi, D. (2014). Self and other: Exploring subjectivity, empathy, and shame. Oxford: Oxford University Press. Zahavi, D. (2018). Phenomenology the basics. New York: Routledge. Zandersen, M., & Parnas, J. (2019). Identity disturbance, feelings of emptiness, and the boundaries of the schizophrenia spectrum. Schizophrenia Bulletin, 45(1), 106–113.

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Figure 8 A very pale boy’s face in a bathroom mirror, he touches his own cheek as if searching for something, looking worried and bewildered.

8 D I A G N O S T I C S, P H E N O M E N O L O G Y, A N D T H E EASE MANUAL IN THE FIELD OF PSYCHOSIS RISK

To investigate basic self-disturbances in clients in a meaningful and proper way, it is necessary to have a certain degree of relevant experience, insight, and knowledge. One needs to understand the basic nature of the self, subjectivity, and self-disturbance, as discussed in the previous chapters, and to understand their significance in the possible development of psychosis. This chapter presents some reflections on diagnoses and diagnostics, in general and in the context of psychosis risk, self-disturbances, and the EASE manual. Furthermore, some basic abilities of the EASE are presented, as an instrument especially developed to aid the clinical examination of selfdisturbances. The next chapter will then present the five domains of the EASE in some detail. It is strongly recommended to read the official introduction to the EASE manual, as found in the original publication (Parnas et al., 2005).

Diagnostics in the light of psychosis risk Diagnostics exist as an aid to systematic study but do not represent any complete or ultimate truth about mental conditions or mental phenomena. Self-disturbance is not a diagnosis, but nevertheless something similar, in the sense of being a clinical concept. Without concepts, it is impossible to think systematically. As a word and an activity, diagnostics seems strange and incongruent in the context of ‘a possible increased risk of psychosis’. Even though several research-based criteria for such at-risk mental states do exist (Miller et al., 2003; Yung et al., 2005), there is no generally accepted diagnostic category for psychosis risk. Nevertheless, the DSM-5 (2013) has put forward a tentative category, attenuated psychosis syndrome, which will be further investigated to clarify its potential conceptual justification. This condition has thus been assigned to a DSM-5 section titled ‘conditions for further study’. Therefore, it is in principle still impossible to provide

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an official diagnosis for such at-risk states. This is in fact a good thing, simply because we presently have nowhere near sufficient understanding about what characterises such conditions. (A possible solution on a purely technical level, to meet the demands of public authorities for diagnostic documentation, could be to use ICD-10 F21 (WHO, 1992), schizotypal disorder, a condition which is closely related to schizophrenia phenomenologically, but which does not present (fully developed) psychosis phenomena.)

Precise diagnostic definitions of mental phenomena are in principle impossible Even in general, diagnoses and diagnostics in mental health are subject to considerable discussion, from both within (Andreasen, 2007; Fusar-Poli et al., 2019; Connors, 2021) and outside of the professional and academic field. Leading academics and professionals over many decades have emphasised that diagnoses should be regarded as working tools and a necessary aid to professional work, but that they also carry with them several significant limitations (Andreasen, 2007). Nevertheless, diagnoses have become widely recognised and used. Moreover, according to clinical experience in the last couple of decades, explaining to clients about their own diagnosis is increasingly common and regarded as basic good practice. For this reason, several challenges arise when it comes to a proper understanding and practice of diagnostics, including their use and how they are presented to clients. A major concern is that over time diagnoses tend to become almost like a ‘given truth’. They may easily be misconceived and regarded as complete, correct, and stable definitions of the different mental disorders, which of course they are not. Even with the right kind of precautions, diagnoses and diagnostics in the field of mental health still present a considerable professional challenge, simply because precise diagnostic definitions of mental phenomena are in principle impossible. The mind is abstract, transient, and in constant flux, and there is absolutely no way of weighing, measuring, or ‘capturing’ it completely or precisely.

Sorting and clarifying in the best possible way But with all limitations said, what is the alternative, particularly in the field of psychosis risk? Persons who actually are developing psychosis are extremely vulnerable, suffer greatly, and are often desperate to find help to understand what it is that is tearing their lives apart. Both the main persons and their family may ask the following questions: What is this? What is going on? Can anything be done? It is the duty of professionals to listen very closely, for as long as needed, and thereafter to use all available knowledge to provide an overview. Signs and experiences should be sorted and clarified in the best possible way, to create some order of the chaos. Furthermore, after the assessment, therapists should to a reasonable degree

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be able to answer the central question from the distressed families: What is happening? In medicine, in mental health, and all illness sciences, it is precisely this kind of sorting and clarifying that is usually referred to as diagnostics. But perhaps a better name would be a ‘provisional summary of mental health status’? The overall rationale behind diagnoses is that most disorders and illnesses in bodily and mental functions follow certain basic patterns, which reflects the fact that all humans have a certain functional commonality, even though every individual is unique. If it were the case that diagnostic sorting and clarification was only based on the individual health professional’s personal and individual experience and knowledge, the result would be chaos and, not least, potentially dangerous. The role of scientific health research is quite simply to continuously improve our understanding of the basic nature of bodily and mental conditions, to illuminate more and more facets of these, and to constantly develop better ways of dealing with the limitations of diagnostics. It is probably this latter aspect – the limitations – that might be inadequately addressed by mental health professionals today. This also applies, not the least, to the provisioning of reasonable and adequate information to service users themselves and their families. Accordingly, the research on basic self-disturbances is motivated by the need to discover and describe more accurate clinical characteristics in the case of psychosis risk (see Henriksen et al., 2021). The ‘official criteria’ that currently apply in the field of ultra-high risk are the SIPS/SOPS (Miller et al., 2003) and the CAARMS instruments (Yung et al., 2005). Even though people identified with these criteria have significantly greater risk of psychosis compared to the general population, substantially declining rates of psychosis conversion are reported in recent years (Yung & Nelson, 2013). In this situation, basic self-disturbance would have the potential to function as a clinically useful supplementary risk criterion, thereby improving precision. There is a logical and inevitable connection between the indeed profound nature of self-disturbances on the one side, and the wide range of its effects on mental life and daily functioning on the other side. This is also apparent in clinical work, in that many self-disturbance phenomena (reflected by the items of the EASE) are of a severe and deeply disturbing nature. The severity may be such that many individuals, after a certain period of time, is incapable of functioning and coping without help. There is barely any area of daily life and experience, bodily or mental, that cannot be affected by self-disturbances. In this sense, it may seem a little strange to call the many and varied phenomena disturbances of the self, when these can involve everything from thoughts, perceptions and ambivalence, to attention, bodily movements and views of the world. However, the reason for this is that the wide range of phenomena merely reflects the central structural role of subjectivity in all forms of experience. Disturbed subjectivity can be traced and revealed in all facets of life, and a transformed sense of identity is always the consequence, in one way or another: that is, the feeling of what, who, and how (and even where) the person is.

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The EASE – a combined qualitative/ quantitative instrument The Examination of Anomalous Self-Experience (EASE) (Parnas et al., 2005) is a symptom checklist for semi-structured, phenomenological exploration of experiential or subjective anomalies that may be considered as disorders of basic or ‘minimal’ self-awareness. The EASE is developed exclusively on the basis of self-descriptions obtained from clients diagnosed with schizophrenia spectrum disorders (a group of disorders including schizophrenia and closely related conditions). The instrument has a strong descriptive, diagnostic, and differential diagnostic relevance, particularly for disorders within the schizophrenia spectrum. The EASE manual is a compilation of 57 aspects or experiences (main items) of self-disturbance. These are assumed to be the most central kinds of distortions and transformations in daily experience which are frequently and consistently reported by persons themselves, especially in the prodromal phase but also, albeit to a more limited degree, in fully developed psychosis. These phenomena span an almost infinitely wide spectrum of experience. There are several highly characteristic (prototypical) self-disturbances, which may be signs of a developing schizophrenia spectrum condition, and there are less characteristic phenomena, which also can indicate risk for other types of psychotic disorders, and certain other mental condition. Shorter item lists of self-disturbances (for certain epidemiological use or for quick first-line clinical screening) have also been developed. One of these, the SQuEASE-6, is shown at the end of this book, and is shortly described at the end of next chapter. This screening instrument contains a small sample of frequently occurring self-disturbance phenomena, based on clinical experience, theoretical and technical considerations, and empirical studies. The EASE manual can also be regarded as a ‘scale’, because it is possible to specify degree of severity using approximate quantitative measures on the individual items. It is therefore also possible to create a sum score (EASE total score), after the full administration of the EASE. This unit of measurement is the one used in most publications. However, it is still the case that the qualitative (non-scalable) aspects of EASE are the most important, with the aim of providing rich and informative clinical images. Put differently, it is of utmost importance to closely address the characteristic content of the phenomena, to ensure that we identify them correctly (thereby ensuring validity). Specifying their strength or intensity is of less importance, though sometimes relevant. This is because the need for treatment measures is so central, and the nature of the treatment has to be determined by the overall qualitative pattern (Gestalt) of the disturbance, that is, the total picture seen in each individual, being the sum of any identifiable aspect. The meaning and the consequences of the entire individual sum of basic selfdisturbance will also depend on the individual’s coping abilities when meeting these basic personal changes.

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Psychometric properties of the EASE Interrater reliability presupposes clinical experience, psychopathological knowledge, and a training course in the EASE interview and scoring. The interrater reliability of the EASE scale has been investigated by several researchers. A study by Vollmer-Larsen et al. (2007) was based on the Bonn scale, and reported an interrater reliability (IRR) (Cohen’s kappa) of >0.60 for 68 out of 79 phenomena. Recent, larger studies have demonstrated the IRR to be good to excellent (Møller et al., 2011; Nordgaard et al., 2012, 2018). Møller et al. (2011) reported an interrater correlation (Spearman’s rho) between two independent raters of >0.8. The average IRR (Cohen’s kappa) value for the whole EASE scale was 0.65 and varied from 0.51 to 0.73 across the five domains. In a five-year follow-up study, Nordgaard et al. (2018) found an IRR between baseline and follow-up interview of 0.81. The internal consistency (Cronbach’s alpha) has been reported to be 0.85 (Møller et al., 2011) and 0.9 (Nordgaard et al., 2014), and the correlation between the EASE total score and the domain scores was moderate to high (0.55–0.93). Factor analysis, using Varimax rotation in principal component analysis (PCA) for the five domains, yielded a one-factor solution, accounting for 60% of the total variance (Nordgaard et al., 2014). This chapter has presented reflections on dilemmas connected to diagnoses and diagnostics in the context of psychosis risk, self-disturbances, and the EASE manual, and some clinical and psychometric abilities of the EASE were briefly summarised. The EASE is divided into five domains or main areas of self-disturbance, to be presented in the next chapter.

References American Psychiatric Association. (2013). DSM-5: Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Arlington: American Psychiatric Association. Andreasen, N.C. (2007). DSM and the death of phenomenology in America: An example of unintended consequences. Schizophrenia Bulletin, 33(1), 108–112. Connors, M.H., & Halligan, P.W. (2021). Delusions and disorders of self-experience. The Lancet Psychiatry, 8(9), 740–741. Fusar‐Poli, P., Solmi, M., Brondino, N., Davies, C., Chae, C., Politi, P., . . . & McGuire, P. (2019). Transdiagnostic psychiatry: A systematic review. World Psychiatry,  18(2), 192–207. Henriksen, M.G., Raballo, A., & Nordgaard, J. (2021). Self-disorders and psychopathology: A systematic review. The Lancet Psychiatry, 8(11), 1001–1012. Miller, T.J., McGlashan, T.H., Rosen, J.L., Cadenhead, K., Ventura, J., McFarlane, W., . . . & Woods, S.W. (2003). Prodromal assessment with the structured interview for prodromal syndromes and the scale of prodromal symptoms: predictive validity, interrater reliability, and training to reliability. Schizophrenia Bulletin, 29(4), 703–715. Møller, P., Haug, E., Raballo, A., Parnas, J., & Melle, I. (2011). Examination of anomalous self-experience in first-episode psychosis: Interrater reliability. Psychopathology, 44(6), 386–390.

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Nordgaard, J., Nilsson, L.S., Sæbye, D., & Parnas, J. (2018). Self-disorders in schizophreniaspectrum disorders: A 5-year follow-up study. European Archives of Psychiatry and Clinical Neuroscience, 268(7), 713–718. Nordgaard, J., & Parnas, J. (2014). Self-disorders and the schizophrenia spectrum: A study of 100 first hospital admissions. Schizophrenia Bulletin, 40(6), 1300–1307. Nordgaard, J., Revsbech, R., Sæbue, D.,  & Parnas, J. (2012). Assessing the diagnostic validity of a structured psychiatric interview in a first-admission hospital sample. World Psychiatry, 11(3), 181. Parnas, J., Møller, P., Kircher, T., Thalbitzer, J., Jansson, L., Handest, P., & Zahavi, D. (2005). EASE: Examination of anomalous self-experience. Psychopathology, 38(5), 236. Vollmer-Larsen, A., Handest, P., & Parnas, J. (2007). Reliability of measuring anomalous experience: The Bonn Scale for the assessment of basic symptoms. Psychopathology, 40(5), 345–348. World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines (Vol. 1). Geneva: World Health Organization. Yung, A.R., & Nelson, B. (2013). The ultra-high risk concept – A review. The Canadian Journal of Psychiatry, 58(1), 5–12. Yung, A.R., Yung, A.R., Pan Yuen, H., Mcgorry, P.D., Phillips, L.J., Kelly, D., . . . & Buckby, J. (2005). Mapping the onset of psychosis: The comprehensive assessment of at-risk mental states. Australian & New Zealand Journal of Psychiatry, 39(11–12), 964–971.

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Figure 9 A seemingly troubled and gloomy girl’s face and head, her forehead covered with a series of thought bubbles, containing simple words such as you, I, we, they, is, self, me, and, are.

9 THE FIVE DOMAINS OF THE EASE MANUAL

This chapter will discuss the five phenomenological domains of the EASE and their contents more closely. One overarching point must be particularly emphasised: the five domains and the 57 experiential phenomena (items) are dimensional aspects of a coherent whole, in the sense that they represent parts of an overall gestalt (see Sandsten et al., 2022). Individual phenomena cannot be regarded as separate symptoms but constitute overlapping and complementary facets of an entirety in the individual. Psychometrically, this is reflected by the fact that EASE has been found to fit with a one-factor model. In each affected individual, unique combinations of these phenomena will be present. However, they are not clearly distinguishable, separate ‘symptoms’, as symptoms are commonly understood. In clinical assessments using the EASE, it is easy to get stuck in endless deliberations if one aims to find sharp boundaries between the different phenomena. Therefore, the phenomena must be clinically judged – or psychometrically scored – liberally and inclusively, that is, not as mutually exclusive. The clinician needs to explore and look for facets belonging to a larger and coherent alteration of human experience, a sense of being or feeling of identity.

In this chapter, the broad domains of EASE will be presented and discussed, and illustrative quotations of the individual phenomena (items) will be given. For further details and explanations, I refer to the complete EASE manual (Parnas et al., 2005). Quotations are from clients and research participants, and consent to anonymise and publish has been obtained, and this applies to all samples of quotations in this book. In this chapter, for each EASE domain, a concise domain definition is provided (in the original manual referred to as a general description), thereafter follows DOI: 10.4324/9781003127895-10

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a slightly broader description of the same domain, and finally a box presenting several typical quotations. The domain definitions strongly reflect phenomenology as a philosophical discipline, so the language may come across as somewhat inaccessible or esoteric. The descriptions which follow (in this chapter) attempt to balance this, providing a more elaborated account in lay language. In the complete EASE manual, one will find similar definitions, but not the broader and deeper discussion of them. Furthermore, one will also find detailed descriptions of each item, the individual phenomenon, including relevant quotations linked to them. Providing general and broad descriptions of domains on the one hand, together with details pertaining to the individual items/phenomena on the other hand, aims to be mutually explanatory and illuminating. The five domains of the EASE manual No. Domain name 1 2 3 4 5

Cognition and stream of consciousness Self-awareness and presence Bodily experiences Demarcation/transitivism Existential reorientation

Domain 1  Cognition and stream of consciousness Definition: refers to a normal/usual sense of consciousness as being continuous over time. It flows unimpeded and evenly, belongs to only one subject, is transparent to introspection, i.e., is immediately and directly given, in an abstract (non-spatial/non-physical) way.

Description. This domain includes mental states and phenomena which, in the most basic sense, we most associate with the brain: cognition (thinking) and the stream of consciousness. Seventeen phenomena/disturbances are listed, among other various types of thought disturbance, obsessive worrying, audible thoughts, spatially/physically objectified thoughts, ambivalence, disturbed ability to distinguish between different types of emotions, disturbances of attention, memory, perception of time, language and expressive ability, and gaps in consciousness when recounting events. The domain includes several apparently well-known cognitive or neurotic disturbances (such as ambivalence), but EASE describes these disturbances in detail to distinguish them from the more commonly understood meaning of these ‘symptoms’. For example, ambivalence as a part of a basic self-disturbance has a strong sense of perplexity and hyper-reflection (obsessive self-monitoring and worrying). The phenomenon may be more accurately referred to as polyvalence, in the sense that it involves a strong tendency to concern oneself 96

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not just with one or two alternatives, but rather with an overwhelming range of them. All the phenomena in domain 1 have in common that they in different ways are concerned with, directly or indirectly, changes in fundamental thought processes. Clients and research participants who have spoken about these types of thought disturbances have shed considerable light upon the many aspects and qualities of thought that can be distorted, thereby showing their extremely complex nature. Once again, we see how a disturbance of subjectivity in a striking way can illuminate the immense range of resources embedded in intact mental functions.

Domain 1  Cognition and stream of consciousness Illustrative quotations (from clients/research participants) • • • • • • • •

Making choices is almost impossible, I need to judge everything from every possible angle. When I think a thought, an opposing thought arises immediately on the other side of my brain. Meaningless, sudden thoughts can suddenly break into whatever I’m thinking of. It feels like the thoughts are falling somehow tilted downwards towards a special point. It feels like thoughts are pressing physically on my skull from the inside. The thoughts seem to be physically contained. I am kind of observing my own perception, rather than experiencing it directly. Thinking happens in me (i.e. it is not s/he who initiates and controls the thinking)

Domain 2  Self-awareness and presence Definition: Refers to a normal/usual sense of being (existence), including an automatic, un-reflected (experience of) presence in one’s own body and mind (self-presence) as well as in the world (immersion). In our daily interaction with the world, we experience the unique phenomenon ‘presence’ when these two qualities – a sense of self and a sense of immersion – are inseparable (subject and object), mutually dependent and woven into each other. A well-known phenomenological quotation: ‘Subject and object are two abstract moments (aspects) of a unique structure which is presence’. (Maurice Merleau-Ponty, 1908–1961) (Merleau-Ponty, 1945, p. 430)

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Description. This domain includes mental states and phenomena which, in the most basic sense, we most associate with the mind, psyche, or consciousness. It concerns the very sense of existence, and the feeling of what in phenomenology is referred to as primary presence (Merleau-Ponty, 2013; see also Parnas, 2003). From a phenomenological point of view, this feeling consists of two abstract phenomena which are completely woven together: self-awareness (awareness of my own existence) and presence in the world (feeling of immersion, embeddedness [Sass & Parnas, 2003]). We cannot connect these complex phenomena directly to specific brain functions, even though all mental phenomena naturally have their origin there. In the manual, 18 disturbances are listed in this domain, among others a compromised ‘sense of self’, a disturbed first-person perspective, dissociative depersonalisation (as if watching oneself from the outside) and derealisation (the environment appears transformed, unreal or strange), a weakened sense of presence, hyper-reflexivity, identity confusion, a disturbed experience of age, a weakened understanding of the obvious, weakened clarity of awareness, and a weakened experience of vitality. Domain 2 comprises many phenomena which involve a weakening or reduction of normal mental qualities or functions. Furthermore, these phenomena are mainly global (pervasive, wide-ranging), that is, pertaining to existence, presence, vitality, ownership, awareness, basic understanding, etc. There is therefore a contrast between the global characteristics of domain 2 and the somehow more constricted/limited phenomena in domain 1, which often represent more confined aspects of thought and thought processes. Clients/research participants who have spoken about such disturbed feelings concerning existence and self-awareness have in doing so demonstrated aspects of our existence which are normally taken care of by intact subjectivity, that is, being outside of our everyday conscious awareness.

Domain 2  Self-awareness and presence Illustrative quotations • • • • • • • • • •

It’s as if it’s not me doing things. The me-person is gone. Something has torn the personality out of me. Something inside of me has become un-human. I have lost my entire self. It’s as if I have ceased to exist. I have no inner core. I am constantly observing my own experience. Is it me looking at the picture, or is it the picture looking at me? This deep sadness is incomprehensible because it’s as if it isn’t my sadness.

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• • • • •

The world around me is just an illusion. I do not feel fully present. I need to analyse all the time where I’m supposed to be I have a ghostly feeling of being from another planet, like in an immovable vacuum. ‘The I’ in me has moved a few centimetres backwards.

Domain 3  Bodily experiences Definition: refers to a normal/usual sense of psycho-physical unity, and coherence. This implies a seamless and unproblematic interplay between the body as a spatial, localised, and physical object, and at the same time as a non-spatial, abstract subject, lived from within. Bodily experiences and bodily awareness are in other words not tied to a pure object or a pure subject but are both at the same time.

Description. The domain includes mental disturbances and phenomena that we associate with bodily experiences. Regarded as such disturbances, nine phenomena are listed, including feelings of the body changing shape or size; a strong need to examine the face and body in the mirror; bodily alienation; body and mind do not seem to ‘belong together’; a feeling of bodily disintegration; distorted perceptions concerning inner bodily processes, inner organs, or visible physical movements; metaphysical resonance between one’s own and others’ movements. The conventional conception that psychosis and schizophrenia primarily are characterised by hallucinations and delusions has resulted in too great an emphasis on mental functions at the expense of a whole universe of bodily phenomena (corporeality) (see Parnas, 2003). Subjectivity also sustains and underlies myriad automatic, physical bodily related experiences. There is an extremely fine-tuned and complex interaction between the body and mind. To exist or live in the form of a pure mind, or as a purely physical body, is meaningless (hence the concept of embodiment). Strictly speaking, this means that several of the phenomena in domains 1 and 2 may have a bodily aspect built in. And in the same way, it indicates that the bodily phenomena discussed here in domain 3 will have mental aspects – they are of course experiences – even though they are primarily concerned with bodily events. In principle, domain 1, stream of consciousness, can also be said to include the bodily oriented stream of consciousness (domain 3). The experience of the body’s many facets of movement, positions, signals, appearance, touch sensations, senses, inner visual imagery, etc. are all dependent on subjectivity as a component of consciousness. The changes concerning bodily experience reported by clients in the case of disturbances in subjectivity have an almost endless variation. This shows that 99

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bodily experiences share the same degree of complexity as experiences without a direct link to the body. An illustrative example of the mutually inextricable relationship between body and mind, in general, is precisely the role of the body in self-experience. We also find this in the definition of domain 2, in the phenomenon primary presence. The everyday feeling of being present, not just in oneself, but also in the physical world (immersion, embeddedness) is obviously to a large extent determined by the body. Both the body and the mind play important roles in the experience of presence.

Domain 3  Bodily experiences. Illustrative quotations. • • • • • • • •

My face seems witch-like. I don’t like looking at myself in the mirror, I’m afraid of seeing a satanic smile. The muscles on my neck seem weirdly pronounced. It feels like my left and right lower arm have changed places, and they don’t feel like mine. It’s as if my body is disconnected, as if my head is just stuck on to the rest. It always feels as if there is a little man inside my head, controlling this big robot. The visible part of me is not connected to the mental part. It feels like my skin is too small and too tight for my body.

Domain 4  Demarcation/transitivism (weakened boundaries to others and to the world) Definition: Demarcation refers to a normal/usual feeling that the boundary between oneself and the surrounding world is intact and impenetrable. Transitivism is a special variant of a disturbance of demarcation: i.e., an experience of the splitting off and displacement of a part of one’s personality onto another person. In such a state, whatever is being currently experienced, will at the same time feel as if it is being experienced by the other person. Demarcation is in several ways closely connected to self-awareness and presence (domain 2) but has been established as a separate domain because of the unique and specific presentation of symptoms.

Description. This domain includes mental states and phenomena which, in the most basic sense, are involved in our experience of not only being whole 100

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and coherent but also being clearly and reassuringly separate from other people and from physical objects in our surroundings. Regarded as disturbances in this domain, five phenomena are listed, and all of these must be characterised as more marked and severe than phenomena from the other domains. They usually reflect a more advanced and differentiated developmental stage towards a probable disorder within the schizophrenia spectrum. Among the phenomena listed are these: confusing oneself with (1) another person, (2) one’s own or another’s reflection, or (3) with a portrait or similar image. Moreover, the domain includes disconcerting experiences of bodily contact or touch sensations, a feeling of being extremely vulnerable, exposed, defenceless (feeling of ‘passivity’), abnormally transparent, unprotected, thin-skinned, or without a protective barrier. In empirical studies using the EASE, both in risk populations and in the case of fully developed firstepisode psychosis, it has been shown that phenomena from domain 4 have a lower prevalence than phenomena from the other domains. These phenomena are nevertheless allocated to a separate domain, due to their uniquely marked characteristics, where they are assumed to have a special status as prodromal phenomena.

Domain 4  Demarcation/transitivism: weakened boundaries to others and to the world. Illustrative quotations. • • • • • •

In conversations, it feels like I confuse myself with others, and I don’t understand which thoughts or feelings come from who. When I see myself in a mirror, I’m not sure who is who. I can’t stand too close to others or be touched, because it seems like I disappear or cease to exist. I feel very exposed, in a very unpleasant, passive position. I feel almost completely defenceless to the world, in a way that is impossible to put into words. I’m constantly brooding about what it is exactly that separates me from my surroundings.

Domain 5  Existential reorientation Definition: refers to a fundamental feeling of change in one’s general, metaphysical view of the world and/or hierarchy of values, goals in life and interests. It is this domain where the experience of anomaliesin self-awareness expresses itself both existentially and in behaviour.

Description. This domain is not defined based on what is a normal/usual feeling, as in the previous four domains, quite simply because it is impossible to define 101

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a ‘normal’ existential orientation. Therefore, the domain is defined as a change or reorientation. This reorientation is a result of attribution, that is, the application of meaning to altered self-experience and self-understanding (see Chapter 2, the three [didactic] supporting concepts that represent developmental ‘stages’; self-experience, self-understanding, and self-disturbance). The domain includes mental states and phenomena which illustrate how deeply intrusive the consequences of basic self-disturbances may be in a person’s life. As examples of such disturbances, eight phenomena are listed. Certain phenomena (such as primary self-reference) are quite usual and typical in most types of psychotic disorders (including acute and transient), but several phenomena should be regarded as advanced and differentiated phenomena, which increase the likelihood of a process towards a more severe psychotic disorder. Phenomena include the following: self-reference (very common); pervasive changes in areas of interest (common); magical thinking (common); a feeling of being uniquely special in the world; a feeling of having uniquely outstanding and extraordinary qualities as a person; feeling vastly superior to others; feeling that reality is limited only to that which can be seen here and now; feeling that the world does not really exist. The process of attribution is of great significance in domain 5. In Chapter 2, fallacious attribution was discussed as an essential part of the pre-psychotic process, running from spontaneous, non-thematic self-experience (being transformed), via conscious, deliberate self-understanding (being flawed), and then eventually to self-disturbance (as a tentative precursor of delusion). Put another way, the attribution consists of a distorted self-experience being interpreted and given a new and completely private meaning, unique for the individual. In such a process, phenomena in domain 5 can represent a provisional result of this attribution, precisely in the form of existential reorientation. We can imagine several steps to the process. One step can consist of the individual allocating one or a few experiences a provisional and restricted meaning in his own life. If the disturbance of subjectivity remains stable and increasing, new steps in the process may imply that attributions linked to several individual phenomena come together as more wide-ranging, subjective ‘explanations’, and eventually as more overarching, inner mental ‘scripts’. Over time, these may combine into wider systems of irrational beliefs. Earlier lifegoals, values, and views of the world can thereby be transformed and reformulated, sometimes quite dramatically.

An example of existential reorientation developing into psychosis This case excerpt is from a research participant, anonymised and approved for publication for educational purposes. A young 20-year-old man had an emerging feeling that the world appeared in an increasingly new and beautiful light, accompanied by a sense of clarity

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and purity, but also an uneasy feeling of strangeness within himself (altered self-experience). This intensified over several months and led to him feeling a deep need to dispense with all his old concepts, views, and values (altered self-understanding). After some time, he felt the need to deny himself completely, and ‘as if’ he had to communicate that the whole world should be given ‘a new chance’ through his sense of new insight (self-disorder). He left his home country for India in search of a guru he could follow. After a short time, he became severely emaciated and in very weak health, as all food was considered unclean and he refused to eat (psychotic conversion). He was flown home in a severe, psychotic condition with the assistance of health professionals, and he received the necessary health care in time.

Domain 5  Existential reorientation Illustrative quotations • • • • • • •

When meeting up with a group of people, it seemed that everything came from me, that everything was dependent on me. New ideas about supernatural mental phenomena gradually overtook all my thinking and my life. I had to define and analyse everything I thought about. I had to acquire new concepts about the world and human existence. I felt that I was the only true doctor in the whole world, and that the health of all humanity was dependent on me. I get a fleeting and floating feeling that it is only what I can see that exists, but almost immediately I understand that this is nonsense. I often wonder if the world really exists.

A pragmatic approach using the EASE Based on two decades of experience with national and international courses and teaching for professionals and treatment facilities, and also reflected by the rapidly increasing number of studies and publications in the field (EASE manual, >900 citation as per 03/23 in Google Scholar), the psychopathological perspective of basic self-disturbance and the Subjectivity Model enjoy growing recognition among clinicians. The greatest hindrance to an even speedier dissemination of the model is that the full version of the EASE is quite time-consuming for busy clinicians. This obstacle is clear from the many requests for ‘short versions’ of the scale, conveyed by course participants and clinicians, over many years. The full version is quite substantial to administer, but in research the full version has so far been the only defendable choice. The reasons for this also include the fact that EASE has been 103

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found to have a one-factor structure (considerable overlap between phenomena (Nordgaard & Parnas, 2014), but notably with immense variations of individual profiles within the full breadth of BSD. Consequently, any condensation of the EASE, used in research, runs the risk of being phenomenologically skewed. Moreover, an advantage of using the full scale in clinical practice is that it can be regarded as a good training instrument in psychopathology, as it contains more ‘explanations’ and discussions of these complex phenomena than is typical for this type of psychometric instrument. A screening version under trial: the SQuEASE-6 Short versions of psychometric instruments are often considered as capable of identifying individuals almost as well (or well enough) as the full version, and they are usually interview based. Screening versions are not the same. Screening is usually self-administered, and provides a first-step, economical-pragmatic, less time-consuming way to quickly identify individuals possibly at high risk of having the relevant characteristics. In our context, after such an initial screening, the identified individuals at possible risk have to be interviewed with the full EASE, to verify or falsify truly BSD-positive individuals. Variants of such coarse screening versions for identifying possible BSD are presently being tested in Norway and some other countries. One of these is the SQuEASE-6 (Screen Questionnaire for EASE, 6 items), presented in the Appendix of this book. The number of EASE-phenomena being examined in the SQuEASE -6 (N=11) is considerably reduced as compared to the full EASE (N=57). Moreover, seven of these 11 EASE-items are combined and collapsed into two cluster-like items (due to considerable internal similarities), and then asked for by means of broader questions. The items selected are limited to those considered most prototypical, and which have been shown in empirical studies to be among the most prevalent in relevant populations. Still, this item-selection can never be anything close to an equal replacement for the EASE. The questions in the SQuEASE-6 are formulated particularly in order to allow for self-administration. Therefore, it must be emphasised clearly that, in case of positive scoring (endorsement), the individuals’ answers and interpretations need to be validated and assured through a followup interview (preferably shortly afterwards). This affirmative or refutative interview can in the first place be limited to the SQuEASE-6 elements, and then the entire EASE should be administered in case of confirmed suspicion of psychosis risk. Another variant that is now being tested is the SQuEASE-11, which is very similar to the 6-version, but assesses the eleven items separately, just as they are in the original EASE, and by interview. This version has been used in an extensive UHR intervention study in Melbourne, Australia (not yet published). Based on the very first, systematic, population-based EASE study of firsttreatment psychosis (Haug et  al., 2012, N=91), the identified self-disturbance items have been arranged according to frequency of occurrence. Of all the EASE items, the 22 most frequent phenomena were present in more than a half of the 104

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participants with schizophrenia. When constructing the SQuEASE-6, half of the items from this group of 22 were removed. This was partly because (1) some items are extremely difficult to describe precisely and understand correctly in screening/self-administration, (2) some items were particularly difficult to distinguish from more general mental disturbances, and finally (3) some phenomena were so similar or parallel to (i.e., overlapped with) other EASE items, that they were difficult to differentiate without an interview. Seven of the remaining 11 items, as described, have been combined into two somewhat broader questions in the SQuEASE-6. The SQuEASE-6 has proved useful and popular in clinical settings, as a first-line, short, and rapid screen for the tentative presence of selfdisturbances in a busy clinical practice where there is a suspected development of psychosis. To be noted: Both the EASE and the SQuEASE phenomena must be evaluated in the context of other information and findings and interpreted by experienced specialists in the field. Likewise, it is not relevant to operate with a ‘cut-off’ in EASE or SQuEASE, that is, a threshold for the number of criteria which has to be met. On the contrary, it is of importance that any truly positive self-disturbance items are regarded as a possible sign of risk of psychosis development and should be further investigated and validated in a thorough clinical interview. In this chapter, the five domains of the EASE and their contents have been presented and exemplified. It has been emphasised that the phenomena are dimensional aspects or facets of a coherent whole, in the sense that they represent parts of an entirety or gestalt, with reciprocal part-whole relationships. This chapter also concludes the first part of the book, the mainly theoretical one. The next chapter is the beginning of part two, essentially dealing with various aspects of treatment.

References Haug, E., Lien, L., Raballo, A., Bratlien, U., Øie, M., Andreassen, O.A., . . . & Møller, P. (2012). Selective aggregation of self-disorders in first-treatment DSM-IV schizophrenia spectrum disorders. The Journal of Nervous and Mental Disease, 200(7), 632–636. Merleau-Ponty M. (1945). Phénoménologie de la perception. Paris: Gallimard. Merleau-Ponty, M. (2013). Phenomenology of perception. New York: Routledge. Nordgaard, J., & Parnas, J. (2014). Self-disorders and the schizophrenia spectrum: A study of 100 fi rst hospital admissions. Schizophrenia Bulletin, 40 (6), 1300–1307. Parnas, J. (2003). Self and schizophrenia: A phenomenological perspective. In T. Kircher, A.S. David, & A. David (Eds.), The self in neuroscience and psychiatry. Cambridge: Cambridge University Press, pp. 217–241. Parnas, J., Møller, P., Kircher, T., Thalbitzer, J., Jansson, L., Handest, P., & Zahavi, D. (2005). EASE: Examination of anomalous self-experience. Psychopathology, 38(5), 236. Sandsten, K.E., Zahavi, D., & Parnas, J. (2022). Disorder of selfhood in schizophrenia: A symptom or a gestalt? Psychopathology, 55(5), 273–281. Sass, L.A., & Parnas, J. (2003). Schizophrenia, consciousness, and the self. Schizophrenia Bulletin, 29(3), 427–444.

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10 THE VIEW OF PSYCHOSIS T R E AT M E N T A M O N G P R O F E S S I O N A L S A N D H E A LT H AUTHORITIES IS CHANGING

This chapter introduces the part of the book which is concerned with treatment targeting basic self-disturbance (BSD). Since the beginning of the century, the view of the form and content in the treatment of schizophrenia and other psychotic disorders has been changing. To a considerable extent, the user organisations have been the driving forces, and this has spread to clinicians and national and international policy makers. This development fits well with the ambition to integrate BSD into the overall treatment picture. Two main aspects of the new development stand out in leading international professional environments: first, increased active service user participation in treatment; second, targeted strengthening of service users’ and families’ knowledge and mastery skills in relation to severe mental disorders. Additionally, changes have emerged regarding (1) efforts for early identification, (2) an increased use of ambulatory treatment, and there seems also to have emerged an increased emphasis on (3) more thorough assessments being used to a greater extent in actively building therapeutic alliance.

The many contexts of psychosis treatment In the remaining chapters of this book, treatment targeting basic self-disturbances will be discussed and viewed in relation to the many general treatment methods and contexts which together constitute the central framework for psychosis treatment today, according to recognised evidence and international guidelines. First, in this chapter, I will present some general perspectival changes to the prevailing views on what psychosis treatment should be. Then, in Chapter 11, I will seek to put the Subjectivity Model in perspective by comparing it with other central theoretical perspectives. The underlying question is: to what degree do other theoretical perspectives use subjectivity, self-experience, or self-understanding as 106

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explicit concepts in their understanding of schizophrenia and psychosis? From Chapter  12, basic self-disturbances are specifically described in the context of being a possible pervasive supplementary approach in treatment. Furthermore, the significance of the phenomenologically oriented way of talking/conversing in treatment is highlighted (Chapter 13), followed by a discussion of possible therapeutic effects and hindrances in the case of basic self-disturbances (Chapter 14). Treatment of self-disturbances is then looked at directly in terms of today’s main methods and settings in psychosis treatment (Chapter 15), before an outline of a specific seven-step treatment module is finally proposed (Chapter 16).

Crucial in treatment directed at basic self-disturbances We have seen that both psychotic and pre-psychotic experiences (including selfdisturbances) indeed represent ‘real’ distortions of individuals’ experiential, firstpersonal world, and these distortions may represent serious departures from a culture’s interpersonal and conceptual consensus. For the good of the individual concerned, it is this severe break that may need to be reversed or repaired (as part of treatment), and the consensus restored, contributing to the co-creation of a new and sounder way of experiencing. So, as not to lose from view this overarching perspective, I would like to emphasise the overall essential goal of all treatment directed at self-disturbances: To establish a reflective, intersubjective sharing, in a conversation between client and therapist, and through this pave the way for the cocreation of new meaning and interpretation of the distorted experiences. The formulation intersubjective sharing emphasises that there are two subjective parties who meet, not to find some objective truth, but so that one ‘subject’ (person) freely and openly can share frightening and incomprehensible experiences with another ‘subject’. One client put it this way: ‘The ideal therapeutic meeting point is when it feels like I can find myself in the therapist’s genuine interest in me’.

New directions in psychosis treatment The numerous developments in professional areas and research, and in society and technology, are continuous, happening at a rapid pace, and affect our views of mental health treatment. The most marked general changes in the view of psychosis treatment in recent years are: active service user involvement; psychoeducation and coping strategies for service users; targeted efforts at earlier identification and intervention; more ambulatory treatment; more shared decision-making between clinical staff and service users; precise and reduced use of medication and coercion; better use of thorough assessments as an active starting phase of treatment and to build alliance; more emphasis on psychological treatments; and the establishment of feedback systems in therapy. 107

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The separate effects of each one of these new perspectives is indeed difficult to document in research. This is because several changes happen simultaneously at different speeds and in different settings, and the different approaches are impossible to isolate or monitor with good research designs. However, it is important to remember that most of the mentioned perspectives, if not all, also carry a clear ethical and humanistic justification, in addition to the scientific one. Allowing young persons to live with an untreated psychosis over considerable time, without any attempt at treatment, is unethical. The average length of untreated psychosis was about two years when the wave of early intervention arrived in professional circles at the start of the millennium. This treatment lag is of course an unacceptable situation, independent of whether early intervention and treatment can be documented to improve long-term prognosis.

Service user involvement becomes essential Active participation and significant involvement from the service users in all treatment are now a clear expectation – almost a demand – from central health and political authorities. Very rapidly, these changes have become a part of national professional guidelines for clinical pathways and ‘treatment packages’, although still not sufficiently and systematically implemented. The changes have been partly a reaction to the view of service users as purely passive recipients of treatment. They have also partly to do with the general modernisation of services, making them more ‘democratic’, and with increased shared decision-making throughout the entire health care system. Finally, the changes are also a result of both treatment research and common sense, which indicate that inner motivation, the provision of knowledge, and active involvement all increase the effect of, and the satisfaction with, treatment.

Talking about the nature of the disorder was previously discouraged Today, it may seem incomprehensible that many candidates training to be psychiatrists in the early 1980s, including myself, were discouraged from talking to service users about the actual content of the psychotic experiences. Many of us were warned that this might worsen the condition and possibly trigger relapses of serious psychotic episodes. This warning was partially based on clinical experience that such worsening could occasionally be observed. This approach was nevertheless too simple, and contrary to the knowledge we have today. This approach sealed off and prolonged psychotic experiences, which in all cases have a destructive influence on the service user’s function. To cover up or close off such frightening symptoms (often then referred to as ‘sealing over’) was a well-known and common approach. It was probably justified based upon certain cases and documented episodes but functioned mainly as a postponement, and a building-up of more tension. Cautious and service user-friendly reality orientation was the approach often recommended in the 1980s. Even though it 108

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was emphasised in teaching and supervision that the service user’s worldview must also be respected, there was no mutual ‘understandable’ solution to this ‘reality dilemma’. As clinical staff, it was our job to listen and accept (referred to as ‘containing’) the service user’s often despairing and incomprehensible reality, rather directing attention to practical, everyday aspects of life (hygiene, meals, physical and social activities, etc.), hoping that the psychosis experiences would fade over time, without therapists being too confrontational. The effect was unfortunately often the opposite: the psychotic experiences and associated private interpretations led to the psychotic ideation often becoming more cemented. The establishment of psychoeducational family interventions as a treatment approach towards the end of the 1990s was a clear turning point and marked the end of a time when the service user was regarded as a passive recipient of treatment. Today we know that exposure to and active exploration of symptoms is a key factor in slowly regaining the most possible control and mastery of psychotic phenomena and the inner mental life.

Early and ambulatory treatment changes the basic requirements Early identification and intervention in psychosis also became watchwords in psychiatry at the start of the millennium and were strongly emphasised in the same way as psychoeducational family intervention. These have, to a large extent, changed the basic foundations for planning and carrying out psychosis treatment. Earlier, long-term hospital admission was common, and the identification and treatment of psychotic disorders occurred at much later stages, partially because there was less knowledge about which early phenomena should be looked out for. As a result, the service user’s condition was often poorer, more locked, and less available for psychotherapies than is the case today. Early intervention has also in many cases made it far easier to enter constructive conversational contact with service users. In principle, this will enable conversations more directly about how the main person can understand and cope with his psychotic experiences. However, and this is a major background issue of this book, another central hindrance has thus become apparent, which is that service users and clinicians do not have available a model of understanding that is shared and agreed upon. A shared model could have made early pre-psychotic experiences the aim of intersubjective sharing in conversation, and provided a foundation for healthier interpretations and ascribing new and constructive meaning to the disturbed self-experiences. Therefore, in one sense, we have come no further: conversations with the service users in the early phase are often now perfectly possible, but the understanding of the phenomena and the way in which their assessment should be carried out is lacking, sometimes almost non-existent. The hope is that this book can contribute to such knowledge and clinical competence for all health professionals. Central to this competence is the conversational form inspired by phenomenology, which is discussed in Chapter 13. 109

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Thorough assessment of experiential phenomena builds common ground In line with advances in medical technology, particularly in somatic diagnostics, the distinction between assessment and treatment has become more erased. Treatment procedures can be initiated immediately when a source of disease is identified, regardless of whether this is in the middle of an ongoing assessment procedure, and often with the same technical apparatus. One can almost speak of a ‘therapeutic assessment’. Generally, diagnostic assessment involves looking for (more or less certain) symptoms and signs of disease/disorder with the best possible instruments. Likewise, when clinicians in mental health have worked thoroughly with the systematic identification of central symptoms, signs, and narratives, important preparations for treatment are in place. The central themes are then observed, explored, described, and made available and aware to the clinician and the main person. This establishment of common ground should be considered a central first part of the treatment process. Particularly in mental health services, this mutual positioning between the two main participants, both in search of the core experiences, is vital to the success of the therapy. It is the start of the development of alliance and the therapeutic relationship. A good therapeutic relationship is dependent upon a mutual understanding of what the problem consists of, in addition to the desired outcomes of the therapy. In addition, it is important that there is a certain atmosphere and ‘chemistry’ between service user and clinician, in the sense that they share common elements in their ways of talking, ways of language use, temperament, and ‘tempo’. Still, a certain degree of difference in style and personality can be beneficial, as the service user’s individual characteristics then become more salient. It is the early developmental stages and phenomena, that is, the prodromal phase and prodromal phenomena, which are the central focus of this book. These are phenomena the service users struggle with every day, which means that these experiences will be decisive reference points both in terms of problem understanding and therapeutic aims. First, the specific disturbed experiences must be made explicit and understood, and that is to say: how can such experiences have arisen in the mind? Second, the service user needs help with these specific difficulties, that is to say: what can be done to change the ‘balance of power’ between the individual and the disturbed experiences? In the light of this, mutual systematic exploration (intersubjective sharing) of self-understanding becomes a pivotal part of the overall treatment.

Clinical work with basic self-disturbances builds understanding and alliance Against the background of the general points outlined earlier, it will be natural to include the subjectivity perspective in assessment, diagnostics, and treatment as an additional knowledge-based aspect of the overall process. Integrating explicit 110

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work with self-disturbances in the overall treatment clearly includes significant involvement of the main person. This will encourage an active role for the service user, to be in the driving seat of his or her own improvement. In general, understanding one’s physical and mental condition or disorder is a fundamental human need, and a necessary condition for coping. It is a question of understanding – here and now – how my symptoms and my condition could have arisen. For example, this: how is it possible that I can hear loud thoughts or voices talking about me even though nobody but me is present? Working in this way, posing ‘how-questions’ like this, may result in a mutual partnership in the interpersonal construction of the individuals’ knowledge and competence about the role of selfdisturbances in the understanding of pre-psychotic or psychotic experiences. And finally, it will involve a new look at, and an expansion of the assessment phase, with the benefits this can give for therapeutic alliance and as a preparation for treatment.

Reduced and appropriate use of antipsychotic medication Another marked change in psychosis treatment concerns the demands of service user organisations for reduced use of medicines and opportunities for medicine-free treatment. Since the mid-1950s, it has been almost indisputable that treatment of psychotic disorders must also include psychopharmacological treatment. It has also often been taken for granted that this is the most central aspect of treatment. This understanding may be because of the usually rapid onset of effect of medication in acute situations. There is no doubt that the introduction of antipsychotic medication in its time was a revolution that enabled talk therapy for these disorders. However, during the 2010s, it became increasingly clear that documentation, particularly of long-term effects and side effects, is deficient or even lacking. Neither is it clear which persons will profit from medication from the start, and which to a lesser degree (or not at all) will improve. The effect of antipsychotics will naturally vary over a wide spectrum, from very good to very poor. It has also been claimed by some that antipsychotics can worsen the natural course of the disorder. International research communities are increasingly realizing that continuous updates of the research literature in this area is an absolute necessity. The symptom-relieving effects of antipsychotics in the acute phases and in the first couple of years of treatment seem to be well documented. In these specific time periods, side effects are usually weighed up by the positive effects for most service users, but even here not for all of them. After the first two years of treatment, however, there is to date no clear research evidence as to this balance between positive and negative effects. It is therefore of utmost importance to individualise these clinical decisions from the very start of treatment. Average estimates of effect are group based and not necessarily applicable to a given client. Each individual service user should be closely and regularly monitored in relation to the balance between positive effects and side effects of antipsychotics. 111

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The need to emphasise psychological treatments An obvious consequence of working towards a reduction in the use of medication is that this must be entailed by an increased effort to provide other supplementary treatment alternatives. The different talk therapies must acquire a systematic and stronger position. Clearly, the recent emphasis on psychoeducational family interventions and active service user involvement fits in well with this. Other recent and innovative measures need to be supported too, such as various creative/expressive therapies as well as activity-based forms of treatment, recognised relaxation techniques, and music therapy. A disturbed experience of identity, such as the Subjectivity Model describes, has a fundamentally negative effect on a person’s ability to develop and express themselves in a positive way. For most people, in general, it is increasingly challenging to plan and carry out the many complex projects in one’s own life. When, additionally, the experience of the self is disturbed, this will obviously undermine the feeling of being a person who is vital, whole, and coherent, present in the moment, cognisant, and autonomous. It is obvious from this that a goal of treatment must be to strengthen the self that is under threat, as well as autonomy and the feeling of being a useful and important individual. In this quest, medication may have a useful role in calming symptoms, but at the same time, there is a danger of worsening the pacification already caused by the disorder. The main focus in the building up of new forms of treatment must therefore be on active, psychologically supportive measures.

Adolescents at increased risk of psychosis The key area ‘early detection and intervention in psychosis’ started in the adult sector, but in the last few years has moved to the child and adolescent sector also. As a result, clinical methods and approaches to children and young persons with possible risk signs of psychosis (and related severe mental disorders) are now being developed, in addition to work with adults. However, at the present time, there is also no real consensus in this field. Different national ‘treatment packages’ aim to increase service user involvement and a more unified and fair provision of treatment, but the results of these remain to be seen. A useful international forum has been established for the development, discussion, and sharing of best evidence, ideas, and competence: The Association for Child and Adolescent Mental Health (acamh.org). In this forum, the development and character of treatment measures will be subject to constant revision, depending upon new and ongoing research, new forms of therapy, and not least the experiences of service users. The approach to psychosis risk in adolescents must in any case be a pragmatic one: it must continue to build upon different views of psychosis, because there is still a lack of any decisive breakthrough in relation to which understanding or which measure is best. Central elements in an overall programme can therefore include contributions from cognitive, neurocognitive, psychodynamic, narrative, and phenomenological/existential traditions, and from psychoeducational family 112

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interventions. In addition, efficient forms of cooperation with child welfare and family welfare services must also be attended and developed. A strong emphasis on building alliance and relationships must be central. Ensuring for continuity and long-term follow-up of risk signs will ensure speedy intervention when the onset of psychosis is imminent. Assessment and follow-up should also be regarded as a good preparation for treatment in the present context, as they all contribute towards a common understanding of the at-risk mental state and aim at prevention of a further development into psychosis. Finally, it should be underlined that, in childhood and adolescence, one must be particularly cautious of making conclusive diagnoses. Many mental disorders in this age group can present in a similar and undifferentiated way, and persons of a young age still have much further development. Not least, it is important to have a secure follow-up where there is contact over time so that measures can be implemented in the case of changes in the individual clinical picture. Measures must be aimed at the difficulties and distress that are currently present, and not blindly address a diagnostic category with uncertain boundaries and validity at such an early stage. This chapter has presented contemporary and recently changing main views on the form and content of treatment of schizophrenia and other psychotic disorders. Before proceeding to specifically describing BSD as a promising supplementary theme or subject in treatment, I will compare the Subjectivity Model to other central theoretical perspectives, trying to clarify to what extent they use subjectivity, self-experience, or self-understanding as explicit concepts in their understanding of schizophrenia and psychosis.

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11 WHAT ABOUT OTHER MODELS OF UNDERSTANDING AND THERAPEUTIC APPROACHES TO PSYCHOSIS? DO THEY USE SUBJECTIVITY, SELF-EXPERIENCE, OR SELF-UNDERSTANDING AS EXPLICIT CONCEPTS?

A significant breakthrough for schizophrenia research is yet to be seen. There is no generally agreed-upon and comprehensive understanding of this condition, nor any truly effective treatment. The field therefore needs new and supplementary models and perspectives. The Subjectivity Model presented in this book – also called Ipseity Disturbance Model – is a theoretical and clinical perspective which consistently focuses on the understanding of the experiential phenomena in schizophrenia and is therefore fully compatible with other established perspectives. This chapter seeks to put the Subjectivity Model in perspective by comparing its core concepts to other central perspectives. The question is this: to what degree do other theoretical perspectives use subjectivity, self-experience, or self-understanding as explicit concepts in their understanding of schizophrenia and other psychotic disorders? Throughout the history of psychiatry, psychotic disorders have brought with them especially demanding challenges, for the clients, families, clinicians, and researchers. All medical and psychological traditions within mental health have had to confront these conditions. Despite an enormous amount of research for over 100  years, to the present date, there has been no breakthrough which can provide an acceptable and all-encompassing understanding, or a truly effective treatment. The field needs therefore new, supplementary, and integrative models and perspectives. 114

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The Subjectivity Model – a supplement Since the millennium, the Subjectivity Model has received increasing international acclaim (Henriksen et al., 2021; Nordgaard et al., 2021). The model is, as a supplement, fully compatible with all established models and perspectives, offering a unique and consistent experiential supplementary perspective. The model may even function in an integrative way in relation to all the relevant scientific perspectives, such as medicine, neurology, psychology, philosophy, neuroscience, and consciousness research. In the research literature, there is an ongoing dialogue about the clinical use and usefulness of this and related perspectives, as a model of understanding of schizophrenia (Lysaker & Lysaker, 2010; Lysaker et al., 2012) and more particularly for the sake of early identification. New findings are constantly raising the status of the field. Certain authors have also discussed possible implications for treatment (Stanghellini & Lysaker, 2007; Nelson et  al., 2009; Pérez-Álvarez et  al., 2011; Škodlar et  al., 2013). In a paper titled ‘New life for schizophrenia psychotherapy in the light of phenomenology’, PérezÁlvarez et al. (2011) writes: Patients, for their part, reveal that the process of recovery from schizophrenia involves strengthening the sense of self. The clients’ experience of recovery backs the specific method of treatment claimed by the phenomenological conception, which is not found in the more often applied treatments. Several recent debates in the field of psychotic disorders give the model extra relevance: such as emerging demands from a growing number of national authorities for the availability of medicine-free treatment (Yeisen et  al., 2019), treatment centred on the service user, reduced use of coercion, and not least debates on the concept of schizophrenia and mental health diagnostics in general. All these themes penetrate to the core of this field, and the Subjectivity Model here does have something to contribute. The model can potentially address several areas linked to the mentioned guidelines and trends. This book also points out the immense importance of stimulating more research specifically on pre-psychotic experiential phenomena per se. The possible effects on improving early detection, particularly as a ‘close-in’ strategy for more precise identification, can provide direct usefulness at all points throughout the client’s course of treatment: prevention, assessment, diagnostics, active treatment, and follow-up – also in an era where ‘treatment packages’ are being established.

A reductionistic review In the following brief outline of the most central psychological models and perspectives, it has been necessary to limit the number of references. The review only describes the most overarching and basic features which have been developed 115

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over many years within the perspective in question. There is always a long list of contributors within each model, and the danger of under- or overrating a particular author’s significance is great. The reader may therefore, quite rightly, get the impression of certain authors being too lightly or heavily addressed. Perhaps some will feel that a specific view is somehow being championed at the expense of others and that scientific rigour is being circumvented. Here I would say that there is absolutely no basis for suggesting that other perspectives do not measure up to the Subjectivity Model. It would be a serious misjudgement, given all the important and necessary perspectives present in the field today. It would also undermine my personal wish that the model should create interest and open new avenues and perspectives precisely inside of the many related fields of study, which clearly touch upon and are an important backdrop for the present model. The intention of this chapter is to place the contribution of the Subjectivity Model in an even clearer context by comparing it with other central models of understanding and scientific perspectives, which therefore function as a contrasting backcloth. The review aims primarily to describe to what extent other perspectives use the core concepts (or clearly related concepts) as explicit elements in their understanding of psychosis. Touch points and close parallel ideas will also be mentioned. Living with self-disturbances often puts the individual under great strain, involves several secondary related mental health issues, a failure of coping and functioning, makes the individual isolated and vulnerable, and has a clearly traumatising potential. In the light of these many consequences, all existing perspectives on psychosis understanding are important and necessary, but the full picture and details of these many perspectives do not fall within the confines of this book.

The stress-vulnerability model Zubin and Spring’s (1977) stress-vulnerability model is a well-known, general model of understanding which in fact has relevance for all mental disorders but was developed in relation to schizophrenia. This bio-psycho-social model integrates in principle all biological, psychological, and social factors that can be considered to contribute to predisposition (vulnerability) and to the development and triggering of the mental disturbance. All accepted perspectives on psychosis have this general model as part of their foundation, continually taking on board new factors which can be shown to have significance for the development of psychosis. The model is therefore by nature very general, eclectic, and pragmatic and represents in this way a non-specific model of understanding. The background for its development with a view to schizophrenia was precisely the large and somewhat confusing number of causal and risk factors present, and therefore its primary aim was to draw up a generic overview of the many influences which affect the development of these complex conditions. How these influences behave in more detail, their relative strength, specific areas of influence, and mode of 116

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operation in relation to the mind are not a part of the stress-vulnerability model, which is therefore fully compatible with the Subjectivity Model.

The traditional cognitive perspective Cognitive behavioural therapy (Beck, 2020) has for a long time been one of the leading perspectives in the field, not least in research. Over time, several approaches within cognitive behaviour therapy (CBT) have emerged, and new variants are constantly appearing. Common to these perspectives is that they regard schizophrenia as a disturbance of formal thought, which is to say a deficit in cognitive processes which in turn lead to cognitive errors of interpretation. The idea is that biases in cognitive information processing can help to explain the development of psychotic symptoms, with associated excessive worrying, brooding, and catastrophic thinking. The treatment measures developed within this perspective are therefore directed at helping to correct various thought and reasoning errors, pointing out alternative views, attitudes, and interpretations in a dialogue with the client, to increase the ability to cope and to challenge the stress factors. Cognitive theory and therapy are not dependent upon knowing the causes of the psychosis; the central point is to confront the client’s thoughts and interpretations in relation to his surroundings here and now. The therapist will be concerned with making the client aware of certain ways of thinking and uncovering rigid thought patterns which lead to errors of interpretation. Schematically and simplified this can be summarised as follows: changes in thought can lead to changes in emotion, which in turn can lead to changes in behaviour. It is important however to remind ourselves that understanding the individual and personal relationships has also acquired an increasing status and role in more recent cognitive approaches. Meta-Cognitive Therapy (MCT) (Fisher, 2021) and Acceptance and Commitment Therapy (ACT) (Hayes et al., 2011) are more recent (third wave) further developments within the cognitive tradition, characterised by more attention to thought processes than the contents of thought. In fact, this last feature may resemble how the Subjectivity Model de-emphasises the specific contents of thought in favour of looking at what happens to thoughts when the basic conditions underlying them are changed. Cognitive therapy also has working methods which to a certain extent can remind us of those outlined for the Subjectivity Model, but without including the concepts of subjectivity, identity feeling, and basic self-experience as an explicit foundation for understanding. In other words, CBT does not base its understanding on concepts from the pre-reflexive level.

The neurocognitive perspective This perspective on schizophrenia understands these conditions as a neurodevelopmental group of disorders (Green, 1998). This implies a complex disorder of several (neuro)cognitive and neuromotor functions that (to a varying extent) are characteristic for schizophrenia, and especially those related to psychomotor speed, concentration, verbal memory, and executive functioning. These functional 117

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impairments are relatively stable and can be present even when the psychotic symptoms no longer are apparent, for example after a period of treatment. The neurocognitive perspective provides important contributions to functional assessment of several types of mental disorder as well as damage to the brain and CNS. Neuropsychological examinations are objective functional tests that are used to provide profiles of functional loss. These profiles are not fully specific to certain conditions but can nevertheless direct the diagnostic process. The task of treatment is to provide focused and individually adapted training programmes to improve neurocognitive skills. Neuropsychological assessments can also provide a basis for important recommendations regarding education, work, and suitability for certain treatment measures. Interestingly, there seems to be strikingly sparse correlations, next to no correlation, between basic self-disturbance and neurocognitive deficits (Haug et al., 2012; Nelson et al., 2014). Neither does this perspective include themes such as identity feeling, basic self-experience, or subjectivity as an explicit basis for understanding these conditions.

Social cognition theory This tradition represents a third cognitive perspective on schizophrenia, which emphasises the significance of the cognitive processes underlying the creation of mental representations about other people’s feelings and inner states (Green et al., 2015). The perspective touches upon newer trends such as mentalisation and mindfulness. The approach is practically useful for goal-directed, social, and independent functioning, and has developed useful programmes for social skills training. Even though social cognition theory is not considered to be an independent and unique model of understanding for psychosis, the perspective emphasises one of the most important areas of functional failure in such disorders. Supplementing social cognition theory by using self-understanding and the understanding of at-risk and psychotic phenomena might possibly increase the effect of skills training, over and beyond goal-directed aspects.

Psychodynamic and psychoanalytical perspectives These theories and perspectives on the treatment of mental disorders, including schizophrenia and other psychotic disorders, exist in many parallel and partly overlapping versions and describe human development in different ways (Dickerson & Lehman, 2011). They are all developmental theories assuming that early experiences are of fundamental significance for later emotional life, at all ages. The theories are therefore in some circles labelled sciences of the emotions, as opposed to for example the neuro-sciences. Central to these perspectives is that the unconscious mind is steered by specific driving forces and motives. In more recent directions, the focus in treatment has shifted from retrospective descriptions to observable phenomena in the here and now, such as real-life experiences, actual relationships, and feelings. 118

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The psychodynamic/psychoanalytical tradition has provided many different contributions to the understanding of psychosis and to psychosis therapy (Fenton, 2000; Jung & Newton, 2009; Rosenbaum, 2012). In this book, it is impossible to do justice to the many contributors. However, it is particularly relevant to mention Otto Kernberg’s (1928–) theory of the organisation of personality (Kernberg, 1967) which, among others, rests on the concept of identity diffusion (Kernberg, 2005), an idea which clearly touches on self-experience and identity experience as used in the Subjectivity Model. Furthermore, the Swedish psychodynamic thinker Johan Cullberg addresses the prodromal phase in his work, using an integrative approach (Cullberg, 2014), also including phenomenological understanding of psychosis and encompassing disturbances of the self. This is an example of how these perspectives readily can be combined. Freud was himself unsure whether psychoanalysis was possible in the case of psychosis because of the difficulties in establishing a therapeutic relationship (Rosenfeld, 1969). He and other psychoanalysts discovered later that this could in fact be possible in certain cases if the technique took into consideration the client’s lack of so-called ego-strength (Silver, 2001). Clients with psychosis should therefore be encouraged to sit upright during treatment and look directly at the therapist. Moreover, the therapist should be active and supportive, and the intensity of the therapy should be toned down. Countertransference could be used to test out social skills and identity status, as well as being used diagnostically and therapeutically. Interpretations of transference can be effective within certain limits but can easily be counterproductive and can create insecurity if they exceed these limits. Most branches in this tradition emphasise the variants of identity aspect, but they do not refer to subjectivity as an intrinsic structure of consciousness to understand the psychosis phenomenon itself (see Lucas, 2013). Ego psychology and object relations theory Ego psychology is (was) a collective term for several variants of psychoanalysis that particularly focused on how the individual, through the help of specified egofunctions, manages the conflicts that arise between the demands of the outer world and inner drives and forces (Marcus, 1999). The perspective is today significantly further developed in new directions, but representatives of the tradition have made contributions by showing that psychosis clients easily get confused by (too many) transference interpretations in psychodynamic therapy (see Müller, 2004), though they can be assured if the therapist regulates transference so that it becomes mildly positive. This is in line with new understanding that a mildly positive activation provides an optimal therapeutic learning window for such conditions. The so-called object relations theory and tradition according to the Austrian– British child analyst Melanie Klein (1882–1960) (Segal, 2018) has provided a deeper understanding of psychotic development as one characterised by withdrawal, deficiencies in contact, and a strong splitting in self-experience and the experience of others (Flanagan, 2008). This tradition emphasises the therapist’s 119

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ability to contain the client’s conflicting and often destructive ways of relating to others. The client’s desire for contact with himself as a subject, and with others, is central to the therapeutic work. The therapist makes use of transference and countertransference phenomena to understand the client’s experience of others, and as a starting point when dealing with the client’s attempts at contact. The tradition’s focus on self-experience in clinical work represents a potential meeting point with phenomenological understanding. But once again, subjectivity as a unique and indispensible structure of consciousness when understanding psychosis phenomena is not emphasised, and this means that the concept of self-experience mainly relates to ‘higher’ levels than the pre-reflexive one. Self psychology This is a branch of psychoanalysis which has the self as a central pivot (Baker & Baker, 1987), and the touch points with self-disturbances are many, though it does not represent a special perspective on psychotic disorders. Self psychology focuses on areas such as identity, meaning, ideals, and, importantly, self-experience. This tradition describes the phases lived through by the child and what is required at the different phases to develop towards a mature self. A dynamic, sequential theory and conceptualisation of the development of the self is emphasised. The phenomenological concept of the self in psychotic development as earlier discussed (Chapter 7) is of course ‘the same’ self as in self psychology, but particularly three aspects are differently weighted in the phenomenological concept. First, a developmental perspective over the life span is not explicitly emphasised. Clinically speaking, in psychosis, we see a time-limited development which is often observed to start in the late teens and early twenties. Even though all illness development in principle is dimensional (gradual and without abrupt stages), in psychosis, we can usually pinpoint an approximate clinical beginning. Often it shows itself as a fairly prominent break in development, particularly during the time when the brain is also going through a developmental surge, that is, in late puberty. From the point of view of self psychology, it is not usual to set such a starting point. Second, it is first and foremost the spontaneous, global, nonthematic self-experience which is in focus in phenomenology, that which one is aware of here and now, continuously, each and every moment. Third, and this is the most important, phenomenology emphasises the pre-reflective, pre-verbal, pre-cognitive levels of identity experience, those levels which enable a feeling of being fully present and embedded in the world, of being alive, and of having human qualities. Losing oneself at the phenomenological level of subjectivity implies a significantly deeper level of disturbance than identity confusion, insecurity, shame, and feelings of inferiority, which one observes in neurotic-like disorders and in personality disorders. The psychodynamic perspectives have long and deep roots in several countries, and the perspectives are regarded by most as valid to understand the basic

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underlying forces in the human psyche. In clinical psychotherapy communities, psychodynamic theory and understanding still constitute an important perspective in the case of psychosis. These perspectives are regarded by many as a necessary part of a therapeutic culture, also in relation to psychotic disorders. Even so, classic psychodynamic and psychoanalytical psychotherapy are used to a limited degree in relation to psychotic disorders and schizophrenia, because psychotic phenomena demand a more active approach and a higher degree of directness from the therapist than the typical approach in dynamic therapy. Self-experience in a more general sense is obviously relevant in the psychodynamic and psychoanalytical traditions. Disturbed self-experience based on a specific failure in subjectivity, however, as formulated by phenomenological theory and research, is not an explicit part of these theories. Analytical and dynamic directions in therapy have also contributed to other conceptions of psychosis development, linked for example to failure in the development of shared language understanding, failure in the construction of a coherent self-narrative, and also linked to a dissociative form of defence against intolerable experiences (traumas).

Existentially orientated perspectives Existential philosophy and existential psychotherapy are closely related. The focus, in both the philosophy and therapy, is on the existential challenges humans are confronted with. The themes revolve around how we relate to the meaning of our own life, loneliness, responsibilities, guilt, freedom, and death. The groundswell of existential ideas was originally a reaction to particularly two psychological polarities in the mid-1900s: psychoanalysis and behaviourism. Existentially orientated therapists have generally been critical to the fact that the interpretations of the psychoanalyst were ‘pushed onto’ the client rather than him being allowed to get to know himself better by creating new meaning in life through reflection and interpretation together with the therapist. The exploration of a new self-narrative, a life-story about oneself, became the essence of narrative, existential, and phenomenologically oriented approaches, and have therefore interesting lines of connection to the understanding of schizophrenia as a self-disturbance. Existential theories had critical questions as to whether psychoanalysis and behaviourism had placed enough emphasis on humans as active, emotional, and living beings. Central in the early development of the existential perspectives were two psychiatrists and phenomenologists, the Swiss Ludwig Binswanger (1881–1966) (see Ghaemi, 2001) and the Polish–French Eugene Minkowski (1885–1972) (see Urfer, 2001). Both thinkers provided early and central contributions to continental phenomenological psychiatry, as well as to the understanding of psychosis. Existential therapy is therefore the branch among the psychotherapy perspectives having closest links to the Subjectivity Model.

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The trauma perspective Starting in 2015, an internationally reaching conference has been established between the fields of trauma, dissociation, and psychosis (traumaconference.no), signalling the importance of further exploring this crucial inter-thematic connection. The dissociative defence mechanisms involved in trauma also touch upon self-experience and the experience of identity quite directly, and are relevant to the development of psychosis (Kilcommons & Morrison, 2005). Dissociation is a psychological ‘uncoupling’ of the individual, from experiences, feelings, or somatic memories which have not been possible to tolerate. This uncoupling will necessarily also touch upon subjectivity. Being subjected to trauma is one of many well-known risk factors for the development of psychosis, and an increasing number of research reports have shown a connection between severe traumatisation, particularly at young age, and increased risk of psychosis (Stanton et al., 2020), as well as other mental disorders. The window of tolerance and the regulation of activation are central in the treatment of trauma. The window of tolerance refers to a range of bodily activation which is optimal for the individual concerned, where s/he manages to relate to the world as mindfully present and can focus attention and learn. The trauma perspective might play an increasingly important role in the treatment of schizophrenia, through working with the regulation of activation to calm symptoms and enable reflection. Significant traumatic experiences can narrow the tolerance window so that apparently trivial events lead to hyperactivation (or hypoactivation). Such regulation difficulties may have significance for, and contribute to, an expanded understanding of subjectivity. That the regulation of activation is important in the treatment of psychosis is also apparent in light of the concept of ‘expressed emotion’ (Vaughn & Leff, 1976), which emphasises the importance of the emotional climate in the client’s immediate environment, and the reduction of stress. Although disturbed experiences of self and identity are involved in trauma experiences, these are often easy to recognize as related to traumatic events in that they are episodic, limited in time, and often start abruptly, while basic selfdisturbance is considered largely stable trait-like features.

The dopamine hypothesis and neurobiological perspectives Extensive neurobiological research is being carried out on schizophrenia and psychosis, investigating independent, biochemical, neurophysiological, neuroanatomic, and genetic factors. For more than half a century, the so-called dopamine hypothesis was dominant (Meltzer & Stahl, 1976), but today this is regarded as too simplistic, and changes in dopamine transmission in the brain is probably also not the primary disturbance (Yang & Tsai, 2017). The hypothesis rests upon the presence of dopaminergic hyperfunction in active psychosis and supposes that antipsychotic medications can block dopamine receptors and through this calm psychotic symptoms. Neurobiology studies the neurobiological structures and 122

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mechanisms in themselves, their natural correlates, and their relationships with standardised measures of psychotic symptoms. Once again, it should be remembered that even in neurobiology, there is currently no comprehensive and agreedupon hypothesis for the understanding of psychosis. On the contrary, the picture is more complex and confusing than ever, investigating an ever-increasing number of chemical transmitter substances, receptors, neuroanatomic and genetic anomalies, as well as epigenetic mechanisms. The ‘jigsaw’ is increasing in size, while the pieces are becoming more numerous and smaller.

The drug dependency perspective There is a significant and justified interest in the impact of destructive drug use for the development of psychosis. It is well known that cannabis, amphetamines, and opiates can trigger both symptoms of psychosis and psychotic disorders. Certain reports also indicate that high-level, long-term use of cannabis may be an independent cause schizophrenia (see McLoughlin et  al., 2014). The chemical nature of these drugs has served as a model for building theories about the causes of psychosis, but no such theory has so far received general and broad support (Gage et  al., 2013). Neither is the drug dependency perspective a contribution to the understanding of psychosis in a way that can be regarded as a perspective relevant to the current book. The drug dependency perspective does not provide any significant understanding of the basic dynamics in development or how psychotic experiences are shaped and arise because of these. Destructive drug use is more to be regarded as a risk factor that ties in with the stress-vulnerability model, both as a vulnerability factor and as a triggering stress factor. Whether detrimental drug experiences later manifest themselves in psychosis or not depends on other underlying, general vulnerabilities. This is quite clear from the fact that the vast majority persons with a serious and destructive drug problem never develop a psychotic disorder. And conversely, many persons with psychotic disorders do not report about relevant drug problems. However, we must consider that such subjective reports are always associated with uncertainty. Other frames of reference, perspectives, and models for psychotic disorders could be mentioned, but the traditions presented here have provided the most fundamental contributions to the understanding of psychosis. As we have seen, the perspectives discussed have not been concerned with descriptions of specifically how psychotic and pre-psychotic phenomena themselves may be developed, shaped, and articulated in our mind. They have also to a minimal extent been concerned with which critical structural aspects of consciousness (ref subjectivity) are involved, and why it seems to be the case that many psychotic phenomena, as recorded over hundreds of years, seem to be surprisingly similar in form. None of the mentioned contemporary perspectives or models of understanding, or any psychotherapeutic approach to psychosis, addresses directly what elements of consciousness may lie behind these enigmatic and striking experiences. This 123

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is the unique contribution of phenomenological psychiatry and the Subjectivity Model. In the next chapter, I will describe how self-disturbances should be an integrated part of the treatment in the entire range of evidence-based measures, and always tailored to the individual.

References Baker, H.S., & Baker, M.N. (1987). Heinz Kohut’s self psychology: An overview. American Journal of Psychiatry, 144(1), 1–9. Beck, J.S. (2020). Cognitive behavior therapy: Basics and beyond. New York: Guilford Publications. Cullberg, J. (2014). Psychoses: An Integrative Perspective. New York: Routledge. Dickerson, F.B., & Lehman, A.F. (2011). Evidence-based psychotherapy for schizophrenia: 2011 update. The Journal of Nervous and Mental Disease, 199(8), 520–526. Fenton, W.S. (2000). Evolving perspectives on individual psychotherapy for schizophrenia. Schizophrenia Bulletin, 26(1), 47–72. Fisher, P.L. (2021).  Metacognitive therapy. Washington, DC: American Psychological Association. Flanagan, L.M. (2008). Object relations theory. Inside Out and Outside in: Psychodynamic Clinical Theory and Psychopathology in Contemporary Multicultural Contexts, 2, 121–160. Gage, S.H., Zammit, S.,  & Hickman, M. (2013). Stronger evidence is needed before accepting that cannabis plays an important role in the aetiology of schizophrenia in the population. F1000 Medicine Reports, 5. Ghaemi, S.N. (2001). Rediscovering existential psychotherapy: The contribution of Ludwig Binswanger. American Journal of Psychotherapy, 55(1), 51–64. Green, M.F. (1998). Schizophrenia from a neurocognitive perspective: Probing the impenetrable darkness. Boston, MA: Allyn & Bacon. Green, M.F., Horan, W.P.,  & Lee, J. (2015). Social cognition in schizophrenia. Nature Reviews Neuroscience, 16(10), 620–631. Haug, E., Øie, M., Melle, I., Andreassen, O.A., Raballo, A., Bratlien, U., . . . & Møller, P. (2012). The association between self-disorders and neurocognitive dysfunction in schizophrenia. Schizophrenia Research, 135(1–3), 79–83. Hayes, S.C., Strosahl, K.D., & Wilson, K.G. (2011). Acceptance and commitment therapy: The process and practice of mindful change. New York: Guilford Press. Henriksen, M.G., Raballo, A., & Nordgaard, J. (2021). Self-disorders and psychopathology: A systematic review. The Lancet Psychiatry, 8(11), 1001–1012. Jung, X.T.,  & Newton, R. (2009). Cochrane reviews of non‐medication‐based psychotherapeutic and other interventions for schizophrenia, psychosis, and bipolar disorder: A systematic literature review. International Journal of Mental Health Nursing, 18(4), 239–249. Kernberg, O. (1967). Borderline personality organization. Journal of the American Psychoanalytic Association, 15(3), 641–685. Kernberg, O.F. (2005). Identity diffusion in severe personality disorders. In S. Strack (Ed.), Handbook of Personology and Psychopathology. Hoboken: John Wiley & Sons Inc. Kilcommons, A.M., & Morrison, A.P. (2005). Relationships between trauma and psychosis: An exploration of cognitive and dissociative factors. Acta Psychiatrica Scandinavica, 112(5), 351–359.

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Lucas, R. (2013). The psychotic wavelength: A psychoanalytic perspective for psychiatry. New York: Routledge. Lysaker, P.H., Buck, B., & Lysaker, J.T. (2012). Schizophrenia and alterations in the experience of self and agency: Comparisons of dialogical and phenomenological views. Theory & Psychology, 22(6), 738–755. Lysaker, P.H.,  & Lysaker, J.T. (2010). Schizophrenia and alterations in self-experience: A comparison of 6 perspectives. Schizophrenia Bulletin, 36(2), 331–340. Marcus, E.R. (1999). Modern ego psychology. Journal of the American Psychoanalytic Association, 47(3), 843–871. McLoughlin, B.C., Pushpa‐Rajah, J.A., Gillies, D., Rathbone, J., Variend, H., Kalakouti, E., & Kyprianou, K. (2014). Cannabis and schizophrenia. Cochrane Database of Systematic Reviews, 10. Meltzer, H.Y.,  & Stahl, S.M. (1976). The dopamine hypothesis of schizophrenia: A review. Schizophrenia Bulletin, 2(1), 19. Müller, T. (2004). On psychotic transference and countertransference. The Psychoanalytic Quarterly, 73(2), 415–452. Nelson, B., Sass, L.A., & Škodlar, B. (2009). The phenomenological model of psychotic vulnerability and its possible implications for psychological interventions in the ultrahigh risk (‘prodromal’) population. Psychopathology, 42(5), 283–292. Nelson, B., Whitford, T.J., Lavoie, S., & Sass, L.A. (2014). What are the neurocognitive correlates of basic self-disturbance in schizophrenia? Integrating phenomenology and neurocognition (Part 1) (Source monitoring deficits). Schizophrenia Research, 152(1), 12–19. Nordgaard, J., Henriksen, M.G., Jansson, L., Handest, P., Møller, P., Rasmussen, A.R., . . . & Parnas, J. (2021). Disordered selfhood in schizophrenia and the examination of anomalous self-experience: Accumulated evidence and experience. Psychopathology,  54(6), 275–281. Pérez‐Álvarez, M., García‐Montes, J.M., Vallina‐Fernández, O., Perona‐Garcelán, S.,  & Cuevas‐Yust, C. (2011). New life for schizophrenia psychotherapy in the light of phenomenology. Clinical Psychology & Psychotherapy, 18(3), 187–201. Rosenbaum, B., Harder, S., Knudsen, P., Køster, A., Lindhardt, A., Lajer, M., . . . & Winther, G. (2012). Supportive psychodynamic psychotherapy versus treatment as usual for first-episode psychosis: Two-year outcome. Psychiatry: Interpersonal & Biological Processes, 75(4), 331–341. Rosenfeld, H. (1969). On the treatment of psychotic states by psychoanalysis: An historical approach. International Journal of Psycho-Analysis, 50, 615–631. Segal, H. (2018). Introduction to the work of Melanie Klein. New York: Routledge. Silver, A.L.S. (2001). Psychoanalysis and psychosis: Trends and developments. Journal of Contemporary Psychotherapy, 31(1), 21–30. Škodlar, B., Henriksen, M.G., Sass, L.A., Nelson, B.,  & Parnas, J. (2013). Cognitivebehavioral therapy for schizophrenia: A critical evaluation of its theoretical framework from a clinical-phenomenological perspective. Psychopathology, 46(4), 249–265. Stanghellini, G., & Lysaker, P.H. (2007). The psychotherapy of schizophrenia through the lens of phenomenology: Intersubjectivity and the search for the recovery of first-and second-person awareness. American Journal of Psychotherapy, 61(2), 163–179. Stanton, K. J., Denietolis, B., Goodwin, B.J., & Dvir, Y. (2020). Childhood trauma and psychosis: An updated review. Child and Adolescent Psychiatric Clinics, 29(1), 115–129.

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Urfer, A. (2001). Phenomenology and psychopathology of schizophrenia: The views of Eugene Minkowski. Philosophy, Psychiatry, & Psychology, 8(4), 279–289 Vaughn, C.E., & Leff, J.P. (1976). The influence of family and social factors on the course of psychiatric illness: A comparison of schizophrenic and depressed neurotic patients. The British Journal of Psychiatry, 129(2), 125–137. Yang, A.C., & Tsai, S.J. (2017). New targets for schizophrenia treatment beyond the dopamine hypothesis. International Journal of Molecular Sciences, 18(8), 1689. Yeisen, R.A., Bjørnestad, J., Joa, I., Johannessen, J.O., & Opjordsmoen, S. (2019). Psychiatrists’ reflections on a medication-free program for patients with psychosis. Journal of Psychopharmacology, 33(4), 459–465. Zubin, J.,  & Spring, B. (1977). Vulnerability: A new view of schizophrenia. Journal of Abnormal Psychology, 86(2), 103.

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12 S E L F-D I S T U R B A N C E S A S PA RT O F A W I D E R T R E AT M E N T CONTEXT

As has been emphasised, not only psychotic disorders per se but also the often-prolonged pre-psychotic phase prior to these disorders can have a strong negative influence on functioning and life quality, particularly among adolescents and young adults. Several parallel treatment and support measures may therefore be necessary even in this ‘silent’ prodromal phase. As part of the entire range of approaches, self-disturbances as core phenomena must have a place. A natural place to begin is systematic thematisation, that is, the therapeutic description, clarification, and sorting of the different types of self-disturbances each individual experiences. This can expand and deepen the other psychotherapeutic and psychoeducational measures, via sharing and talking through, as well as stimulating the development of new and sounder meaning related to the core experiences.

Self-disturbance as a ‘warning’ phenomenon: a supplement to a whole Explicitly focusing on self-disturbances – core phenotypic phenomena – should belong to the range of treatment approaches for both psychotic disorders and where there is an increased psychosis risk. Despite differences across geographical contexts, standard treatment for psychotic disorders in many Western countries today is a broad ‘package’ of systematic measures which need to be implemented flexibly and across a range of clinical contexts. The measures must include individual and family-based conversations with the clinician; psychotherapy; psychoeducational family intervention (individual families or multi-family groups); medication; strengthening and building social networks in relation to school, friends, the local community, and leisure activities; as well as appropriate assistance with accommodation, finances, work, and education. Such an overarching model using a broad and multifaceted package of measures is nothing new. Since the beginning of the 1980s, very much the same type of approach went DOI: 10.4324/9781003127895-13

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under the name of case management (as part of assertive community treatment), a ubiquitous practice central to 21st-century public mental health services in many Western countries (see Smith & Newton, 2007). The initial main motive for the establishment of several alternative models of case management was to support the deinstitutionalisation of psychiatry, an initiative which started in England in the 1960s and 1970s (see Leff & Trieman, 2000). However, the new, locally based psychiatric health services proved difficult to deliver for the most severely ill, particularly those diagnosed with schizophrenia spectrum disorders. This was the background for the training of ‘case managers’, whose role was to coordinate the various treatment measures and provide guidance for service users (Leff & Trieman, 2000). Case management models have been extensively researched, but with mixed results. Despite positive effects on several outcomes, this was by no means the case for all. Among the numerous outcomes which have been examined, only engagement with services has been solidly and consistently positive (Smith & Newton, 2007). The necessity of such broad and resource-intensive treatment packages also reflect, previously and currently, a certain frustration related to the fact that the treatment is so demanding and extensive, and in fact unclarified. Enduring psychotic disorders have a marked influence on almost all aspects of life, and there is no singularly effective treatment. Many measures are needed to run in parallel, and even then, it is not always possible to achieve the desired outcome. It is within this broad range of treatments that an explicit focus on selfdisturbances needs to be included, at the appropriate points of time during treatment and in appropriate settings, not to lose sight of these underlying intrusive experiences.

A common understanding: seen from the outside, lived from within It should be emphasised that self-disturbances, in isolation, cannot be the object of ‘treatment’, as such. They are not isolated, free-standing targets for treatment, but wide, complex, underlying components of a larger picture. They can contribute to a broader understanding and can draw a more complete picture of the experiences and dynamics behind psychosis development: they are a natural, experiential core phenotype in these disorders, that do not simply consist of disordered outer behaviour and functioning. Self-disturbances represent implicit, generative core processes lying behind both the early, pre-psychotic phenomena and the psychosis symptoms that may develop later. In the pre-psychotic phase, the selfdisturbances are therefore a logical and natural place to start work on finding the basic personal themes in the person’s inner, mental life and landscape. The outer, practical life difficulties and peculiarities that have arisen always have an inner, experiential correlate. However, these inner phenomena are only directly accessible for the main person, and it is therefore necessary to provide help to open up and share these experiences.

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Self-disturbances should also be made known to close family members, through planned, predictable, and secure cooperation with the family. Only then can a form of emerging connection between outer behaviour and inner mental life be made available for all concerned. Usually, the family tend to observe outer behaviour and events, while the main person is largely concerned with inner aspects. It is a greatly important step when such a contrast in perspective transforms to a common picture of the situation for everyone involved. To reiterate, there should be no separate treatment plans for self-disturbances, but the existing measures should be expanded in line with the nature of BSD. One aim of psychosis treatment is to seek wholeness and coherence, also in the sense of ‘seen from the outside and lived from within’, as well as sharing of knowledge, that is to say a common understanding for all those involved. Such wholeness and sharing can lead to a positive cascade effect from area to area, and can contribute to connections and touch points between the treatment areas: psychoeducation, self-understanding, service user involvement, experience of identity, family relations, social network, etc. Wholeness and sharing will also stimulate the coordination of individual therapy with family and network interventions. It may enable bridge building between the professional fields and the various other public services which often are involved in the individual case (e.g. social services, child welfare services, and family welfare services).

Psychotherapy and self-disturbances Clinical work with self-disturbances, like all forms of psychotherapy, takes as its starting point the actual life circumstances and challenges of the main person. There will be basic themes relating to feelings, the regulation of feelings, relationships, experience of identity, childhood, physical/emotional/sexual traumas and abuse, family conflicts, etc. Also, comorbidity with other mental disorders, complicating factors to the primary disorder (such as depression, anxiety, and substance abuse and dependency) must in the usual way be part of the treatment. Among the treatment methods for schizophrenia and related psychotic disorders, the cognitive approaches (CBT) are by many regarded as the most researched and documented. Little to moderate effect on positive psychotic symptoms seems to be established, but not on functioning and quality of life (Bighelli et al., 2018), and there is still controversy in this field. Controversy and uncertainty are even more the case for psychodynamic psychotherapy and other psychological interventions. Despite some evidence for positive effect of supportive psychodynamic psychotherapy (Rosenbaum et al., 2012), this field of research is associated with major methodological challenges (Fenton, 2000; Jung & Newton, 2009). Music therapy has also got some support by research (Geretsegger et al., 2017). In the introductory chapters of this book, it was discussed how self-disturbances affect the individual’s basic existential experiences, namely, feelings of vitality, feelings of identity, a basic sense of meaning, a sense of ownership of

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experiences, etc. This will of course strongly affect psychotherapy, and the focus of the talking therapies needs to take these fundamental issues into account, as psychotherapy always needs to identify and work with thoughts, feelings, behaviours, and relationships. However, what if the client is unable to convey fundamental and decisive issues to the therapist, like these: • • •

What if experiences are not felt as stably anchored to, or belonging to the person her-/himself? What if s/he doesn’t have a feeling of being her-/himself, or even truly existing? – that s/he feels ‘backstage’ and literally distanced from their own life? What if s/he feels like not really belong to humanity, or that they are a fictional character in a novel?

How will such pervasive and harrowing insecurities and doubts affect the working through of anger, guilt, or conflicts in relationships? As clinicians, we risk being totally misguided if we start up any kind of psychotherapy without first clarifying these basic preconditions for therapeutic work. In other words, a preparatory phase, not typical in the case of other mental disorders, is of utmost importance. A therapist needs to know whether the therapy will take place with a person who has basic aspects of his or her self-experience intact. The individual must feel mentally and physically present, and part of a shared, physical world. It would be misguided to start therapy, with the aim of self-insight, without checking whether the self is experienced as coherent and can be explored from a mutual position. Without this, a productive dialogue is not possible. These preconditions for constructive therapy are discussed in more detail in Chapter 13 in the context of therapeutic effects and hindrances. To most people, it would seem like stating the obvious that a fragmented self would be taken strongly into account by a therapist. However, the problem is that such a disturbance of the self may be quite difficult to detect, especially when the phenomena are in an early phase. Moreover, it is not always a matter of procedure to check these phenomena. It seems that there are several specific hindrances to overcome: the person’s awareness of her-/himself, their ability to relate this verbally, and the therapist’s knowledge, experience and understanding of how the disturbances express themselves in everyday language. In this chapter, I have emphasised how self-disturbances should be an integrated part of the treatment in the entire range of evidence-based measures, and always tailored to the individual. There are good reasons to claim that this phenomenological perspective is an essential one and can augment the effects of other treatment approaches from other perspectives. Being aware that behavioural disturbances in fact are the result of underlying invisible changes in experience is highlighted as central in the case of psychotic disorders. The incipient breakdown of the inner landscape can remain hidden for a long time, even though behaviour is visibly disturbed. Coherent and common knowledge about both ‘inner’ and ‘outer’ phenomena should be available for the main person and for the family. 130

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Finally, it has been reiterated that there are certain specific considerations and conditions that should be addressed before the start of psychotherapy for psychotic disorders. The different treatment modalities will be described in more detail in Chapter 15. In the next chapter, I will highlight that the phenomenologically inspired clinical conversation can be a strikingly effective and powerful instrument in the endeavour to access precise and detailed descriptions of the distorted experiences in schizophrenia, particularly in its prodromes.

References Bighelli, I., Salanti, G., Huhn, M., Schneider‐Thoma, J., Krause, M., Reitmeir, C., . . . & Leucht, S. (2018). Psychological interventions to reduce positive symptoms in schizophrenia: Systematic review and network meta‐analysis.  World Psychiatry,  17(3), 316–329. Fenton, W.S. (2000). Evolving perspectives on individual psychotherapy for schizophrenia. Schizophrenia Bulletin, 26(1), 47–72. Geretsegger, M., Mössler, K.A., Bieleninik, Ł., Chen, X.J., Heldal, T.O.,  & Gold, C. (2017). Music therapy for people with schizophrenia and schizophrenia‐like disorders. Cochrane Database of Systematic Reviews, 5(5). Jung, X.T.,  & Newton, R. (2009). Cochrane Reviews of non‐medication‐based psychotherapeutic and other interventions for schizophrenia, psychosis, and bipolar disorder: A systematic literature review. International Journal of Mental Health Nursing, 18(4), 239–249. Leff, J., & Trieman, N. (2000). Long-stay patients discharged from psychiatric hospitals: Social and clinical outcomes after five years in the community. The TAPS project 46. The British Journal of Psychiatry, 176(3), 217–223. Rosenbaum, B., Harder, S., Knudsen, P., Køster, A., Lindhardt, A., Lajer, M., . . . & Winther, G. (2012). Supportive psychodynamic psychotherapy versus treatment as usual for first-episode psychosis: Two-year outcome. Psychiatry: Interpersonal & Biological Processes, 75(4), 331–341. Smith, L., & Newton, R. (2007). Systematic review of case management. Australian & New Zealand Journal of Psychiatry, 41(1), 2–9.

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Figure 13 Rough sketch of two identical female figures (upper body and head) seen from the side, where one figure is slightly displaced back in relation to the other.

13 C O N V E R S AT I O N A N D PHENOMENOLOGY

We need access to precise and detailed descriptions of the disturbed experiences in schizophrenia, with a view to both research and treatment. The clinical conversation can be an effective and powerful instrument in this regard, notably also in the field of psychosis. The conversation in this case must be structured and organised in a way that supports a gradual and detailed exploration, revelation, and clarification of the individual experiences. No branch of science can help to achieve an understanding of these complex landscapes better than phenomenology. This scientific discipline is not just concerned with ‘learning about the phenomena’ but with investigating the necessary conditions underlying the expression of the mental phenomena, human experience in general, and the construction of meaning in experience. In this area, as in this book, clinical aspects, such as treatment, and research issues go hand in hand, and the two parts should communicate and work together in a circular process.

Words and language are the central therapeutic tools for mental illness ‘In the beginning was the word’ – this is a well-known quote from the Bible, concerning the creation (John, 1:1). This is understandable, as human life mere or less depends on words and concepts. Words, language, and the consequent possibility of self-reflection is the essence of the human condition. It allows us to think and communicate about our own existence and that of others. If we are born without the ability to form and use words, or in some way lose this ability, there will be a pressing need to find other channels out into the surrounding world and into the world of others. The functions of language are many, but some of the most important are the tasks of naming (designating), categorising, and storing all experiences and events in our memory.

DOI: 10.4324/9781003127895-14

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Inner language (thought) and outer language (speech) are the most refined tools for understanding the world and our existence, and therefore are of pivotal significance when challenging mental disorders. Mental phenomena such as hallucinations, hearing voices, overwhelming emotions, and chaos need to be put into words. Our day-to-day experiences and feelings in our life course are named continuously during childhood and adolescence, but highly deviant phenomena, such as selfdisturbances, mostly come to us unnamed, even in adult life or adolescence. Such phenomena must therefore be studied closely and understood to their core, if they manifest themselves, and they must be named and categorised as a certain part of a therapeutic process. Everything must be described, designated, and understood; symptoms, phenomena, oneself, one’s identity, roles and tasks, and what is meaningful in the world. Such naming, putting confusing and painful experiences into words, makes them more ‘visible’, ‘graspable’, manageable, and thus less painful. It is a case of being in a better ‘position’, that is, being prepared and slightly more secure when things become recognisable and more familiar. That which is unnamed, undefined, or inconceivable will also be unpredictable, surprising, and create insecurity. Feelings of insecurity and unreality make pain more painful.

Characteristics of conversations inspired by phenomenology The conversation as a psychological microscope My experiences from my own in-depth study of the prodromal phase, published in Schizophrenia Bulletin in 2000, constitute the backdrop to this book. Among the most important experiences I gained was the gradual recognition of the significance and power of the conversation in the assessment and treatment of psychosis. An open, patient, genuinely interested, and strictly targeted conversation showed itself to be decisive for me to get access to precise and detailed descriptions of the clients’ distorted experiences, and is arguably underrated as a scientific ‘tool’, specifically in the field of psychosis. The conversation can function as a unique ‘microscope’ when exploring the phenomena of psychotic disorders, and particularly their precursors. But how does this differ from the talking therapies referred to in Chapter 11? In research, phenomenological approaches to understanding mental disorder experiences are well established across the humanities and social sciences, but not so in mainstream clinical psychiatry and psychology. Much of what is written earlier in the book applies to all types of psychotherapy. What can be considered unique about the form of conversation inspired by phenomenology will be described in more detail in this chapter, and the essential and most important issue concerns the extremely unusual and almost indescribable phenomena such conversations aim to grasp. As discussed earlier, basic self-disturbances are in the first place regarded as largely ineffable, that is, not easily transferable to verbal expression, which means a great deal is demanded when it comes to how conversation and communication 134

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is approached. The necessity of great vigilance regarding awareness of the client’s personal language, concepts, and ways of conceiving the world, which most often will be set apart from what is usual and recognisable, will make the conversation challenging in a particular way. More mainstream branches of psychotherapy, including their identification of more conventional aspects of the mind, symptoms, and themes of psychological conflict, will of course have their specialised working methods too, but the language and concepts associated with these branches are far more common and readily available. However, the anchoring of basic self-disturbances, in an unspeakable disturbance of subjectivity, only manifesting itself indirectly, often creates a puzzling world full of strange verbal expressions (Baklund et al., 2023), a world which needs to be received by the therapist both sensitively and vigilantly. Good conversations must necessarily be reciprocal, but occasionally the conversation can also function as a kind of ‘one-way’ exploratory instrument, rather like a microscope, aiding the scientific understanding of clinicians and researchers. The reason why many research communities seem to have had limited deeper interest in the ‘infrastructure’ of the subjective phenomena in schizophrenia (see Sass, 2022) may be many, but one of them might be that the conversation as a multi-faceted instrument has not been sufficiently emphasised as a potent tool precisely in these severe disorders. This of course applies to both clinic (therapy) and clinical research, and the two scientific realms should work in a close reciprocal collaboration. Searching for the details in experience This chapter focuses on a mainly clinical aspect, namely the therapeutic conversation. However, this can hardly be separated completely from clinical research issues in this field, which has provided, and still provides, crucial knowledge about the ‘object’ of therapy, the profoundly changed self-experiences. Therefore, research issues are relevant to include and bring along in the discussion. Biological research on genetics, medication, brain structures, transmitter substances, and biochemical processes in the brain are all important. Such research might solve (parts of) the mystery of psychosis in 20, 40, or 60 years of time, but this is far from certain. In the meantime, however, focusing, both in research and in clinic, on the potential further refinements of the in-depth conversation about core experiences may move the field forward in the areas of prevention, early assessment, and treatment. Not least, there is a potential for the main person to be calmed and comforted when there is an increased understanding of his or her own experiences and situation. The aim of my prodromal research was (1) to come as close as possible to the person’s actual experiences, (2) to obtain the richest and most detailed picture and account of the disturbed experiences, with the ultimate goal (3) to be able to establish a genuine therapeutic meeting with the client. The conversation as an instrument in this exploration of the prodromal phase turned out to be more decisive than I had expected. 135

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In clinical work and in research on prodromal and psychotic phenomena, we are, in other words, dependent on access to detailed descriptions of the changed experiences, from the inside. Experiences are abstract by nature and can never be harnessed, stored, or documented in a precise or fixed way. In the early phase, they are in addition frightening and foreign for the main person him-/herself. The affected person often has not found the words to describe them yet. The picture is further complicated by the fact that many adolescents and young adults are in an identity seeking and identity forming phase of life in this period. Typically, this normal search for identity takes the form of the young person asking questions about the meaning of life, basic truths, and views of reality. Most often, this takes the form of a time-limited ‘self-chosen existential/intellectual project’ rather than an enduring, deep, and invalidating uncertainty that leaves the person existentially ‘trapped’. The ordinary existential doubt typical among healthy young persons is something qualitatively quite different to the pre-psychotic dissolution of identity. Clearly, conversations need to be carefully adapted to the nature of the phenomena if we are to succeed in coming close to them, and where we can see the difference between the usual and the unusual, and the phenomena have to be designated and described in ways that provide meaning for the main person. A safe and opening setting Because self-disturbances are of such an unusual and partly frightening character, it is particularly important that the exploratory conversation takes place in an atmosphere of mutual openness and confidentiality. It takes a great deal of courage to speak openly about such unusual, private, and disturbing experiences. That the experiences by their very nature are almost impossible to express in words means that the structure and form of the conversation are even more crucial to address. In relation to this, a phenomenological approach implies helping the main person to speak about their inner life as part of a general social conversation. A sense of a fixed and structured ‘interview’ situation should be avoided. It is essential that questions are formulated as opening rather than closing. A key point here is that clinicians should ask more dynamic ‘how-questions’, like: ‘how is your experience?’ and ‘how is it to experience this?’ and ‘how can it be that you experience this?’. One should try to avoid more static and flat ‘what-questions’, like ‘what do you experience?’. Overlapping phenomena: an atmosphere It is also necessary to bear in mind that many of the phenomena to be investigated are not fully possible to separate from each other. They constitute in principle aspects of a whole, and are experienced as a special kind of atmosphere, or what German phenomenologists have referred to as a ‘Stimmung’ (Sass, 1988; Jansson & Parnas, 2020). The specific content of the individual experience is

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important, but the atmosphere in which the phenomenon appears in the mind is even more important. This atmosphere will be important for the general tone of the conversation. The clinician should not look singly and mechanically for separate, ‘narrow’ phenomena, as this will reduce the likelihood of discovering the client’s experiential atmosphere. For example, structured diagnostic instruments may ask questions such as: ‘Do you feel persecuted/followed/affected by radio signals or other similar things?’ The answer here will tend to be categorical, ‘yes’ or ‘no’ or a borderline answer. However, an alternative is to start up an open conversation about how the person him-/herself experiences their insecurities or uncertainties in daily life. This allows their own words, nuances, and detailed descriptions to create a broader and richer picture of the personal atmosphere. In order to facilitate a meeting of the same ‘wavelength’, therapists should in other words adopt an ‘atmospheric attitude’ in meeting with clients, who can be assumed to have an ‘atmospherically’ marked experience. Use of quotations It can be expedient to use words and expressions from one individual as a starting point for working with another individual’s self-descriptions. Such quotations can lead to instant recognition of a certain feeling, and clinicians can then use this recognition as a door opener, an ‘effective’ point of departure for further assessment and therapy. Two people rarely describe the same type of experience with the same words and phrases. Still, there are often clear similarities on a general level (see client quotations in Chapters 6 and 9). An almost unlimited number of variants of descriptions can be used to characterise one and the same general type of experience. Quotations from others can therefore be very useful as door openers to what seems to be a wordless landscape. Based on both my own prodromal research and experiences from our assessment unit, many clients come to a point in the conversations where they unexpectedly express an experience or pose a question in a strikingly illuminating, characteristic, and in fact very precise way. These phrases should be written down by the clinician, verbatim, for use later, in the present or in other conversations. They can be significant and enlightening points of reference in further clinical work. Typical examples are ‘everything has become nothing’, ‘something has happened in me that has made me un-human’, ‘my I has been lost’; ‘I have lost my whole self’; ‘thinking happens in me’, etc. These and similar utterances have an underlying common denominator: they obviously reflect a pervasively changed self-experience and sense of identity. The conversation form inspired by phenomenology is characterised by an open invitation, where the clinician at the outset does not put forward strict frames about what themes should be the focus of the conversation. It is not the clinician’s role to strictly steer the conversation thematically, but rather to steer their own attention. The clinician’s attention should be directed to potentially relevant expressions

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and peculiarities. A simple and generalising introduction from the therapist might sound like this: I know from others, in situations like yours, that it can be extremely hard sometimes to find the words to express what you are experiencing. For some it can seem almost impossible. Even so, my experience is that if you just start to talk about something in your life that is difficult right now, we will at some point get to the important things. After an introduction such as this, it is of importance to be patient and hold back a little, which will signal respect for the fact that the client will often need time. Opening doors with ‘how-questions’ To reiterate shortly, inviting and opening conversations usually involve more questions of the type: ‘How is it possible that you can experience such things as .  .  .  ?’ than questions of the type ‘Why or what makes you experience such things as .  .  .  ?’ ‘How-questions’ are descriptive invitations and have a greater potential to stimulate the client to bring out their own understanding of what is happening. ‘Why’ and ‘what’ tend to have a narrowing, closing, or concluding effect, whereas ‘how’ functions widening and descriptive. The client’s own understanding and interpretation of the development and of his experiences is decisive in order to, later on, be able to stimulate new interpretations and meanings. The difference between ‘how’ and ‘why’ also has a link to the difference between the two concepts understanding/meaning and explanation/cause, a division which is of great significance (see Chapter 1, p.10). Cause is most often tied to explanation, while meaning is tied to understanding. It is usual that clients and families ask: ‘Why is this happening?’, and in this case, they are often looking for causes. This is indeed understandable, but the challenge of a focus on causes is that there are so many and largely unclear causes of psychosis, and we know little about the relative importance and weighting of the various factors (genetics, infections, events during pregnancy, events during and after childbirth, trauma and child abuse during childhood, relational stress, substance use, etc.). The causal perspective is also further complicated by the fact that there is not necessarily a simple relationship between why things happen and what can be done about it. In contrast, the link between the subjective understanding of meaning and what can be done about it (in the conversation) is often much clearer. Like chiselling out a sculpture The phenomenologically oriented conversation will after some time be directed towards a gradual and quite detailed exploration and clarification of the diverse aspects of the phenomena. Often, an experience will seem vague and indistinct at the beginning of an assessment, to both the clinician and the main person, but little 138

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by little will be more visible and available for conversation. It can then be complemented, expanded, and adjusted. In this way, the different types of experience will be given form and can be addressed. They can be put together rather like a jigsaw puzzle, representing the client’s exploration of him-/herself and their surroundings. This process is resembling the creation of a sculpture in stone. The final sculpture (the phenomenon) already exists within, but it needs to be revealed to take form, which will be the result of what might be called a vigilant, dialogical carving out process over time. Opening and conversational talks Talking therapy in the present context ideally should have the form of a conversation, nonetheless focused, not a formal and structured interview, lying somewhere in between an open-ended and a semi-structured approach. An open interview (with open-ended questions) aims to be purely descriptive and has no pre-defined categories of answers (i.e. ‘tell me about’). The semi-structured interview can have ready formulated probes or questions (which can be varied), but a fixed sequence is not necessary, and it can be adjusted and adapted, but still conducted within a defined thematic frame. The phenomenologically inspired conversation deviates however markedly from the fully structured interview, regularly used in clinical psychometric assessments and in research, which presents standardised questions as well as categories of answers, which both must be stringently followed. Structured interviews are efficient in terms of time, but often result in a closed and rather formal inter-personal atmosphere. Though open forms of conversation are time consuming from one perspective, they can also save time in other ways. Due to qualitative richness and precision, they result in data material which structured interviews cannot access. In the open and exploratory interview, the clinical richness (with relational and therapeutic gains) is greater and more important than the loss of quantitative scoring and grading. Moreover, it should also be remembered that it is an open discussion whether quantitative precision is at all possible, or even relevant, in the field of mental health. The psychometric instruments often used in measuring psychological phenomena are always proxies and involve significant margins of error and uncertainty. This chapter presented certain characteristics of the clinical-phenomenological conversation, as a powerful instrument in the field of psychosis. The next chapter will bring an overview of the fields of therapeutic impact, therapeutic preconditions, and tentative therapeutic effects and obstacles, when the treatment measures are aimed at self-disorders.

References Baklund, L., Røssberg, J.I., & Møller, P. (2023). Linguistic markers and basic self-disturbances among adolescents at risk of psychosis. A qualitative study. EClinicalMedicine, 55, 101733.

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Jansson, L., & Parnas, J. (2020). ‘The schizophrenic basic mood (self-disorder)’, translated by Hans W Gruhle (1929). History of Psychiatry, 31(3), 364–375. Sass, L. (2022). Subjectivity, psychosis and the science of psychiatry. World Psychiatry, 21(2), 165–166. Sass, L.A. (1988). The land of unreality: On the phenomenology of the schizophrenic break. New Ideas in Psychology, 6(2), 223–242.

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14 THERAPEUTIC EFFECTS A N D O B S TA C L E S

Basic self-disturbances are deeply anchored in human consciousness. Despite this, it is possible to access these clinical phenomena, through therapeutic dialogue and conversations, in itself providing an important sense of acknowledgement and recognition for the client. Understanding, transforming, comforting, and preventing might be watchwords for the desired outcomes for the main person, in clinical conversations. Clinical work with self-disturbances always involves starting where the person currently is, using sharing and reflection, being positively curious about, and exploring the core experiences, with a view to co-create new meaning. This can have several positive effects, on vitality and motivation, it may comfort feelings of loneliness, contribute towards activating and energising the self, as well as helping to alleviate feelings of shame and rejection by others.

The clinical availability of basic self-disturbances Before introducing (1) three therapeutic preconditions, (2) the general and the psychosis-specific fields of therapeutic impact, and (3) primary therapeutic effects of psychotherapy, it may be useful to prepare this by first delving a bit deeper into the nature of these phenomena, highlighting the key features which are particularly relevant in this context. ‘Soft business’, but within reach of normal human dialogue We have seen that self-disturbances can be explored in conversations with clients. They can therefore be regarded as phenotypical phenomena (see the next section, on genotypes and phenotypes), in the sense that they are within reach of normal human dialogue. A long European psychiatric research tradition has shown that such phenomena are clinically accessible. Through this, a foundation has been made which can support further work to obtain increasingly precise and DOI: 10.4324/9781003127895-15

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differentiated knowledge about self-disturbances, and about treatment. It is my general impression from clinical work, research collaboration and grant applications that research data in the form of experiences by many are regarded as ‘too soft science’. Particularly positivistic-empirical attitudes to science have tended to include a view of experiences as less reliable scientific objects. It is however no option to give up on the scientific ‘project’ of studying and characterising the mind and the nature of mental disorders, and its precursors. Furthermore, there is no doubt that experiences are the building blocks of human existence, and can be influenced and changed by treatment. The challenge consists of studying experiences with adequate instruments, under the right conditions. The goal is to identify increasingly accurate and detailed characteristics of the clinical phenomena. Genotypes or phenotypes? Medical science identifies three levels of accessibility for the investigation of clinical phenomena in general, which of course also may apply to the question of accessibility of mental phenomena: genotypical, phenotypical, and endophenotypical (see Poletti & Raballo, 2018). (1) Genotypical phenomena (purely biological characteristics of the genes) are not available or detectable by human senses, such as sight, hearing, smell, or touch. Neither are they detectable by normal microscopes, being only demonstrable through molecular genetic techniques. This applies for example when investigating the building blocks of the hereditary material DNA. (2) Phenotypical phenomena (pheno-, from the Greek, means ‘visible’) are characteristics of human beings, disorders, or conditions that can be identified by means of the senses, or are directly accessible through speech or conversation. Examples of this are typical physical signs and reportable subjective symptoms. (3) Endo-phenotypes are phenomena in a mid-position between genotypes and phenotypes, with an ‘inner visibility’, which is to say that they are accessible with relatively simple means or tools, such as ordinary microscopic analysis of bodily fluids (blood, urine, cerebrospinal fluid, etc.), chemical blood tests or radiology. The strength of endo-phenotypical phenomena is that they can be used to differentiate between different conditions which on the surface may be indistinguishable, because they have identical or similar phenotypes, that is, largely the same signs and symptoms. Self-disturbances are phenotypes Self-disturbances have the unique quality that they indirectly reflect subjectivity, the latter being an abstract, implicit, ‘invisible’ phenomenon or aspect of consciousness. Subjectivity in itself is of course inaccessible at any level, be it genotypical, phenotypical, or endo-phenotypical. It is purely an abstract concept (even though certain research communities have suggested possible brain networks which seem to be involved in self-representation). On the other hand, basic selfdisturbances (BSD) are reportable manifestations of a disturbance of subjectivity, 142

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and BSDs are accessible in the sense that they are experienced directly, that is, identified, felt and reported by clients. Self-disturbances can therefore be considered as phenotypical, and they can be investigated directly through conversations. Easily accessible they are not, however. Challenging aspects of selfdisturbances are the following: (1) They are extremely difficult to verbalise for the main person; (2) they are illustrated and expressed differently from person to person (though occasionally strikingly similarly); (3) they may, at early stages, be unstable, transient, and fluid in character, but still often recurrent. These challenges are to a large degree balanced by the fact that they are directly tied to something so fundamental and important as the client’s understanding and experience of him/herself. This proximity to communicable insight is of course also important in treatment. Shifting and stable at the same time As described, the main experiential themes of the prodromal phase are an enduring feeling of unnerving alienation, unreality, and an increasing fragmentation of meaning and ‘common sense’. External and internal events may gradually lose their genuineness, vitality, immediacy, harmony, integrity, and comprehensibility. It is assumed that this is a result of subjectivity – as a critical structure in consciousness – no longer being intact. Working clinically with these phenomena is highly challenging, precisely because subjectivity is anchored in deep and ‘silent’ levels of consciousness, something which gives them a somehow fluid, transient, and changing character (albeit trait-like) which complicates verbalisation. Bringing out (externalising) such experiences in conversations with clients demands insight, experience, and time. Closed, structured questions (as in standard diagnostic instruments) are rarely useful here. The plasticity and changeability of these phenomena also imply an additional reliability problem in mental health research. It is namely a legitimate question to ask: does the phenomenon (subjectivity) truly exist, when it is so evidently and constantly changing? This is illustrated in this client quotation:

Incipient psychosis phenomena are unstable and changeable Again and again, I  get this fleeting feeling that it is only what I  can see that exists (solipsism) – but almost immediately I understand that this is nonsense. The experience described here keeps returning, but has not yet become a stable conviction-like idea, and has thus not acquired a psychotic dimension and interpretation. This illustrates a central point in the assessment of emerging psychosis phenomena: they are constantly changing, but at the same time show a degree of stability in the sense that they continually

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resurface. The presence of the phenomena will be dependent upon the context the individual finds him-/herself in, and if this is safe or unsafe. In unsafe circumstances, for example in the person’s cold and dark room in late evening, the borderline psychotic experiences may be strengthened and assume a psychotic quality. In an office, where it is warm and well-lit, and when talking to a soothing and reassuring therapist, the same experiences may come across as paler and far less terrifying, and without a psychotic quality.

Three therapeutic preconditions for psychosis psychotherapy Talk therapy and other psychological forms of treatment will hopefully and likely gain increased actuality for psychotic disorders in the near future, partially because of the new, critical focus on the negative effects of psychopharmacology. Among the themes that present themselves in talking therapy in psychosis, like in all psychotherapy, are the many life circumstances and challenges relating to feelings, relationships, family, identity, childhood, trauma, and abuse, in addition to comorbidity and secondary complications such as substance use. In addition to this, there are specific themes which are mostly exclusive to psycho therapy with psychotic disorders, and which result in psychotherapy here having a ‘double role’. All forms of therapy rest on several implicit assumptions. In the treatment of psychosis not all of these can be taken for granted. This involves the possibility that significant alterations may be present, of the individual’s experience of his/her existence, identity, and subjective status. For example, a weakened sense of ownership of experiences (ipseity) will naturally strongly affect therapy, which aims to highlight and work through one’s own feelings, thoughts, and relationships. Psychotherapy for psychosis, in this sense, thus always has a double ‘role’ or ‘mission’ (you need to experience secure ownership of feelings to be able to process them), and one of these ‘missions’ can often be overlooked or not understood. Psychotherapy for non-psychotic (essentially neurotic-like) mental disorders can usually assume that the client’s (first-personal) status as a subject is sufficiently intact. In schizophrenia and related disorders, this fundamental condition for therapy is not necessarily fulfilled. Put simply, this means that psychotherapy needs to start at a slightly different place: Ascertaining the status as a subject must be the first mutually established point of reference for client and clinician. In other words, weakened subjectivity actualises some unique and invisible therapeutic preconditions – and potential hindrances. These preconditions can be specified through the following three distinguishable facets: 144

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Experiences must be recognised as one’s own The experiences and phenomena that are the focus of therapy must manifest as though anchored to a personal core, a point of reference, they need to be experienced as one’s own. If this is not fully and safely in place, the treatment focus may obviously be disturbed by the client continually analysing and fretting over whether s/he is in fact her-/himself, rather than focusing their energy on what an episode of, for example, anger or fear truly represents for her/him. It should be emphasised here that the loss of ownership is not necessarily total or very marked, but can be subtle, yet sufficient to appear very disturbing for therapy. In the opening conversation at the beginning of this book (‘A central conversation’) the client said: ‘I can’t find myself, I’m not even sure who I am any more, I need to sort of consciously decide what to think’. Therapeutic efforts relating to a traumatic event can in light of this become an almost ‘impersonal’ cognitive exercise, a type of ‘anonymous’ or ‘pseudo’-therapy: the cognitive processes are going on in me, but they don’t really have any personal relevance. This point will be recognisable for many clinicians with experience of working with clients with a diagnosis of schizophrenia: it is challenging for the main person to generate a genuine motivation and interest for productive and therapeutically useful self-reflection. Nonproductive (hyper)reflection, on the other hand, can often be in abundance – in the sense of almost endless forays into existential, religious, supernatural, or philosophical themes, none of which could be construed as constructive self-reflection. Such an inadequate, or lack of stable and secure anchorage to a core, regarding one’s own experiences, seen in the case of weakened subjectivity, constitutes the first, invisible potential therapeutic obstacle. In Chapter 16, we describe how treatment can be adapted to take account of this. Experiences must provide personal meaning and inner coherence The phenomena in focus must also – given that subjectivity is intact – assume a normal inner ‘form’ (or ‘infrastructure’) which provides personal meaning and inner coherence. In therapy, challenging life events first need to be brought into consciousness and acquire a ‘form’ which is subjectively understandable. Then the events need to be told to the therapist in a way that can tie more recent events together with the other parts of life stories. Therapy is complex, and among other things is about knowing oneself better through looking for continuity in life that seems true or plausible, and seeing connections between the parts and the whole, between past and future, and between oneself and others. If the individual’s past life and personal memories (perception of time can be disturbed by changes in subjectivity) no longer feel relevant and real, and if they doubt the existence of the world, the possibilities for focusing mental energy into a course of therapy are of course strongly diminished. As mentioned earlier, Aaron Antonovsky, the founder of the salutogenesis concept (see Chapter 2 on understanding), maintained that the triad comprehensibility, manageability, and meaningfulness together 145

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provide human beings with a vitalising and health promoting ‘sense of coherence’ (Antonovsky, 1987, 1993). ‘Sense of coherence’ is postulated as an inner connectedness, a condition of finding a direction as well as mobilising mental energy and drive. In the case of weakened subjectivity, this inner sense of wholeness and coherence may be substantially weakened, and over time can become completely fragmented. This threat to internal coherence and personal meaning thus constitutes the second invisible therapeutic obstacle that needs special attention when starting psychotherapy for psychosis. Experiences must be shareable in real, intersubjective communication Third, experiences must also be conveyed in therapy through living, verbal, and non-verbal channels. We have seen that problems with finding words and language can easily be a major hindrance in this field, both in relation to early identification and in therapy. Many clients feel displaced in an unreal situation, full of confusion and doubt and which is difficult or impossible to express in words, being so unique and private. Disordered subjectivity challenges therefore also intersubjectivity, which refers to being able to share, recognising things in others, seeking out feedback, acknowledgement, and a feeling of commonality with others, not least the therapist. That the journey to finding words, and the experience of intersubjectivity, can also take place through other and non-verbal channels, for example through expressive artistic (music or picture) therapy, is also important to bear in mind. But it is primarily through intersubjective, verbalised sharing of feelings and experiences that an emerging new meaning can be co-created. This precondition for therapy that the themes of life can be communicated in a mutual, secure, interpersonal channel is fully dependent upon a functional intersubjectivity, which in turn rests upon subjectivity in the individual. To recap: a (partial) collapse of subjectivity, and thus of intersubjectivity, undermines the natural opportunity of interpersonal sharing, and constitutes the third therapeutic hindrance in therapy for psychosis. One can rightly ask as follows: When a client either cannot relate his or her experiences because they feel strange and impersonal, or when experiences do not seem fully tied to him/herself because s/he doesn’t have a normal feeling of existing, or the world feels somehow artificial and improbable, or there is a hanging doubt about whether one belongs to humanity – how then is it possible to work therapeutically through feelings, in such a landscape? These unique features, particularly prevalent in schizophrenia spectrum disorders, are the most important, when we wish to understand why talk therapy in this area has always been difficult to succeed with. This is not to say that the loss of subjectivity gives us a complete answer as to why, but it is quite certainly an important 146

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part of the answer. Therapists run a considerable risk of missing the mark if talk therapy is started up without addressing these preconditions. Such preparatory work is not the norm when addressing most other mental disorders. The therapist must clarify whether the conversations are taking place with a person who has the basic functions of consciousness and self-experience intact. The client in turn must feel mentally and physically present, and as a natural part of the world. With self-insight as a central overall therapeutic goal, it must be clarified if the ‘self’ is sufficiently coherent and can be explored on a mutual intersubjective basis, in a living dialogue. Only when this has been clarified, the work with building insight and new meaning can start. Only then has the therapist a genuine chance to start where the client truly is (cf. Kierkegaard on the art of helping others). Then it may be possible to explore, clarify, confirm, reflect, and be curious together with the client. This energises the experiences and helps to illuminate them in a new context.

Two main fields of therapeutic impact: the general and the psychosis-specific Having detailed the therapeutic preconditions, we now turn to look broadly at the overall fields of therapeutic impact on mental and social life. Due to the unique nature of psychosis, it is useful to discern between the common fields of therapeutic impact (intrasubjective and intersubjective), and the psychosis-specific fields of impact (supporting identity, dialogue, and empathy respectively). Self-disturbances have their origin and exert their effects at our pre-reflective sense of identity, which at the same time underlie (and may influence) other (higher) levels, including the daily, narrative and personality-related sense of identity, which are levels usually addressed in therapeutic work. Because the sense of identity is anchored to different levels, the potential impact of therapy will likewise have a range of possible effects. This implies also that it is difficult to describe, in a simple and precise way, the possible mechanisms and effects of treatment aimed at self-disturbances. It is useful to simplify and distinguish between two fundamentally different fields of impact, of areas of influence. One may be called the general fields of therapeutic impact, which are common to all forms of therapy. The other is unique to self-disturbances in schizophrenia and psychosis, which we may refer to as psychosis-specific fields of therapeutic impact.

General fields of therapeutic impact It is established that some general fields of therapeutic impact and general therapeutic factors can be discerned, that are universally recognised and typical in all forms of therapy (Wampold, 2015). On this general level, it is a goal of most variants of psychotherapy to address both individual (intrasubjective) and relational (intersubjective) aspects. These two are mutually dependent (also in a developmental perspective), and are natural areas of impact in psychosis therapy too. Briefly summarised: 147

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Intrasubjective impact Without going into too much detail regarding individual themes of therapy, intrasubjective work in therapy is aimed at increased self-insight into which feelings and thoughts seem to arise in various challenging life situations and in meetings with others. It is about to what extent and how I understand these feelings, what they do to me and what I do with them, and how I react and behave in relation to these feelings. Awareness of, and understanding of, one’s own feelings is a condition of being able to regulate them in a good way. To cope with the regulation of one’s own feelings in the best possible way is a central general therapeutic field of impact in all therapy. Intersubjective impact It is also generally true of all psychotherapy that working with the intrasubjective aspects just mentioned cannot be done in isolation, that is, at the individual level. It almost always takes as its starting point events and episodes in the person’s relationships with others. Particularly close relationships, earlier and current, are areas where feelings to the strongest degree become apparent, and important reactions take place. This is referring to intersubjective general therapeutic impact in talk therapy, that is, effects on interpersonal relationships and events. The therapeutic relationship between the therapist and the client is in a sense a ‘substitute context’, where aspects of other relationships and ways of reacting can be played out and made visible. In this context, personal dispositions, aspects, and patterns can be discovered, explored, recognised, worked with, and changed. A good therapeutic relationship is probably the most decisive single general factor for therapeutic effect (Lambert & Barley, 2001) and is dependent upon the genuine interest of the therapist, as well as an acknowledgement and validation of the main person. The clients’ insight from this way of working, is a preparation for testing out in real life, where new experiences can be gathered and brought back to the therapy room for further exploration. The general intra- and intersubjective issues mentioned here do apply to the field of psychosis, as to other mental disorders. But again, at the same time, there is an important additional qualification when it comes to psychosis: these general fields of impact can be partially disengaged if ‘the self ’ is no longer coherent and cannot be explored from a common platform, in a dynamic and genuine dialogue. Regarding the intrasubjective level, it will be difficult or impossible to co-create new interpretations and co-construct new meaning for the distorted experiences, quite simply as the foundation of the mental processes is on unsteady ground. This can easily result in the client being insecure and disengaged with the therapy, because s/he (partly) lacks the prerequisites to be able to take the full responsibility for her/his own feelings. This involves wellknown, unconscious mechanisms that can lead to ascribing one’s own feelings

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to others, for example. If experiences in this way feel partly ‘impersonal’, distant, and unreal, such challenging processes are rendered more or less impossible. This issue is a significant challenge in psychosis psychotherapy, illustrating how intact subjectivity is a fundamental condition for treatment.

Psychosis-specific fields of therapeutic impact Some psychosis-specific fields of therapeutic impact are particularly tied to selfdisturbances. These aspects rarely need to be addressed explicitly in ordinary psychotherapy, where subjectivity is usually not significantly disturbed. The clinician’s attention at the start of therapy needs to be in another place than that which is typical, to be aware of these conditions. The psychosis-specific therapeutic fields of impacts that are described in the following represent central aspects of interpersonal contact that we often find to be affected by self-disturbances. Supporting the identity: mirroring and supporting a sense of self This therapeutic impact is concerned with mirroring and confirming the basic self-experience. At the start of treatment, there is a need for a specific focus on the client’s feeling of being oneself, the experience of having a core. What the feeling of having a core involves was elaborated in Chapter 6, on subjectivity. This feeling is, of course, closely related to the feeling of being oneself, of having a centre that pulls together, so that we feel whole and coherent, a feeling of integration and that the body and mind are one. This focus on self-experience is necessary to (1) clarify the status, and so that (2) identity support can be given, through working directly with self-understanding. The main point is that this deepest level in the client’s sense of self needs to be mirrored and confirmed to positively support the other more explicit and accessible levels of identity. It is of vital importance to feel that one has an existential core that pulls together, where mental and physical experiences become intertwined as a whole. A coherent, organised, seamless experience of thoughts, sensations, and feelings (an orchestra with a conductor) is not only a therapeutic goal but also, at the same time, a precondition for being able to work therapeutically at all, in the landscape of psychosis. In the general population, one would expect the existence of a natural continuum of mental features such as ‘sense of self’, from weak/insecure to strong/ secure. In schizophrenia, however, there is already a significant skew and disorganisation of the sense of self. Therefore, the map needs to be adjusted to the terrain from the very outset of therapy. It may be illustrative to read once again the opening conversation in this book, where the young individual said the following: ‘I’m losing contact with myself, I can’t find myself, I don’t know who myself is’ (to be noted, remember that this is meant quite literally, rather than metaphorically). With such a deeply disturbed sense of self as a starting point, it

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is meaningless to start talk therapy with any other thematic focus than precisely this all-important sense of self. Supporting the dialogue: underpinning a vital and real conversation Another field of specific therapeutic impact which is touched upon when working with self-disturbances, and which requires attention at the start of treatment, is the status of communication and dialogue. For those affected by self-disturbances, conversations can seem closed off, artificial, and superficial, that is, not open and vitalised as one would expect in therapy. After an evaluation meeting, at the previously mentioned psychosis assessment unit, a young man asked spontaneously, when I had thanked him for the conversation; ‘What is a conversation, really? Have we just had one now?’. Deep confusion (weakening of common sense) such as this, when trying to understand ‘obvious’ events, will clearly undermine communication and dialogue. Explicit therapeutic focus on the significance of subjectivity can contribute to re-establishing aspects of a vital dialogue, or at least make one aware of and thematise this hindrance. Once again, we see how a basic prerequisite for psychotherapy very easily can be taken for granted, whereas in reality there is a stumbling block that is relatively invisible, and which the main person has very little chance of talking about him-/herself. Supporting the empathy: allowing empathy and acknowledgement from others The third specific field of impact that a treatment focus on self-disturbances can open for, is empathy and acknowledgement, which the subjectivity perspective can make visible and possible. What Karl Jaspers in his time once called ‘das nicht einfülbare’ (Jaspers, 1997, 2013) – that is, something which does not lend itself to either empathy or sympathy, because it is almost impossible to understand – can in fact to a certain extent be understood and met with empathy. It is a huge step to change the goals of therapy from being primarily a case of general support and containment, to being the sharing of describable and understandable pain, which is tied to the experience of losing oneself. It may become possible to highlight and share the personal interpretations of the self-disturbance, and perhaps also the personal reasons, based in the individual life of the person, as to why this particular attribution could emerge for this experience. In summary, therapeutic work with self-disturbances, in addition to general impacts, can also result in psychosis-specific impacts which are critically important for a comprehensive treatment of these disorders. These include impacts on (1) a seriously weakened sense of self; (2) partially impaired communication; and (3) significant impairment of empathy and acknowledgement provided by others. These effects can in turn set in motion positive and increasing circles of motivation to build new meaning through new interpretations of experiences. 150

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Primary therapeutic effects Understanding and transforming – comforting and preventing The specific challenges associated with the clinical availability of self-disturbances are surmountable. The watchwords understanding, transforming, comforting, and preventing can be regarded as the desired primary goals in therapeutic work with self-disturbances. Working towards a new and common understanding through the sharing of one’s own dramatic experiential changes is a demanding dialogical process between client and therapist. The earlier the intervention starts, the greater the opportunities to explore and understand the experiences, then later to work with, adjust and change or transform the self-understanding, via the co-creation of new meaning linked to the experiences. This may comfort pain and suffering, and it can prevent a further negative development, or even a psychosis breakthrough. Early efforts support a positive and effective alliance with the clinician, which in turn strengthens the positive potential of other treatment measures in the treatment whole. Client and clinician can explore self-experience and changes in self-understanding, changes that can represent warning signs of a possible further development to more salient self-disturbances and psychotic delusions. Each one of these main goals in therapy carries with it various sub-effects which will be discussed later. Effect 1  Activating the self is energising All humans live an inner, mental life in addition to the outer, visible life (behaviour). Our mental life affects, guides, and forms our behaviour, and behavioural experiences in turn influence our mental life. In this cybernetic circle, ideas, impulses, and wishes constantly transform to visible, behavioural events. The consequences of these visible events provide experiential information which feeds new reflection. We are constantly realising and transforming ourselves. An inner ‘drive’ is a considerable source of life quality, directed both inwards towards one’s own life and also outwards in relation to others. Without initiative and drive many aspects of life become pale and weakened, which might be summarised thus: ‘I would rather be one who swims than a piece of driftwood’ (proverb of unclear origin). To be in charge of, or to be at the centre of one’s own life is, in other words, an obvious goal for all, and therefore also a theme in therapy. But where does this inner drive come from? What is its source? And what is ‘the centre of one’s own life?’ Clinicians who have a lengthy experience of clients who are diagnosed with schizophrenia will confirm just how difficult it is to positively affect their inner drive and autonomy. In order to navigate around these challenges and move towards therapeutic progress, it is necessary to explore even more than what is usual in psychotherapy, such as exploring the typical emotional conflicts which in most people can lead to reduced drive and motivation. Contrastingly, in persons diagnosed with schizophrenia, even more basic disturbances are involved, tied to core existential phenomena which are dependent upon intact subjectivity. 151

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The aim of exploring, understanding, and working with self-disturbances can support and rehabilitate a sense of identity that is perhaps in the process of becoming lost, and stimulate development and renewal. The clinical work here may involve adjustments and a slowing down, perhaps even a reversal, of the negative effects of the disturbance of subjectivity. Increased drive can also be a central therapeutic effect of strengthening a sense of identity. Without such an activation of the self, the disturbances in drive and motivation can escalate further, in parallel with increasing self-disturbance. Effect 2  Being the centre of one’s own life What does it mean to be the centre of one’s own life? Elyn Saks is an American professor of law, psychology, and behavioural science, has a doctorate in psychoanalysis, lives with a diagnosis of schizophrenia, and published in 2007 the best-selling autobiography The Centre Cannot Hold (Saks, 2007a). In a podcast interview (Saks, 2007b) after the publication she explained how her first breakdown was experienced, as a frightening dissolution of the self, a disorganisation or breakdown of consciousness, which she vividly illustrated as a sandcastle collapsing on itself. ‘Like your centre, yourself, was falling apart’. There was no longer a ‘captain’ who could hold words, thoughts, feelings, senses, and ideas together in an organised whole. These descriptions of the earliest changes in schizophrenia are consistent with the stories of many clients: the core, the self (myself), that is, the centre of consciousness fails to perform its essential, integrating purpose. Drive and vigour in the lives of human beings are dependent upon intact integration in consciousness of the various experiential qualities, both mental and bodily. A remark on a tentative underlying mechanism. Recent research has pointed to precisely this failure of integration as a possible neurobiological mechanism behind a disturbed ‘sense of self’ – that is, a failing sensory-motor feedback response and intermodal perceptual integration (Borda & Sass, 2015; Sass & Borda, 2015). The concept of amodal perception, which is a concept from developmental psychology similar to perceptual integration, supports this line of thought. This can be pivotal in relation to the early development of coherence and wholeness in a person’s life. Amodal perception involves the child discovering connections between different sensory impressions, arriving through different sense modalities, but which have their origin in a common source, that is, one specific person. From this, there is an emergent selforganisation, which can act as a reference point for the emerging sense of self (Stern, 2018, original publication in 1985). When the child experiences that the specific person is one and the same, whether it hears, sees, touches, or tastes, that is, across several sense modalities, a strengthened sense of ownership (and sense of self) is also developed, that the experience is ‘mine’, due to it being part of self-experience.

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Effect 3  Understanding opens to empathy – in many settings Karl Jaspers (see Chapter 4) once characterised schizophrenia as a condition it is almost impossible to empathise with (Jaspers, 1997, 2013). He was referring to the fact that the person’s ideas and convictions may seem so bizarre and incomprehensible that the clinician to a large extent is limited to accepting and ‘containing’ these phenomena. For example, the individual may be convinced that the thoughts in his/her head quite literally belong to someone else. However, as a phenomenologist Jaspers studied clients’ utterances in depth, and over 100 years ago contributed to major transformations in the development of knowledge. He provided thorough descriptions of changes in experience in schizophrenia: his original textbook ‘Allgemeine Psychopathologie’ was published in 1913, and the last English version in 1997. This became the start of an era in European psychiatry, with a new focus on a phenomenological-psychiatric understanding of these puzzling human conditions. Moreover, towards the end of the 1900s, subjectivity was recognised and gained a growing status as a decisive element to understand the functions of consciousness. With this possibility of understanding psychosis phenomena, there follows a new opportunity for deeper empathy with afflicted individuals. Knowledge of an understandable experiential mechanism which lies behind this mental disorder and dysfunction, opens for empathy from others and can create emotional bonds, not least towards clinicians and family members. On the other hand, suffering or dysfunction, that does not seem to stem from an understandable mechanism often evokes other types of reactions in others, such as scepticism, suspicion, moralism, fear, and anger. Effect 4  Comforting a unique sense of isolation Several aspects of psychosis contribute to create marginalisation and deep loneliness for the person it affects. Already on the individual level, the experiences often involve a feeling that the person is completely alone with these, and that nobody could ever understand what is happening. Through my decades in clinical work, strikingly many clients have described feeling this way, a pervasive and distinctive feeling of loneliness, and correspndingly they have been very relieved and surprised when they have heard about others who have experienced similar problems, and that therapists have knowledge about such conditions. Also, the silent (pre-verbal) nature of the phenomena contributes to marked communication problems in all directions, and delayed treatment. This is one of the reasons why professional knowledge about self-disturbances is a critical factor in the early detection of risk states. In families, the ‘incomprehensible’ dysfunction and behavioural problems, often seen over many years, can create desperation, anger, and conflicts, which in turn can increase the level of anxiety, fear, and withdrawal to even more loneliness. Knowledge that there are others in the world, in fact many, that have similar difficulties may help to reduce feelings of loneliness.

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Effect 5  Reducing feelings of shame Shame is a painful social feeling that affects one’s honour and status (see Scheff, 2003), a conscious, discrete, and basic emotion, often associated with negative self-evaluation. It is also described as a moral or social emotion that drives people to hide or deny their wrongdoings (Wikipedia.org). The word has an uncertain origin, but it may mean (a wish to) cover oneself up. In this interpretation, we are not just referring to pangs of bad conscience or guilt for a specific act or something limited, but rather a global (total) feeling of shame over being the person one is. Schizophrenia, psychosis, and self-disturbances are, as we have seen, conditions that penetrate deeply into the core of a person’s being and leave a mark on the most central aspects of the individual. It is precisely this often reported experience of oneself, as completely different to that which is usual or desired, which triggers the feeling of shame. It is therefore natural to feel shame when experiencing psychosis, or due to the experience of being psychotic. It is well known among therapists that shame may become particularly strong in the period after an acute psychotic episode, when a client may, for the first time, become aware of what has happened in previous psychotic episodes or events. This may of course also lead to the development of suicidal thoughts. Addressing in therapy, the mental mechanisms behind self-disturbances and psychotic phenomena may enable increased understanding of the self and reduce self-stigmatisation and shame. In a state of paranoid fear of having their life threatened, people may undertake compromising things that are highly dissonant with both their own and other people’s normal view of them. When such painful episodes have taken place, driven by a psychotic condition, important relationships may have been damaged even though the client him-/herself has not been in a responsible position. Deep shame and painful feelings can then arise, which need to be addressed afterwards, to prevent further psychological damage. Furthermore, working together with the main person towards a general (i.e. simplified) but comprehensive understanding of his/her self-disturbances can also have strong positive effects on the possibilities for earlier intervention. These positive effects apply both to the individual, intrapsychic level, and to the relationships to clinicians, family, and friends (more drive and empathy, less loneliness and shame). Through building understanding of the individual experiences, there is always something actively destructive (lack of understanding) that can be slowed down or stopped, and at the same time there is always something positive and constructive which can be strengthened. These will be mutually reinforcing effects. This chapter has underscored the important possibility of accessing basic selfdisturbances through therapeutic dialogue, and the entailing opportunities to provide acknowledgement to the clients through understanding, transforming, comforting, and preventing. I then presented three therapeutic preconditions, two broader fields of therapeutic impact, and a cluster of primary therapeutic effects

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of psychotherapy. The next chapter will discuss the various treatment settings and treatment approaches, which can all integrate a focus on self-disturbances.

References Antonovsky, A. (1987). Unraveling the mystery of health: How people manage stress and stay well. Washington, DC: Jossey-bass. Antonovsky, A. (1993). The structure and properties of the sense of coherence scale. Social Science & Medicine, 36(6), 725–733. Borda, J.P.,  & Sass, L.A. (2015). Phenomenology and neurobiology of self disorder in schizophrenia: Primary factors. Schizophrenia Research, 169(1–3), 464–473. Jaspers, K. (1997). General psychopathology (Vol. 2). Baltimore, MD: Johns Hopkins University Press. Jaspers, K. (2013). Allgemeine Psychopathologie. Berlin: Springer-Verlag. Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, research, practice, training, 38(4), 357. Poletti, M., & Raballo, A. (2018). Editorial perspective: From schizophrenia polygenic risk score to vulnerability (endo‐) phenotypes: Translational pathways in child and adolescent mental health. Journal of Child Psychology and Psychiatry, 59(7), 822–825. Saks, E.R. (2007a). The center cannot hold. A memoir of my schizophrenia. Boston: Little Brown Book Group. Saks, E.R. (2007b). NPR Poscast. Interview after the publication of the autobiography The Center Cannot Hold. www.npr.org/templates/story/story.php?storyId=12560033. Sass, L.A.,  & Borda, J.P. (2015). Phenomenology and neurobiology of self disorder in schizophrenia: Secondary factors. Schizophrenia Research, 169(1–3), 474–482. Scheff, T.J. (2003). Shame in self and society. Symbolic Interaction, 26(2), 239–262. Stern, D.N. (2018). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. New York: Routledge (Original publication 1985) Wampold, B.E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14(3), 270–277.

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15 APPROACHES AND SETTINGS I N T R E AT M E N T D I R E C T E D AT B A S I C S E L F-D I S T U R B A N C E S

The treatment of schizophrenia and related psychotic disorders has over several decades consisted of a comprehensive package of different measures. All these main treatment approaches and treatment settings, which are discussed in the present chapter, can integrate a focus on selfdisturbances. This includes (1) individual treatments; (2) psychoeducational family interventions; (3) working with client networks; (4) milieu therapy and psychosocial support; and (5) medication. Moreover, service user involvement, multi-disciplinary work, and reduced coercion are highlighted as pervasive current principles for all the treatment approaches, and even these principles can be supported and boosted by emphasising the focus on self-disturbances.

In the previous chapters, we have discussed various aspects of therapeutic work with self-disturbances. We have looked at important new trends in treatment in the case of psychotic disorders, not least the role of self-disturbances as part of the treatment whole, the important role of the phenomenologically inspired therapeutic conversation as a clinical method, and various aspects of therapeutic preconditions, fields of impact, effects and hindrances. In this chapter, the aim is to demonstrate how self-disturbances can have a place in all the main working methods and contexts that are typical when treating psychotic disorders, and their precursor conditions. It is obvious that, because of the nature of psychosis, a single, therapeutic out-patient conversation per week is not sufficient in the long run to address the many pervasive consequences of these disturbances. And even worse, it is not always the case at all that these clients get the opportunity to talk once a week with a therapist. Furthermore, it is quite a painful dilemma that persons with psychotic disorders may strive a lot to both comprehend and assert themselves, and to promote their treatment needs effectively, while at the same time requiring substantial, long-term follow-up and treatment. It is also a concerning part of this picture that treatment with anti-psychotic and 156

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other psychotropic medications, via their effects on dampening unpleasant symptoms, can conceal needs for long-term psychotherapeutic and psychosocial interventions. The case management model (Leff & Trieman, 2000; Smith & Newton, 2007) has previously been discussed (Chapter 12), being an example of the many attempts to provide broad and comprehensive treatment and follow-up systems in the treatment of psychosis. Some recent national ‘treatment packages’ in mental health (including in Denmark and Norway) can be seen as modern variations of ‘case management’, but with more specific and more authoritative and precise descriptions of intervention forms, measurement issues, and recommended time course of treatment. The main aims of such new treatment packages are ensuring service user involvement, reducing unwanted variations in treatment, as well as offering the most modern and evidence-based treatment to all clients. The term ‘package’ (or ‘course package’) has been criticised (Fordal, 2020), as it has associations with ‘new public management’ terminology which can be construed as overly cold and alienating in clinical work, which, after all, deals with human suffering. It is however the content of the measures that will ultimately show whether they are useful in improving the quality of health services. No reform can be judged other than on whether it achieves the desired outcomes over time. It remains to be seen whether national treatment packages prove to be effective instruments, or whether they will end up more as good intentions. In the following, five main forms of treatment approach/setting will be discussed as well as the possible position of self-disturbances in each approach. Today, all five of these different forms should be present in any evidence-based approach to the treatment of those with a diagnosis of schizophrenia and other psychotic disorders.

Self-disturbances in individual psychotherapy Individual psychotherapy, and the clinical conversation in general, is a necessary mainstay in the treatment of all mental problems, also for psychotic disorders, including schizophrenia, and, of course, for conditions with an increased risk of psychosis. A main focus of this book is that self-disturbances are most pronounced, extensive, and characteristic in cases of schizophrenia spectrum disorders (Haug et al., 2012; Nelson et al., 2013), and therefore particularly important for prevention in cases where a more severe development is likely (Nelson et  al., 2012). When at-risk phenomena are identified, the person may have experienced psychosis earlier, once or several times, and may now be at risk of relapse into a new psychotic phase. Or the person has never experienced psychosis and is now in a possible prodromal phase for the first time, but with a degree of uncertainty. These two variants are called relapse prodrome and initial prodrome respectively. In both situations, conversations in treatment will involve the same elements and stages and have the same aims and purposes. Self-disturbances should be an explicit conversational focus in the treatment, equally important as other themes, and 157

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integrated with them. A tentative first sketch of a treatment module is described in detail in Chapter 16. There are reasons to believe that talk therapy for psychosis may gain increasing importance in the future (see Haddock & Spaulding, 2011; Rosenbaum, 2012), especially considering the growing awareness of the uncertain and limited evidence for positive as well as negative psychopharmacological treatment effects, after the first two years. Another reason may be the emerging right in some countries to choose medication-free treatment options where this is a viable alternative (Bola, 2006; Oedegaard, 2020). The additional focus on self-disturbances can thus assume a natural place and fill a gap in such new perspectives, both because the approach is of a psychological nature and because of the obvious specific usefulness self-disturbances may have for understanding and early identification. The significance of the therapeutic conversation in the acute phase of psychosis should also be mentioned. In this phase, the conversation has a somewhat different role, and one that is not specifically about self-disturbances. Nevertheless, it is still critically important in this phase that the person meets with a therapist with the experience and personal qualities to be able to listen to, deal with, and have time available to take on board the fear and insecurity that is typical. The conversation needs to be concise, clear, explicit, friendly, and reassuring. Actions and measures need to be supplemented with simple verbal explanations of everything that is taking place, with a view to preventing misinterpretations. Practical experience with and knowledge about psychosis phenomena are necessary for therapists to retain their strength and resilience in such an extraordinary human crisis. Knowledge about self-disturbances may even shed light on acute situations, especially if the client is known from earlier treatment interventions, so that the experiences of the client in a calmer period can contribute to understanding the current acute symptoms. Deeper psychological investigation and discussion of phenomena have no place in the acute phase. The main emphasis has to be on calming and reassurance. Medication still has an important place in the acute phase for the majority of people experiencing psychosis, but there are still good reasons not to make unnecessary haste. Care, calm, patience, time, and a sense of safety should always be given room to work and influence positively first, for as long as is justifiable, such that confidence and communication can be established. If the client genuinely seems to be calmed by being in a safe environment, medication should be put on hold. Still, this holding back should not be exaggerated and must be balanced against the emotional and existential pain the client is experiencing. As soon as the acute psychotic phase is diminishing, the mental landscape of psychotic ideas and delusions may gradually transform from conviction to doubt, and when the psychosis slowly subsides, with or without medications, any underlying selfdisturbances may reappear and become more evident and accessible. Further out in the acute phase, the self-disturbances themselves can also gradually assume a more ‘faded’ presentation. With time, clients may become calmer and more secure, and be able to talk about their experiences. The traumatic experiences from the acute phase per se also need to be worked through in therapy, 158

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and the changes of self-understanding can once again be worked with and new interpretations encouraged and looked for. Importantly, the further medication after the acute phase needs to be evaluated continuously, individually, and thoroughly. There are large variations and limited documentation as to how long into the course of the illness the balance between therapeutic effects and side-effects will be positive for the client. Generally, it can be said of psychotherapy for psychotic disorders that it should be individualised, pragmatic, and eclectic. The courses of psychotic disorders are different and have greater fluctuations and cycles than is typical of non-psychotic conditions. It is therefore imperative to work with self-insight and (ego-)support, along a time axis where one continually monitors which personal needs are greatest. Focus on self-disturbances will, as shown in the previous chapter, in a unique way, be able to facilitate the ego-support work. The importance of the therapeutic relationship, as a ‘common factor’ in all psychotherapy, must also be emphasised. This relationship too, can assume a more specialised significance, when working with self-disturbances, because of the critical importance of intersubjective sharing and working with experiences and understanding of oneself, and the construction of new meaning. The therapist must have a good understanding of the relation and insight into his/her role both as ‘the other subject’ in the dialogue and as a context and support structure for the client. How to direct attention to self-disturbances in therapy When talking to persons with psychotic and prodromal conditions, it is rare that, at some point in the conversation, the theme of self-disturbances does not emerge. However, the therapist must have knowledge about such phenomena if they are to be detected. To increase the client’s interest and attention towards such phenomena, the therapist can draw attention to them by being positively curious and exploratory, asking how it is possible that such changes in experiences could arise. Mutual genuine interest in exploring the experience is a condition of becoming familiar with it, working with it, and interpreting and understanding it in a new way. Another way of raising awareness and attention towards selfdisturbances is to give one or more examples of the role of subjectivity in experiences, for example in alienation and feelings of unreality, which many clients will instantly recognise. This can lead the person’s thoughts towards their own experiences, and hopefully a desire to explore them further. Still another way is to use simple first-line screening instruments (like the SQuEASE-6, see Appendix), which touches upon and asks about a strategically chosen sample of frequent and characteristic examples of such phenomena. A simple screening such as this will usually lead to one of two outcomes. Either the client will have little or no understanding of what is being asked (phenomena not at all recognised) and they may be unsure or confused, or the client will respond quite clearly that such phenomena do occur. The client may even be surprised that the therapist is also acquainted with them. In the first case (no/low recognition), the probability 159

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of self-disturbances being present is low, in the latter much higher, but one cannot be sure until a more thorough, follow-up interview has taken place. If several central phenomena are identified, the client and therapist can co-construct a plan for how to work with them, in line with the main steps described in the sketch of a treatment module in the next chapter. The ultimate goal of all therapeutic exploration and working through of self-disturbances is attaining a new and appropriate self-understanding.

Self-disturbances in psychoeducational family interventions: knowledge for understanding together In constructing a building, all the separate parts are equally important if the building is to endure and function over time. In the same way, individual therapy is today not effective enough alone, and thus not the only mainstay in treatment of psychotic disorders (see Nelson et  al., 2021). Even though psychotherapeutic techniques are in continual development and are increasingly sophisticated, probably the most important creative breakthrough in the treatment of psychotic disorders after the millennium is the development of psychoeducational family interventions (Pharoah, 2010; Rodolico et al., 2022). The main premise of psychoeducational family interventions is that the client’s living environment is primarily the family, and it is therefore essential that the family be strengthened and supported. Psychotic disorders can have an onset at almost any age, but most persons seeking or receiving treatment for the possible first-time development of psychosis are young people. They may be accompanied by close family members who have been extremely worried and under considerable strain for a long period of time. The families may have done all they can to hold the situation under control, but in most cases without any real knowledge or experience of the best way to support the young person. In this case, it will be beneficial as early as possible to combine individual therapy with family and network interventions (unless there are good reasons against it, which of course may be the case). The young persons and their families must be regarded collectively as a ‘team’, but one that is tired, worn out, and in need of help to manage a huge challenge in a new way. In some cases, the contact between the client and the family is particularly conflictual and complicated, perhaps even totally broken down. In this case, the family intervention needs to be held back for a period while possibilities for cooperation are carefully assessed. In the present text, I refer to both research literature and not least to extensive clinical experience through more than 20 years, with significant statements from clients and families who have participated in our psychoeducation programmes. Psychoeducation is a slightly misleading term, as it involves a focus on far more than learning and pedagogy. The term also covers family-based ‘peer-support’ work, involving an extremely important opportunity to share experiences and to work on practical solutions to many day-to-day challenges together with several other families who also have a member with schizophrenia or related psychotic 160

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disorders. In these family groups one can talk together to find solutions as to how to manage stress, feelings, and practical issues. Sometimes there can be ‘hometasks’ between meetings, solutions can then be tested out and the results referred to the other participating families. It is of course also possible to work with just one family in cases where multi-family interventions are considered inappropriate.

What is psychoeducational family intervention? Psychoeducational family intervention is a structured intervention designed to meet the client’s and the family’s need for knowledge about the mental disorder and how it should be managed (see Lucksted et al., 2012). It can be provided in a multi-group setting (up to approximately five families) or to the individual family. The duration of the intervention should be minimum 6–9 months. Elements can include the following: • • • • •

Psychoeducation (information and training) Exercises in communication Problem solving Crisis management Emotional support

Knowledge and a shared understanding within the family can represent a great advantage. There are several reasons for this and for why psychoeducational family intervention is therefore a major development in the field. A  shared understanding between the client and the family of both the background and nature of the psychotic disorder and how it comes to be expressed is intuitively important. All the frustration and wear and tear on the family, which must, by necessity, arise when members over time need to take care of another family member, with psychosis, need to be met with knowledge and skills. Understanding of the nature of the experiences of the main person needs to be built up. First, the client needs to be familiar with their own inner mental landscape, as well as possible, then this can be shared and develop into a common understanding. Families must get help to understand what the seemingly bizarre and maybe chaotic behaviour arises from. And they must be given access to trusted, updated, and first-person experience-based knowledge about how to deal with it. The basic tenet of this kind of work is in other words ‘knowledge for understanding together’. Knowledge about self-disturbances is a specifically useful way of approaching this ‘understanding together’, and the common setting that psychoeducational family intervention provides is tailor made. The approach recognises that for many persons with psychosis, the family is often the only stable base and true place of belonging. This applies not only to the youngest clients but also to adults who often find it difficult to maintain or establish a social network by themselves, outside of the family. 161

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Despite the efforts of authorities and health services to provide the best possible support to persons with psychotic disorders, this has been consistently difficult to achieve in practice, and has fallen short in many cases. It seems pretty obvious that psychoeducational family intervention may be equally relevant for several other mental disorders, in principle all severe and complex conditions that require coordinated services, such as eating disorders (Geist et al., 2000) and bipolar disorders (Soo et  al., 2018). Its usefulness for families and clients has been systematically reported and evaluated (see Cochrane review: Pharoah et al., 2010), and it is not unusual in clinical work to hear clients (and families) stating that this intervention was even more important than the conversations with therapists. The ‘educational’ part of the intervention provides information about early signs, assessment, diagnostics, different treatment types and support services, client rights, the background for psychotic disorders, prevalence, symptoms, different illness courses, prognosis, complications, the importance of service user involvement, and problems in communication, to name just some. In this complex picture, an understanding of the core generative experiences should obviously be a natural part, not least as a starting point for finding ways of coping. Frustration in the families can be reduced, and empathy can be increased. When the client and clinician can together build a shared picture of how the many expressions of the disorder are connected, and when this can be verbalised between family members, a new opening is created for mutual respect. Energy and motivation can be built up, rather than just broken down. Many families have told us through the years how participation in such group programmes became a turning point in their lives. To summarise, systematic family interventions have the potential to open up an important experience of comforting acceptance within the family and reduce or stop altogether traumatic experiences related to over-involvement, criticism, hostility, and other secondary consequences of family conflicts. This work can involve effective sharing of traumatic experiences, through mirroring, confirming, and acknowledgement together with other persons with similar experiences. Loneliness and feelings of shame can be relieved; drive and empathy can be strengthened. Why include self-disturbances in psychoeducational family interventions? Programmes used in psychoeducational family interventions today are primarily based on the work of the American researcher William McFarlane (e.g. McFarlane et al., 2003, 2016) and have a background in the Anglo-American perspective on psychosis that was outlined in Chapter 5 on scientific culture. Therefore, the original methods do not focus on the phenomenological perspective on psychosis. This key perspective therefore needs to be assimilated into and adjusted to the existing programmes. This also applies to the programme designed for single families with adolescents with an increased psychosis risk (see Miklowitz 162

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et al., 2003). In the original manuals for family interventions there is an emphasis on descriptions of and information about conventional at-risk symptoms and psychosis symptoms, internal communication in the family, and practical problem solving. However, the programme lacks an introduction to the basic nature of the disorder, based on the experience of identity and self-understanding. This brings us back to the three unseen therapeutic preconditions and hindrances in psychotic disorders which were discussed in the previous chapter. In the psychoeducational manual’s discussion of the first teaching session, there is namely a focus on treatment goals and plans. This includes cooperation and communication in the family, understanding, and acceptance of symptoms and stress factors, improvement of function, and good problem solving. However, understanding and acceptance of symptoms and stress factors is dependent upon something more than outer descriptions. It is here the positive force of understanding the ‘experience of identity’, and the ‘sense of self’ at a deeper level, can assume a great significance. As described earlier, the Subjectivity Model is able to support the positive objectives of psychoeducational family interventions, and in addition be able to supplement with an important understanding of how the source of the difficulties (i.e., the experiences) take shape and play themselves out, for the main person and between the family members. The more that becomes visible of the ‘sand in the machinery’, and where it comes from, the easier it will be to accept, through understanding, the failure of communication and functioning in everyday life. This is what is meant by empathy support.

Self-disturbances in networking Networking is a professionalised model of working where health and other professionals have the responsibility and leadership. It has formal, coordinating, and administrative aspects as well as being an informal arena for the exchange of knowledge, and for practical responsibility for supporting the client. The basic idea behind having a pervasive focus on self-disturbances in treatment is to take into consideration the additional and distinctive needs that a disturbance of subjectivity brings about in all arenas. The main therapeutic goals that were discussed in the previous chapter consisted of understanding the experiences, transforming self-understanding, comforting existential mental pain, and preventing further negative development. Closely related to these goals, we also mentioned increased motivation and drive, identity support, greater acknowledgement and empathy, reduced loneliness, and improved communication. The first setting, where the therapeutic work starts, is, as outlined, the individual conversation. After this, the setting is expanded to include the family and particularly close friends, through psychoeducational family interventions. Finally, 163

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parts of the extended network should also be appropriately included and acquire relevant parts of the knowledge and understanding which are developed. The latter must always be undertaken after an individual assessment of need, working together with the main person. The extended network of involvement would possibly include friends, leisure activities, and the client’s local community, as well as various public institutions such as school, social services, family welfare, and child welfare services. A shared, carefully adapted, and thorough understanding of the various manifestations of psychotic disorders can further accentuate a positive circle of openness and relief around the main person. This is what is meant by network measures, as opposed to a linear chain of measures. There should be multiple and open pathways within such a network, so that it also becomes as far as possible a security net, and less vulnerable if certain network participants fail for whatever reason. The great preventive potential of such a model lies in the fact that all those involved in supportive measures develop a shared sense of responsibility and can provide a coordinated effort when the need arises. Networking procedures It goes without saying that knowledge about subjectivity and self-understanding needs to be provided in a way that is adjusted according to the recipient’s needs and background. Friends, teachers, social workers, and others clearly have a use for relevant parts of knowledge about these things, so that they can provide better support in the context they find themselves in. With such knowledge in mind, a friend might be able to show more patience, and understand that the main person sometimes has difficulties construing a situation or what is said. A teacher might be better able to construct an individual curriculum plan that is more suited to the person, rather than just provide (extra) lessons in a routine way that contributes little to development. Administrative officers, who may be the key to various types of support measures, may be able to communicate better with the main person, finding services and measures that are more meaningful and suitable for the individual. The provision of useful help and information can be done in written form, but also personally and more tailor-made to the person in focus. It is an advantage that one person is singled out to have an overarching responsibility (a network coordinator) and establish efficient systems for the provision of knowledge, information, and services.

Self-disturbances in milieu therapy and psychosocial support Both psychotherapy and psychoeducational family interventions are carried out by therapists and other professionals with the necessary specialist competence, and in specified, formalised contexts. Networking is also a structured, coordinated activity which is performed by professionals, though usually not by specialised psychotherapists. 164

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Psychosocial support work is also usually carried out by professionals, in different parts of the health service. Inpatient sections and day-clinics of mental health services often have an emphasis on milieu therapy (Ciompi & Hoffmann, 2004). Milieu therapy in these types of settings is a confined collective, structured, and systematic form of psychosocial support treatment, but the degree of structuring can vary from place to place. Effective milieu therapy needs to have a clear and functional coordination with individual therapy, through common plans, meeting points, teaching, training, knowledge, and evaluation. The total ‘treatment community’ needs to have a good deal of shared knowledge and a shared pool of concepts as a basis of thorough and reliable communication. At our own assessment unit for early psychosis assessment (2000–2008) (Møller, 2005), the Subjectivity Model was used in this way as a common knowledge base and reference, functioning as a coordinating professional framework for all co-workers and professions. The experiences from this unit are discussed in more detail in Chapter 17 on implementation. Psychosocial support work also takes place in parts of the network measures, as just discussed. Networks are more than the coordination and sharing of knowledge. The extended network will, through its many types of relation to the client, be a provider of psychosocial support, but not necessarily formal or professionalised. The network can be the client’s personal psychological ‘test arena’ where new understanding and insight can be tried out in a reasonably safe way among familiar people. In some cases, it can be of great value if the client wishes to be open and share some of his central life themes with close friends and others. Psychosocial support can also be a part of normal, everyday social contact, which is a possibility to ‘just be social’, and slowly try to break the isolation and withdrawal that for many becomes an unavoidable part of psychosis. In addition, the network is also a place where specific conflict-filled or threatening aspects of daily life can be revealed and explored, whether relational or not. A way of doing this is that the therapist and the client agree how to set up and carry out certain ‘training exercises’. Then the client returns, goes through the result, and new plans or measures are made. As discussed earlier, this procedure is a common and natural form of working, also in psychotherapy and psychoeducational family interventions. It is important to test out practically, in all settings, what is learned. Milieu therapy in a living environment The unique thing about good milieu therapy, carried out in a confined and secure unit, is the opportunity to create a substitute ‘total living environment’ over a significant time period. Milieu therapy can be carried out in day-clinics as well as inpatient clinics, the decisive point is whether the unit has established procedures so that several professionals from different backgrounds work together and are well organised, and that there are several clients that live and interact in the unit. This arena then can function as a kind of ‘family environment’. Such arenas need a lot of resources, but also have a great potential for success, due to 165

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the intensiveness of the treatment. Individual therapy, family work, networking, social and other types of functional training, milieu therapy, and medication treatment can all take place in one and the same setting, with the significant advantages and gains this can, bring in relation to effect and efficiency, therapeutically and economically. A single professional can perform different modalities of treatment at the same place and through that attain therapeutic synergies. In addition, the professionals can easily let important information feed back into the community as a whole and to those performing other treatment forms. In addition to the individual and relational effects, the actual environment provides an additional effect, as the treatment effects gain weight simply because so many are behind them. Milieu therapy settings may also be well suited to teaching, training, and information, for both clients and professionals, and may be a suitable way of bringing in knowledge about self-disturbances.

Self-disturbances and medication Antipsychotic medication is still a mainstay of treatment of schizophrenia but should never be the only form of treatment. The effect of such medication is well documented in the acute phase of psychosis, and at least for the first two years (Leucht et  al., 2012, 2017; Ceraso et al., 2022). Effect, usefulness, and sideeffects of antipsychotics for longer than two years is poorly documented, particularly if one aims to compare antipsychotics with the course without medication (which is practically and ethically challenging to organise in research) or with other forms of treatment. Clinical follow-up of medication is too often weak and unsystematic and needs to be strengthened. If antipsychotics can calm distressing self-disturbances in an early psychotic phase, even before the onset of psychosis (particularly in relapse prodromes), and slow down, stop, or even reverse further negative development, it strengthens the assumption that self-disturbances are central to the development of psychosis. Self-disturbances can then also represent a useful and more ‘human’ parameter to base follow-up measures on, perhaps better than the classical psychosis symptoms. The correlation between positive psychosis symptoms and functioning is also not particularly strong, so self-disturbances, together with conventional negative prodromal symptoms, may contribute well to predict adverse course and functioning, and thus the need for strenghtened monitoring. A clinical case Treatment with medication is not the focus of this book, but the question of selfdisturbances and medication quickly arises in professional discussions, so it needs to be given some attention. Can antipsychotics affect self-disturbances? There are no systematic studies of this question, but it is my clear impression throughout many years of clinical work and discussions, that there is a fair amount ‘out there’ of unsystematic clinical experience with such effects, also when self-disturbances 166

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have not been a part of the specific conceptual repertoire. One such clinical experience, an individual case I have myself been a part of, can illustrate the issue: At the start of this book, I presented ‘A central conversation’, which is a dialogue with a young boy of 16 (let’s call him Joe) who was referred for assessment due to the possible development of psychosis. In the following, a fuller picture of the course is presented, showing the possible effects of medication on self-disturbances. This case has been fictionalised and made anonymous, and is recounted with the consent of the client. When Joe came to assessment conversations, his problems had lasted half a year, with a slow and stable progression. He was continuously and increasingly bothered by a pressing feeling of losing contact with himself; reality seemed distant, he isolated himself and felt that everything was different, new, and strange. There was something that didn’t seem quite right to him about himself; his whole existence seemed turned upside down, nothing seemed to add up and nothing seemed to be meaningful. Everything was odd, and he couldn’t seem to find himself, he didn’t really know who he was any more. These feelings had undoubtedly increased over time, and now he was barely capable of keeping up with school. It was difficult to maintain social relationships or be together with others, even family and close friends. Everything was troublesome and difficult, nothing seemed to run smoothly, not even thinking. Joe had to concentrate hard to do even the simplest of things. In a strange way, he didn’t even know ‘where to be’ or ‘what to do with himself’, and felt he didn’t really belong anywhere. The situation slowly worsened and after a few months of conversations, he didn’t know what the world was any more, everything felt lifeless, artificial, and improbable, not least himself. Schoolwork and social life had now completely stopped. One evening, Joe’s mother called me and said there was a total crisis. He was lying down curled up and was in a state of complete confusion. I visited the family at home and could confirm everything they had told me. Joe could respond to contact, but was extremely confused, frightened, and desperate, and repeatedly said ‘I don’t understand anything’. He had no signs of hallucinations or of paranoid delusions or other psychotic ideas, but the feelings of unreality were even stronger than before. There were no suspicions of the use of illegal substances or other drugs. Joe was admitted to hospital that same evening, and after a couple of days’ observation without improvement and in great distress, it was decided to start antipsychotic medication, still without signs of obvious (conventional) psychosis symptoms. Small doses were tried at first, without effect. The dose was gradually raised to the standard antipsychotic level, this time with quick and significant effect. The painful experiences paled quite suddenly, and after just a couple of days Joe was much better than he had been for several weeks. Even further improvement followed, and he was discharged from hospital two weeks later. He continued in therapy with me, and the medication continued also. The dose was slowly reduced and eventually removed after half a year. Joe’s condition remained stable and significantly improved, but he continued to sense vague and slightly 167

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paler variants of the same feelings of unreality and strangeness. The phenomena were not completely gone, but considerably milder than before the referral, and it was now possible to restart school and more social interaction. A year went without medication, with bi-weekly therapy conversations about practical challenges, feelings, relationships, identity issues, and about mastering the self-disturbances. Activities related to school, friends, and interests were slowly taken back up, but this was not straightforward and needed a lot of planning and consideration. One evening Joe went to the cinema. The film was about supernatural, other worldly invasive forces and was known to be quite frightening. While watching the film, the symptoms came suddenly back with full force, and he had to quickly escape from the cinema. He rang me the same evening and said that he wished to restart the medication. I suggested waiting a few days, but the day after he said the symptoms had only got worse, and that he was afraid of losing his grip once again. The same medication as previously was administered, with the same quick and positive effect. The self-disturbances gradually paled into the background again after about a week. This time, we started the dose-reduction somewhat earlier than the first time, but with smaller steps and longer intervals, carefully adjusted according to the experiential (symptom) status. The situation was less frightening for him than the first time. He had learned some words and concepts (related to self-experience) from our conversations for what was happening, and he trusted that he would get better. After one year, the medication was again completely removed. Joe experienced the same improvement as before, but could still feel some vague discomfort, but they were far less bothersome and restrictive. He and his family were more aware of several things and events that could destabilise him and took these into account. Among other things, he applied for an exemption from Military Service, and he chose to stay living with his parents the first year after college. The following period without medication was positive for Joe, and he was able to start studying at university. The disturbance of experiences became paler and more distant, and after a while he felt secure enough to move to his place of study. In his second year of study, the follow-up was transferred to his local health centre. Reflections on the case It is always true with preventive work that, when it succeeds, it is difficult to know what exactly has been prevented. In this case, I was never in any doubt that we were dealing with a genuine initial prodromal condition, which was slowed down and eventually stopped, and which did not develop into a clear psychosis, as defined by the current diagnostic criteria. No positive, negative, or openly behavioural disorganisation symptoms were manifest. However, a massive loss of functioning, a severe existential confusion, and a serious dissolution of identity feeling were clearly present, against the background of several typical self-disturbances which had developed over the course of a year before medication was administered. 168

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Conversations about self-disturbances gave him some useful words and concepts which were tools he could use to communicate about the experiences in the course of the illness. In two separate phases, it seemed overwhelmingly apparent that antipsychotic medication had a quick and positive effect on the condition, and side effects were minimal and not an important theme in the treatment. Both times, it was possible to lower the medication dose relatively quickly, and eventually remove it without exacerbation. Vulnerability for relapse was obviously not absent, but this could be taken into consideration by the client and his family when planning his life further. With this case study – and this book – I wish to show that the development of psychosis is a continuously floating process, open to psychological and medical influence and intervention, from the period of increasing self-disturbances in the pre-psychotic phase, via an unstable borderline state, where evaluation can be particularly demanding, to fully developed psychosis as defined by current criteria. Given that there seems to exist a seamless developmental continuum in this way, it seems logical to assume that antipsychotic medication has effect not only on fully developed psychotic stages but also on the earlier stages and the prodromal phenomena. The case here referred indicates that antipsychotics can have a significant effect on self-disturbances (but of course psychotherapeutic issues also have to be addressed). It was also a clear experience in this example that the effects of medications in this phase were strong and quick to take hold, and that they were sustained despite dose reduction and eventual removal. Talking therapy versus medication: what is preventive to psychosis? As mentioned in the introductory parts of the book, since the early 2000s, much research has been conducted globally to find reliable and accessible clinical indicators and prodromal phenomena that can be used to stagnate or completely stop the development of psychosis (Miller et al., 2003; Yung et al., 2005; Parnas et al., 2005; Schultze-Lutter et al., 2007, 2010). Of six recent randomised, controlled studies (see Okusawa et al., 2014), only two (van der Gaag et al., 2012: Beckdolf et al., 2012) suggested that cognitive behavioural therapy (CBT) with psychosocial interventions especially designed for the target group can have a potential (but small) usefulness in delaying or preventing the onset of psychosis in individuals at risk. The comparison groups received ordinary, follow-up support treatment. These are quite striking and disappointing results, and the six studies suggest (taken together) that one needs to treat between six and 48 clients to prevent just one onset of psychosis. Several studies which have investigated the preventive effect of antipsychotic medication are not much more encouraging, but show results that are in the more favourable part of this range. Most studies have demonstrated a small or absent additional effect when using medication in addition to CBT compared to placebo + CBT (see Heinssen & Insel, 2015). The reasons for these weak preventive effects may be found in the treatment, that is, that treatment is poorly designed or carried out, or the cause may 169

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lie in that the clients are selected based on too weak criteria, or that clinical criteria or prodromal phenomena are not optimal, so that the real risk of psychosis (in the intervention group or the control group) therefore is generally low. These findings constitute good reasons for the further exploration of (1) whether self-disturbances can represent useful supplementary indicators in the early identification of individuals at risk, and (2) how SDs may increase the effect of interventions, both in prevention and in treatment. A warning: be restrained This section has discussed antipsychotic medication in the prodromal phase and leads us to a necessary warning: the fundamental uncertainty which is inherent when evaluating a possible at-risk mental state correctly indicates the need for caution when using antipsychotic medication in the case of a suspected prodromal condition. The latter is also not a recognised indication for these types of medication, precisely for that reason. It is one thing to identify a high-risk condition (UHR/CHR) according to today’s accepted criteria. But significantly, as mentioned, only a small minority of these states in fact develop into psychosis. In the aforementioned client story, the condition was stably progressive over a considerable period, and it brought with it extremely serious subjective suffering and a major loss of function. An alternative and medication-free treatment would probably have needed resources and facilities that today are unavailable.

Pervasive principles for all types of treatment More involvement of the main person In all the five mentioned forms of treatment, the service user’s active involvement in their own treatment should be ensured. This of course does not mean that they should take over illness management and have complete control over decisions about treatment. Most clients will be satisfied that professionals’ carefully evaluated decisions should be in the forefront. The central point is to be involved in a transparent decision-making process, that they have a respected role in informed, joint decision-making, that is, that relevant background knowledge is shared, and that there is a genuine choice between treatment alternatives. Furthermore, joint decision-making and involvement also apply to several other types of measures. Even in research and professional development, it is now regularly recommended that service users are represented, in the sense of setting priorities and directions for further research and that they are consulted as advisors or act as fellow researchers. Multi-disciplinary approach A second pervasive principle that applies for most forms of treatment is the demand for multi-disciplinary forms of collaboration. In the field of psychosis, 170

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this has been a clear principle for a considerable time and is an expression of how these disorders have deep-seated effects on all aspects of life. The need for the inclusion of several perspectives, traditions, and disciplines in treatment is also a direct result of the many gaps in our knowledge when it comes to causes, understanding and treatment. Less coercion Third, a person’s rights to reject or terminate ongoing psychiatric treatment is now regulated by law in many countries and will probably be strengthened in the future. The conditions for the use of coercion will be further narrowed. This is a feature of a general trend in the entire health system, reflecting a major lift for the rights and involvement of the service user, even in research (see Pitt et al., 2007). In the field of psychosis, the freedom to choose not to receive treatment in certain cases can however result in serious consequences. The clauses in the regulations regarding both reasonable grounds for treatment and the client’s competence to provide informed consent can be difficult to interpret and practice (see Stovell et al., 2016). At the same time, we need to explore new directions in this ethically difficult and often troublesome area within mental health. The trend towards the provision of optional treatment is not new but has now a renewed intensity. In this context too, an early focus on self-experience is likely to promote a more genuinely open, understanding, compassionate, and well-informed dialogue in situations that otherwise could result in the use of coercion. This concludes the chapter, in which I have discussed how all main treatment approaches and treatment settings should integrate a focus on self-disturbances. In the next chapter, the basic principles of a pragmatic approach to treatment will be proposed and outlined.

References Bechdolf, A., Wagner, M., Ruhrmann, S., Harrigan, S., Putzfeld, V., Pukrop, R., . . . & Klosterkötter, J. (2012). Preventing progression to first-episode psychosis in early initial prodromal states. The British Journal of Psychiatry, 200(1), 22–29. Bola, J.R., Lehtinen, K., Aaltonen, J., Räkköläinen, V., Syvälahti, E., & Lehtinen, V. (2006). Predicting medication-free treatment response in acute psychosis: Cross-validation from the Finnish need-adapted project. The Journal of Nervous and Mental Disease, 194(10), 732–739. Ceraso, A., Lin, J.J., Schneider-Thoma, J., Siafis, S., Heres, S., Kissling, W., . . . & Leucht, S. (2022). Maintenance treatment with antipsychotic drugs in schizophrenia: A Cochrane systematic review and meta-analysis. Schizophrenia Bulletin, 48(4), 738–740. Ciompi, L.,  & Hoffmann, H. (2004). Soteria Berne: An innovative milieu therapeutic approach to acute schizophrenia based on the concept of affect-logic. World Psychiatry, 3(3), 140–146. Fordal, L. (2020). Pakkeforløp i psykisk helsevern: Profesjonenes syn (Treatment package in mental health care: The professions’ view) (Bachelor’s thesis). NTNU, Trondheim, Norway.

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Geist, R., Heinmaa, M., Stephens, D., Davis, R., & Katzman, D.K. (2000). Comparison of family therapy and family group psychoeducation in adolescents with anorexia nervosa. The Canadian Journal of Psychiatry, 45(2), 173–178. Haddock, G.,  & Spaulding, W. (2011). Psychological treatment of psychosis. In Schizophrenia: Third edition schizophrenia (3rd ed., pp.  666–686). Hoboken, NJ: John Wiley & Sons Ltd. Haug, E., Lien, L., Raballo, A., Bratlien, U., Øie, M., Andreassen, O.A., . . . & Møller, P. (2012). Selective aggregation of self-disorders in first-treatment DSM-IV schizophrenia spectrum disorders. The Journal of Nervous and Mental Disease, 200(7), 632–636. Heinssen, R.K., & Insel, T.R. (2015). Preventing the onset of psychosis: Not quite there yet. Schizophrenia Bulletin, 41(1), 28–29. Leff, J., & Trieman, N. (2000). Long-stay patients discharged from psychiatric hospitals: Social and clinical outcomes after five years in the community. The TAPS project 46. The British Journal of Psychiatry, 176(3), 217–223. Leucht, S., Leucht, C., Huhn, M., Chaimani, A., Mavridis, D., Helfer, B., . . . & Davis, J.M. (2017). Sixty years of placebo-controlled antipsychotic drug trials in acute schizophrenia: Systematic review, Bayesian meta-analysis, and meta-regression of efficacy predictors. American Journal of Psychiatry, 174(10), 927–942. Leucht, S., Tardy, M., Komossa, K., Heres, S., Kissling, W., Salanti, G., & Davis, J.M. (2012). Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: A systematic review and meta-analysis. The Lancet, 379(9831), 2063–2071. Lucksted, A., McFarlane, W., Downing, D., & Dixon, L. (2012). Recent developments in family psychoeducation as an evidence‐based practice. Journal of Marital and Family Therapy, 38(1), 101–121. McFarlane, W.R. (2016). Family interventions for schizophrenia and the psychoses: A review. Family Process, 55(3), 460–482. McFarlane, W.R., Dixon, L., Lukens, E., & Lucksted, A. (2003). Family psycho education and schizophrenia: A review of the literature. Journal of Marital and Family Therapy, 29(2), 223–245. Miklowitz, D.J., George, E.L., Richards, J.A., Simoneau, T.L., & Suddath, R.L. (2003). A randomized study of family-focused psycho education and pharmacotherapy in the outpatient management of bipolar disorder. Archives of General Psychiatry,  60(9), 904–912. Miller, T.J., McGlashan, T.H., Rosen, J.L., Cadenhead, K., Ventura, J., McFarlane, W., . . . & Woods, S.W. (2003). Prodromal assessment with the structured interview for prodromal syndromes and the scale of prodromal symptoms: Predictive validity, interrater reliability, and training to reliability. Schizophrenia Bulletin, 29(4), 703–715. Møller, P. (2005). (in Norwegian) Schizofreni og selvet – Eksistensielle perspektiver på forståelse og utredning. (Schizophrenia and the self-existential perspectives on understanding and assessment.) Journal of the Norwegian Medical Association, 125 (8), 1022–1025. Nelson, B., Thompson, A., & Yung, A.R. (2012). Basic self-disturbance predicts psychosis onset in the ultra-high risk for psychosis “prodromal” population. Schizophrenia Bulletin, 38(6), 1277–1287. Nelson, B., Thompson, A.,  & Yung, A.R. (2013). Not all first‐episode psychosis is the same: Preliminary evidence of greater basic self‐disturbance in schizophrenia spectrum cases. Early Intervention in Psychiatry, 7(2), 200–204.

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Nelson, B., Torregrossa, L., Thompson, A., Sass, L. A., Park, S., Hartmann, J. A., . . . & Alvarez-Jimenez, M. (2021). Improving treatments for psychotic disorders: Beyond cognitive behaviour therapy for psychosis. Psychosis, 13(1), 78–84. Oedegaard, C.H., Davidson, L., Stige, B., Veseth, M., Blindheim, A., Garvik, L., . . . & Engebretsen, I.M.S. (2020). “It means so much for me to have a choice”: A qualitative study providing first-person perspectives on medication-free treatment in mental health care. BMC Psychiatry, 20(1), 1–11. Okuzawa, N., Kline, E., Fuertes, J., Negi, S., Reeves, G., Himelhoch, S.,  & Schiffman, J. (2014). Psychotherapy for adolescents and young adults at high risk for psychosis: A systematic review. Early Intervention in Psychiatry, 8(4), 307–322. Parnas, J., Møller, P., Kircher, T., Thalbitzer, J., Jansson, L., Handest, P., & Zahavi, D. (2005). EASE: Examination of anomalous self-experience. Psychopathology, 38(5), 236. Pharoah, F., Mari, J.J., Rathbone, J., & Wong, W. (2010). Family intervention for schizophrenia. Cochrane Database of Systematic Reviews, 12. Pitt, L., Kilbride, M., Nothard, S., Welford, M., & Morrison, A.P. (2007). Researching recovery from psychosis: A user-led project. Psychiatric Bulletin, 31(2), 55–60. Rodolico, A., Bighelli, I., Avanzato, C., Concerto, C., Cutrufelli, P., Mineo, L., . . . & Leucht, S. (2022). Family interventions for relapse prevention in schizophrenia: A systematic review and network meta-analysis. The Lancet Psychiatry, 9(3), 211–221. Rosenbaum, B., Harder, S., Knudsen, P., Køster, A., Lindhardt, A., Lajer, M., . . . & Winther, G. (2012). Supportive psychodynamic psychotherapy versus treatment as usual for first-episode psychosis: Two-year outcome. Psychiatry: Interpersonal & Biological Processes, 75(4), 331–341. Schultze-Lutter, F., Addington, J., Ruhrmann, S., & Klosterkötter, J. (2007). Schizophrenia proneness instrument, adult version (SPI-A). Rome: Giovanni Fioriti. Schultze-Lutter, F.,  & Koch, E. (2010).  Schizophrenia proneness instrument: Child and youth version (SPI-CY) (p. 98). Rome: Giovanni Fioriti. Smith, L., & Newton, R. (2007). Systematic review of case management. Australian & New Zealand Journal of Psychiatry, 41(1), 2–9. Soo, S.A., Zhang, Z.W., Jia, S., Khong, E., Low, J.E.W., Vamadevan, S., . . . & Sim, K. (2018). Randomized controlled trials of psycho education modalities in the management of bipolar disorder: A systematic review. The Journal of Clinical Psychiatry, 79(3), 16073. Stovell, D., Morrison, A.P., Panayiotou, M., & Hutton, P. (2016). Shared treatment decision-making and empowerment related outcomes in psychosis: Systematic review and meta-analysis. The British Journal of Psychiatry, 209(1), 23–28. van der Gaag, M., Nieman, D.H., Rietdijk, J., Dragt, S., Ising, H.K., Klaassen, R.M., . . . & Linszen, D.H. (2012). Cognitive behavioral therapy for subjects at ultrahigh risk for developing psychosis: A randomized controlled clinical trial. Schizophrenia Bulletin, 38(6), 1180–1188. Yung, A.R., Yung, A.R., Pan Yuen, H., Mcgorry, P.D., Phillips, L.J., Kelly, D., . . . & Buckby, J. (2005). Mapping the onset of psychosis: The comprehensive assessment of at-risk mental states. Australian & New Zealand Journal of Psychiatry, 39(11–12), 964–971.

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16 O U T L I N E O F A P R A G M AT I C S E V E N-S T E P T R E AT M E N T MODULE

Clearly, basic self-disturbances cannot be treated in isolation. This phenomenological focus must be integrated as a parallel module in a recommended wider course of treatment. When there is clinical suspicion of increased psychosis risk or a psychotic disorder, self-disturbances need to be investigated and, if confirmed, brought in as a therapeutic theme in the same way as several others. In any case, the client’s feeling of identity is always a central theme, and it is a basic issue pertaining to most aspects of psychotherapy. At our previous (2000–2008) in-patient early psychosis unit in Norway, we had a pervasive focus on basic self-disturbances in assessment and treatment. This approach was experienced as highly relevant, motivating, and useful by clients, families, and clinicians. In this chapter, the basic principles in a pragmatic approach to treatment are proposed and outlined, which build upon these clinical experiences. The treatment module outlined should not at all be followed mechanically, but is an initial, descriptive structuring of subprocesses which can be a part of treatment directed at self-disturbances.

Building on clinical experiences This module’s content and structure build primarily on eight years of running the mentioned early psychosis unit. Over two years, we planned, designed, and drifted an assessment and treatment programme which consistently had what we refer to in this book as the Subjectivity Model as its frame of reference. Put briefly, this implied that the client’s subjective realities, that is, their own words and phrases, experiences, life stories, and their initial subjective opinion of their problems were consistently made the starting point for all work with the clients: assessment, understanding, diagnostics, treatment, and family work. One strikingly effective strategy in the efforts was to replace most of the conventional technical words and designations for symptoms and signs in our working tools with words and formulations that the clients themselves had used before hospitalisation. A pragmatic and specifically adapted common phenomenological knowledge base for all 174

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staff was continually built up, which broadly encompassed the main elements in this book. Daily and weekly programmes for the unit were created in accordance with this. Digital supportive tools for systematic clinical work in diagnostics and milieu therapy were developed. Over these years, approximately 120 young persons with either an increased risk of a psychotic disorder or a newly established disorder were assessed, and treatment was started up, before further treatment at Community Mental Health Centres or another in-patient clinic.

The module in a tabular summary First, the module will be presented briefly in tabulated form, to give an initial brief overview. Then I present a more detailed description of sub-processes, step by step. First of all, I provide a very brief reminder of the three specific preconditions for psychosis therapy which were presented in Chapter 14. These potential hindrances will, naturally to varying degrees, exert influence on all the clinical phenomena which are in treatment focus, and therefore clinicians must know about them and take them into account. These are the three preconditions: • • •

Experiences must be recognised as one’s own, that is, they should be felt as (reasonably) anchored to an individual, personal core, a kind of existential ‘centre of gravity’. Experiences must provide inner coherence and personal meaning, which is to say that they should assume a reasonably familiar, seamless and integrated inner form or structure. The experiences must be intersubjectively communicable through a dynamic, inter-personal channel, which is mutual and safe, that is, wordlessness must be reasonably surmounted and the client should be supported to find ways of expressing the experiences.

An expanded view of treatment: including the sense of identity In the following, the sub-processes in this treatment module will be discussed in more depth. In the descriptions, it should be noted that the term phenomena, rather than symptoms, is often used when referring to self-experiences and self-disturbances. Treatment in the case of self-disturbances is never intended to stand alone but needs to be integrated into and supplement/broaden a generally accepted course of treatment for psychotic disorders. Where there is clinical suspicion of a disorder related to psychosis, the presence of self-disturbances should always be checked, on a par with conventional symptoms, perhaps initially with the aid of a simple, self-administered screening instrument such as SQuEASE-6 (see Appendix). When the suspicion of relevant phenomena is strengthened, this is then further assessed in a broader interview, based on the EASE manual. If self-disturbances 175

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are further confirmed by the EASE, and found clinically significant, these phenomena are then incorporated as part of the psychotherapeutic, psychoeducational, and psychosocial measures, as well as other themes. In this way, self-experience is regarded as a broadening of the treatment focus. Professionals’ experience with this clinical broadening is that it more than many other approaches, is experienced as useful and constructive for all those involved. Table 3  A sketch of a seven-step module for treatment aimed at self-disturbances: Summary of sub-processes which should be a part of therapeutic work with self-disturbances, and what can be a natural progression. Target group and conditions It is a condition in this module that the client or the client’s family seek help for psychological problems, and that there is a clinical suspicion of psychosis or enhanced psychosis risk. It is also a condition that self-disturbance is confirmed through assessment with relevant clinical tools, such as the EASE manual and associated screening tools, and that the client shows interest and motivation to explore and work with these experiences. Settings The module can be applied as part of assessment and treatment in all types of setting: in-patient clinics, day clinics, outpatient clinics, and ambulatory services. In-patient and day facilities will provide a higher intensity, depth, and tempo than in an outpatient setting. For outpatient work, two meetings a week is recommended and preferably of longer duration than the usual 45-minute sessions, possibly split into two but always carefully adjusted to the client’s tolerance. Ambulatory work will result in a lower treatment intensity but can be used when other settings are not available. In all settings, tempo and intensity must always be adjusted to the client’s tolerance window and whatever stage of awareness has been reached about his own condition. Flexible practice In practical clinical work, the steps or aspects of the process will of course not be possible to distinguish clearly from each other. This outline will primarily show which subprocesses should be a part of therapeutic work focusing on self-disturbances, and what could be a natural progression. They will rarely exist as pure linear processes, from step 1 to 7, but rather flexible, circular loops and repetitions, depending upon the individual’s capacity, stage of awareness and observed condition. Some clients will understand and work faster than others, and for some the model will be difficult to apply and for some completely inappropriate. It is also of great importance that the model is not understood as a purely cognitive process. At all stages, attention should also be directed at emotional and relational aspects and consequences, since anxiety, anger, fear, shame, depression, etc., will almost always accompany experiences related to selfdisturbances. Hopefully, through the sketch, some therapists can also simply get inspiration to some relevant methods and topics for assessment and treatment, even if it is not possible to include or follow all steps as they are described.

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Step 1  Which phenomena are experienced? – a systematic shared overview Already existing information about self-disturbances is first processed systematically into a written, ordered overview of phenomena, preferably in order of importance for the client, that is, how great an influence the individual phenomena have on the client’s mental functioning and daily life. New phenomena which become apparent during this process, and when using the EASE manual, are continously added to the list. The phenomena are written up as far as possible as true and accurate reproductions of the client’s original words and phrases. It is important that a written overview is constructed that is easily available for the client (e.g. printouts, notebook, tablet, or smartphone) and therapist, which can be supplemented, modified and changed during the assessment process. Step 2  ‘Learning about the mind’. A psychoeducational learning stage about subjectivity and being oneself When the list of phenomena is ready, an initial collation of knowledge can begin relating to those aspects of the mind and consciousness which are important for the client to better understand his own risk phenomena and/or psychosis phenomena. This knowledge will also function to support the therapeutic conversations afterwards, where self-disturbances will be a theme on a par with emotional and relational themes. A short, initial introduction, both verbally and in written form, about the nature of the self and subjectivity is given. It is valuable for the client to share this knowledge with close friends and family. Simple, written information material can be used for support. In in-patient and day clinics, group teaching can be provided. This teaching can also be a part of comprehensive psychoeducational programmes. Step 3  Attribution. What meaning has been ascribed to the experiences? Based on the list of phenomena (step 1), an assessment is made at this stage of which personal meanings (attributions) the individual changes in experience have for the client, that is, which ‘model of explanation’ or what perspective the client has developed for his understanding and interpretation of the phenomena. We are looking for cognitive, apparently rational evidence of the gradual attribution of meaning which seems to have taken place. The same or similar variants of self-disturbances can acquire completely different meanings/attributions in different individuals. The attribution of meaning is coloured by the individual’s life story and life events. This third step also needs to be documented in written form, as a supplement to the first overview (step 1). Some persons can have meanings tied to one single phenomenon, some can have broader and more overarching systems of meanings tied to several phenomena. Step 4  ‘Learning about the mind’. Alternative understanding of the experiences, in the light of subjectivity and the self Starting from the subjective attributions that the client has developed (step 3), we must now motivate sharing, mirroring, and curiosity related to these. We need to lay the ground for a movement towards an alternative understanding of meaning considering what has been learned about the self and subjectivity (step 2). Possible connections between (a) the original, ordinary (premorbid) self-experience and (b) the changed, disturbed self-understanding which the client has developed are tested out and described by using supplementary knowledge about the self and subjectivity, related to these experiences. Each individual phenomenon on the written list is worked through and described shortly in the light of subjectivity’s possible role. The task at this stage becomes: ‘How can the relevant experiences be described and understood when subjectivity is to be a part of this?’ (Continued)

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Table 3 (Continued) Step 5  The rationale behind the personal meaning that has been developed: How is it possible that it became like this? At this stage, the person’s individual, mainly conscious reasoning behind the attributions which are developed, are explored, that is, the cognitive reflections (and ‘as if’ feelings), whether they are rational or not. These can be psychological, physical, meta-physical, religious, mystical, philosophical, or other types of underlying ideas. This stage should reveal insight into how it was possible that this specific attribution could arise. Through this, alternative interpretations can be more easily encouraged, considered, developed, tested, and evaluated. An incipient understanding of one’s own rationale behind the misattribution can contribute to the consolidation of new meaning. It is of great value for the client to find meaning in his own interpretations, understand them for himself, and put them into a personal context. It will facilitate a more open reflection around the alternative interpretations that we wish to establish. Step 6  From ideas and beliefs to behaviour and functioning At this stage, a further assessment is carried out, this time an overview of the behavioural consequences of the relevant experiential phenomena in relation to daily functioning. Marked consequences can become apparent unexpectedly early in the development of psychosis. The consequences are not necessarily noticeable for those around the individual, but can be present for a long time, causing much suffering on an inner level. Consequences can also include coping or self-protective behaviour, for example rituals or compulsions, to soothe anxiety and discomfort, and can include destructive or dangerous behaviour, towards oneself or to others. Self-harming or suicidal behaviour is not uncommon, even before psychosis has begun. Step 7  Re-attribution. New interpretations of experiential phenomena can create new meaning and modified self-understanding Ideally, at this stage the conditions should be present for more targeted work on possible modifications of the distorted ideas and interpretations of self-experience. We are therefore at the stage of the re-attribution process. This is now supported by the fact that the main person, after the previous work, has a reasonable initial overview of his altered experiences, and even the working model. Being able to see the journey from ordinary, previous self-experience, through changed self-understanding and onto selfdisturbance, and the role of subjectivity and sense of self in this, can contribute to such a re-attribution, that is, describing and testing out a new alternative understanding of the self and others.

Who belongs to the target group? The treatment module is predicated on the client seeking help for psychological problems, and that psychosis or related features are mentioned in the referral, or present themselves as a clinical suspicion in other ways. Next, it is a further condition that one or several self-disturbance phenomena are tentatively identified at the screening stage, and thereafter confirmed on further assessment. It is also a condition that the client shows interest and motivation to explore their experiences further. If this is not the case, it should be considered whether further work with motivation is required, or if this is unrealistic. This can take time, and it is of great importance that motivational work is adjusted to the client’s tempo. For many, it will create insecurity and stress 178

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to open up for the first time about psychosis phenomena – and perhaps even more so about self-disturbances – because the ‘sense of reality’ is still intact, though fragile, and consequently there may be ambiguous feelings and understandings. Eight obstacles to the client’s self-narrative My own research and clinical experience have revealed several potentially important subjective hindrances for the client when it comes to communicating openly about his/her prodromal phenomena (Møller & Husby, 2000, p. 221). Among the hindrances clients reported are these: 1

The phenomena have developed so slowly and gradually that it can be difficult to know when, and even if, changes have really occurred. Even though the changes can also take place quickly (days, weeks), the most usual is that this takes months and years. Such a long, drawn-out process naturally gives rise over time to subjective doubt about what is normal and what is changed. 2 The individual clients have a widely varying ability regarding self-observation and being able to look inwards to know and recognise their own feelings. Involved in this is the ability and will to sense, differentiate, and name complex feelings. In other words, it is important the extent to which the person is ‘psychologically minded’. 3 The clients often have significant difficulties finding the words and concepts for the new and strange phenomena. It is a particularly characteristic feature of prodromal phenomena that many of them are nearly unavailable for precise verbal expression. They are often of a uniquely global and complex nature, and in any case often so unusual that they are outside of ordinary, daily language. 4 The individual can also be characterised by an intentional prioritisation of ‘closed introspection’ in his own world, at the cost of external contact, to ruminate on new ideas and private mental constructions. The client can experience that it is important not to disturb or ‘pollute’ these constructions through contamination from a trivial, outer world. The internal world can overtake the external because it may be experienced as the discovery of a new type of secret and unique insight, which others, for the time being, should not know about. It is easy to see the connection from this to fully developed psychosis, where a psychotic delusion is, almost as a rule, something not to be readily revealed to the outside world. 5 Several of the mentioned points here are naturally associated with social and emotional withdrawal. Social contact can be intimidating, and may expose the internal world to challenges. Distorted experiences can be felt so strongly that for the client it is ‘as if’ they can almost be ‘felt’ by others who come too close. It is then safer to keep a distance. 6 Many clients experience great general insecurity in their total life situation and can distrust their therapist, in addition to avoidance and fear in relation to the frightening experiences themselves. Uncertainty, insecurity, and suspicion 179

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7

8

are completely natural responses in a pre-psychotic situation. Therefore, the treatment approach must be implemented against the background of insight into possible reasons behind withdrawal and silence. Clients may also actively avoid talking about their difficult feelings because they have a basic conviction that they will only get worse by talking about them, that these feelings should be kept at a distance or ‘suppressed’ in the hope that they will be stalled or take up less room. It is also possible that the themes and content of the ideas in themselves involve a ‘mandatory’ secretiveness, for example because the main person has an ‘as if’ feeling that the world will be unable to acknowledge the unique truths s/he is the holder of.

All the aforementioned hindrances to open communication have frequently been experienced and reported by clients. It is part of the therapist’s skill to be aware of and able to manage such hindrances, and to approach the client in a way that maintains security, but with a view to overcoming the relevant hindrances. The importance of written material in treatment Clinical experience tells us that clients regard it as a real support if the working through, clarification, and sorting of the phenomena are shared in writing. This will contribute to acknowledge the phenomena and highlight their real importance, a serious attempt at ‘making real’ what the client is communicating. Abstract mental states can be experienced as truer and more tangible when written down. More precisely, it is important that the phenomena do not ‘disappear’ after being ‘just talked about’ but are rather physically put down onto paper. Initially, this should be carried out by the clinician, but the document should be owned mutually right from the start, in the sense that the main person is provided with a physical or electronic copy (provided adequate data protection) of what has been agreed upon and written down. The clinician should both during the therapy sessions and afterwards note down the phenomena as quotations. These notes are clarified and written up more precisely between sessions and thereby provide a good foundation for journal keeping too. There now follows an elaboration of the seven steps. The outline is intended to be flexible, and the order of the steps can of course be interchanged, depending upon specific needs, capacity, and progress. The procedure can be circular or linear or both.

Step 1  Which phenomena are experienced? A systematic shared overview During the initial assessments, most of the significant phenomena have been identified, but this early in the process they can still present themselves as relatively fresh and provisional, and for the client possibly also as surprising, when they are expressed clearly and written down in this way, not just felt and thought about. Talking about such special experiences, which have been held inside for months and perhaps years, 180

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also does something with the experiences themselves, they can change character and significance, and can present as either more or less meaningful than before. It is necessary that the client and clinician together systematically work through the personspecific phenomena which the client has reported up to the present time and use some time on them. Every phenomenon is described as precisely as possible, in the form of one or several verbatim quotations, through statements and formulations that the client fully acknowledges. It is possible and desirable to adjust/change descriptions along the way in this clarificatory process. Experience shows that if one manages to achieve agreement about the formulation of a quotation, through rounds of clarification, the client will rarely reject or dismiss the experience later. Both therapeutically and from a learning point of view, it is recommended that the client also works with this list of phenomena at home, between the sessions with the clinician or a group. Having his attention directed towards the experiences over time will contribute to even more clarification, more precise descriptions and both recognition and acknowledgement of his own phenomena. It will depend on the individual how early one starts with home working, and the effect of this will vary. Some may experience it as an additional burden to have to think about unpleasant phenomena too often, at least at the start. In this case home working should be postponed. The sub-goal at this first step is to obtain an ordered and focused overview, possibly organised in order of importance for the client, that is, how much influence the individual phenomena have had for his mental state and daily functioning. The client’s own scaled evaluation of unpleasantness and pain will be of importance for the corresponding priorities in the therapeutic work which follows. At treatment units where group teaching is provided, with several clients present, presentation and sharing of phenomena/quotations may function to motivate further.

Step 2  ‘Learning about the mind’ (1): a psychoeducational learning stage about subjectivity and being oneself As supporting knowledge, when basic self-disturbances have now become a theme after the initial compilation (step 1), the clients are given a short introduction into the nature of subjectivity (Chapter 6), the self, and being oneself (Chapter 7). The concepts of self-experience, self-understanding, and self-disturbance are briefly explained (Chapter 2), so that they can function as supporting concepts to understand the mental development involved in what has happened. The client should also receive the same psychoeducation in short written form, with a recommendation to read and think further through the material outside the sessions and encouraged to share with close family and friends. The concept of the self (and thus what makes me myself) is not simple to explain, and explanations should be provided as simply as possible, though without trivialisation. We saw in Chapter 7 about the self and self-disturbances that Kierkegaard defined the self as the human reflection over oneself and one’s existence, that is, the self can be seen as a mental process. The self of a given individual can be understood as a mental process containing the individual’s reflections 181

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about himself, coloured by personal life-events and unique features – in other words, the individual’s ways of thinking, feeling, and relating to himself, others, and the world. One can express this in several ways, such as: the self is the most central part of me; my typical inner core; the most important part of me; what makes me the unique individual I  am, my accumulated experience of identity; what makes me myself, – that is, according to my thoughts and feelings about it. It is simple and complicated at the same time. It is simple because we are all ‘specialists’ when it comes to our own identity, but also complicated when it comes to expressing this precisely in words. The concept of subjectivity can be explained extremely sophisticated, but also as that component, element, aspect or ‘structure’ of our mind and consciousness that makes the self possible. Metaphorically speaking, it is a fundamental element of the mind. As such, this basic mental component – subjectivity – colours and pervades everything in me and ensures that everything I experience seems unquestionably tied to me and only me, and that all experiences are in a sense a part of me. Experience, and the one doing the experiencing, cannot really be extricated. To a certain extent one can say that ‘I am what I experience’. The concepts self-experience, self-understanding, and self-disturbance can against this background be proposed and explained as stages in the development of a disturbed experience of identity: from altered self-experience, through changed self-understanding, progressing to self-disturbances (i.e. prodromal phenomena), and possibly further to psychotic delusions (see Chapter 2). The sub-goal at this step 2 is to start the collation of a small, general base of knowledge of those parts of the human mind which are useful to gain a better understanding of one’s own mental state. Such supporting knowledge can be woven into the treatment whole, together with emotional and relational work, at places and times which are appropriate for the individual concerned.

Step 3  Attribution.  What meaning has been ascribed to the experiences? At this step, the aim is to clarify which personal meaning the experiential changes have had, or are beginning to have, for the client, that is, which model or perspective the client has developed for his understanding of the phenomena. What does the client’s overarching, often somewhat unclear and hidden, personal project (goals and motivation) look like? It may be that the client gathers his new experiences into a summed whole, against the background of several types of experiential changes. In this way, an alternative ‘life-project’ can be created, often of great personal significance, sometimes with an element of latent grandiosity. This is a result of the feeling that ‘who I am’ has changed markedly. The changes can be experienced as so powerful that totally redefining the thoughts about one’s own life and existence seems inevitable. In all these works, it is important that the clinician as consistently as possible notices and uses (in the written material) the client’s own words and concepts about the phenomena. It is always important that the quotations are correct because these 182

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statements will have an important status in the forthcoming work when they are recognised and acknowledged by the client him-/herself. At that step, the list of phenomena (step 1) will come into play again and will now be supplemented (in a new column) by the attribution of meaning which has taken place, perhaps in the pre-conscious or unconscious mind. To have given one’s disturbed self-experience a new, private, and irrational meaning is the first stage in the direction of possible psychotic delusions. Therefore, this is a critical milestone in the exploration and working through of the core experiences. At this step, the client’s reflections about everything that has changed may still be malleable and constantly shifting and, in that sense, easier to influence in the context of a mutually creative dialogue. In the list of personal, core experiences, it is now the meanings the client attaches to his experiences that need to be noted. However, it is not always the case that a completely clear attribution of meaning has taken place. On the contrary, there may be confusion and uncertainty, and the client may have an extra need for safety. In such cases where attribution has not really come far, the journey back to a more recognisable and ordinary self-understanding may in fact be shorter. A state of confusion is more malleable than a clear standpoint. The sub-goal at this third step is to take a ‘phenomenological journey’ back in time, to look for cognitive and apparently rational traces of the gradual attribution that has taken place. At the same time, this work slowly merges with the following step 4, in that it slowly becomes possible to use newly acquired knowledge about subjectivity and the self as a support to understand how the deviant selfunderstanding could have arisen.

Step 4  ‘Learning about the mind’ (2): alternative understanding of the experiences, in the light of subjectivity and the self The client and clinician have now together worked out a list of the phenomena (step 1), the client has received an initial introduction to the concepts of subjectivity and the self (step 2), and descriptions of how the phenomena have been interpreted and understood by the main person have emerged (step 3). At step 4, the goal is that the listed phenomena and the meaning they have acquired by the client may be understood somewhat differently in the light of the new, and this time intentionally applied, knowledge of subjectivity and the self. Each single personal phenomenon is studied again, now using the perspective of the role of subjectivity. Which role has subjectivity had for self-experience in the first place, and what effect has the weakened subjectivity had for the ‘individual’ self-disturbance phenomena? The assumption is that it is important to include subjectivity as part of the entire fabric of a new understanding when it comes to experiential changes. An example may illustrate; feeling deeply different, foreign, and unreal is a typical example where self-experience will be changed because subjectivity is compromised. But beware; shorter, milder, and transitory episodes of such experiences are not necessarily anything to do with the development of psychosis but can be a result of acute physical illness or short-term periods of overwhelming mental strain. 183

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However, long-lasting and progressive changes in self-experience should raise concerns about the onset of the development of more serious mental disorder, though still only tentatively.

Examples from steps 1, 3, and 4:  A phenomenon that is described and understood in light of subjectivity Step 1 Aim: Description of a self-disturbance Phenomenon: I feel so unreal and different phenomenon that it feels almost like I’m not human. Sometimes I even wonder if I really exist. Step 3 Aim: Clarify the meaning attributed to the phenomenon: an emerging new self-understanding

Step 4 Aim: Searching for an alternative understanding, in light of subjectivity

Attribution: I’m constantly thinking about what this can mean. I have this recurring thought that maybe I’m going to be told about a special task I have to perform in the world, because I’m actually immortal? But of course, that sounds weird. New understanding: weakened subjectivity has brought with it such a strong and persistent sense of alienation (sense of self) that it is natural and ‘necessary’ to question one’s existence and human nature. (But it is still possible to doubt this understanding/interpretation.)

The sub-goal at this fourth step is to help the client identify a possible connection between the original ‘normal’ self-understanding and this new, disturbed self-understanding by applying knowledge about the interpretative significance of subjectivity. This can strengthen the possibilities for viewing and interpreting his own self-experience and self-understanding from a new angle, as a step towards new self-insight. This can also stall and possibly reverse a negative development, particularly in young persons but also adults in the risk zone, if they get help early enough.

Step 5  The rationale behind the personal meaning that has been developed: how is it possible that it became like this? The steps in this sketch for a treatment module need to be rolled on and consolidated in circular repetitions over time. Broadly speaking, we pre-suppose at this step that phenomena and attributions are initially investigated and to a certain degree clarified. It is also desirable to have elaborated and understood them considering the role of subjectivity in experience. On the agenda, at this step 5 184

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is to investigate the private rationale (reasons) s/he might have for the attributions. This is not necessarily something the client has a clear idea of or is totally convinced of at this stage. The rationale must be searched for, in an exploratory dialogue. There may be mental, physical, meta-physical, religious, mystical, philosophical, or other aspects that form the basis of a particular attribution. It will be of therapeutic advantage to develop the broadest possible insight into why it could be the case that precisely this attribution arose, because this also tells us something about this person’s life and personality in a wider sense, and it can contribute to further self-insight. When both the phenomenon (self-disturbance) and the interpretation are clarified, the hope now is to seek out a rationale: how is it possible that it became like this? Everyone has their own inner ‘scripts’, which form the basis for logical or rational decisions. A script is based on one’s own knowledge, values, attitudes, life history, experiences, and vulnerabilities. The full extent of ‘truth’ behind a reason is of less interest, as it is in any case this which lies behind the client’s actual reflections about himself. An example: how could it be the case that something that was originally experienced as belonging to one’s own thoughts has over time changed character and ended up as an ‘as if’ experience of having others’ voices in one’s head, maybe even ‘as if’ having religious spirits or other ‘persons’ inside one’s head? What specifically may have contributed to this transformation, to the development of precisely these ideas, representations, and decisions? The sub-goal at this fifth step is therefore to seek out and become familiar with the person’s individual, and to a certain extent sub-unconsciously rooted, cognitive reflections, and decisions which may lie behind the attributions that have been shaped. This is not merely a cognitive process. It involves the entire mental life, including the person’s feelings and relationships.

Step 6  From ideas and beliefs to behaviour and functioning At this step, the consequences that the self-disturbances have had for behaviour and daily functioning are assessed. Despite individual variation, it is the case that serious consequences can arise remarkably early during the development of psychosis, sometimes several years before the psychosis is fully developed. This is probably expectable when one considers the powerful changes self-disturbances can involve for the experience of one’s own identity. A further development from prodromal phenomena to psychosis phenomena can have a wide range of time courses, from a few days to several years, but a common denominator is that the changes relatively quickly make deep impressions on inner life. However, these early impressions are not necessarily outwardly visible, or otherwise noticeable to the surrounding world. They can take place in isolation for a long time before the mental ‘pressure’ becomes so intense that the individual is no longer able to compensate through coping strategies. It is clear from the lists of quotations from the prodromal phase (see Chapters 6, 7, and 9) that relating to other 185

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people and the daily demands of school, work, or spare time can be extremely demanding when self-disturbances have developed. Eventually, it will not be possible to keep the changes hidden as the behavioural consequences will emerge and be noticeable for others. This will include aspects of normally trivial daily activities such as meals and hygiene, but also coping or self-protective behaviours, for example that the person performs compulsive actions that can soothe fear and discomfort. The behavioural consequences can also include directly destructive or dangerous behaviour towards oneself or others. The strongest existential pain is a matter of life and death. Both psychosis and self-disturbances can, in some cases, be life-threatening. It is not unreasonable to expect that among the unexplained cases of suicide there may be persons developing schizophrenia that could see no other way out of unbearable pain. The behavioural consequences will often be the factor that brings the individual and the family to seek help. Behaviours and dispositions, and just as likely the absence or cessation of certain behaviours, can be traumatic and highly shameful, as well as difficult to talk about, and therefore correspondingly important to work with in treatment. Painful events may have paralysed the individual, created great loneliness and isolation, which in turn have made it difficult for friends and family to understand and show sympathy. On the contrary, events may have created anger, bitterness, and despair. Dialogue and contact with the outside world are often strongly impaired or broken. Much of this can be reversed and improved through sharing, understanding, and processing. Just ‘putting to one side’ a livedthrough period of active psychosis, letting traumatic events just lie dormant in sub-consciousness as an unmentionable chapter of one’s life, automatically leads to increased vulnerability for new episodes of psychosis. Unacceptable memories create avoidance, fear, and shame, and easily become a new ‘elephant in the room’, which can slowly initiate a new negative process towards a psychotic relapse. Therefore, it is an important goal to assess and process behaviours based upon self-disturbances (or psychosis). Experiences and behaviours build mutually on each other. The sub-goal at this sixth step is to help the client to draw a much more complete picture, in relation to the consequences self-disturbances have had for daily activities and functioning, but also for secondary mental complications (anxiety, depression, substance abuse, obsessions/compulsions, etc.). If the therapist can approach these difficult areas in an opening way, this can have major positive consequences for the motivation for change, where one becomes more aware of the many aspects of life that may have stagnated or are in the process of doing so.

Step 7  New interpretations of experiential phenomena can create new meaning and modified self-understanding At this ‘final’ step, the client and the clinician can have as a common goal to look at the full range of reported phenomena which over time have resulted in a painful change to the experience of one’s own identity. They can now see the 186

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interpretations the client has imposed upon the phenomena, and maybe the private rationale on which they are based. They can use qualified knowledge about the self and subjectivity as a compass in the journey ahead when reflecting, recognising, and acknowledging. They can both emotionally and rationally better understand that which earlier had been incomprehensible, but still taken a great deal of room in the client’s life. Finally, they can also see together the unfortunate practical and functional consequences of the development. When these steps have been worked on in treatment, and the outcomes are available in written and systematic form – phenomena, the construction of meaning, interpretations, rationale, and new knowledge – then alternative interpretation and new meaning can be fully addressed. Such modification (new meaning) is supported by the client now possibly seeing the entire picture which has been drawn up. It will be possible to see the contours of a path from the past to the present. Using the connection between one’s own experience and newly learned concepts can encourage positive change. This will take place against the background of a wider perspective on a whole process, not just a fragmented chaos. A process of respectful and genuinely curious therapeutic exchanges can increase the client’s feeling of control, reduce pressure and pain, isolation and shame, and thereby strengthen the experience of identity which is under threat. In addition to this, there will often be present unique, personal experiences which have been significant in the formation of the disturbed experiences. Life events will as always make their mark upon the understanding of oneself and the world, but subjectivity’s decisive role in being able to experience that one is oneself, in an ordinary, general way, is unavoidable. It is my impression that subjectivity’s role is today highly underestimated in the general understanding of psychosis. The sub-goal at this seventh step is to amalgamate emerging self-insight and new knowledge with a view to consolidating new understanding and meaning, drawing on self-reported phenomena from the client and knowledge of how the mind, consciousness, experience, and identity can be understood. With this as a platform, it can be possible to talk together, with a common language, about experiences and behaviour that earlier had been regarded as largely unavailable and incomprehensible.

Limitations of the model It is an incisive and succinct view that ‘All models are wrong, but some are useful’ (Box, 1976). The treatment module outlined here should not at all be followed mechanically, but is an initial, descriptive structuring of sub-processes which can be a part of treatment directed at self-disturbances. The client and clinician decide together the extent to which self-disturbances at any given time will be in the background or foreground of the treatment whole, and therefore this will vary during treatment. The self-disturbance phenomena should not have an exclusive position at the expense of other themes. Often, self-disturbances will in any case 187

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underlie other themes in treatment, even if they are not yet made explicit. They will affect and colour many seemingly commonplace issues. During the course of regular treatment, curiosity regarding these underlying phenomena and aspects may emerge in the client, so that self-disturbances move into the foreground. Then the time may suddenly be ripe to carry out one or more steps in the module. The present sketch does not go into detail regarding the emotional and relational themes that by nature are of greatest significance, and which are permanently woven into the process. Anxiety and depression are almost a natural part of self-disturbances, bringing with them powerful existential overtones and undertones. Self-destructive behaviours are not untypical, and suicidal thoughts arise in many clients. Pervasive and significant losses in function and associated social isolation will often bring forth deep feelings of guilt and shame. Invaluable relations to friends, trusted others, and not least family can be strongly impaired. In many cases, all these have been under heavy pressure for many years, and there will often be considerable need for repair and reconciliation which needs to be addressed. Therefore, it is also clear that family intervention should constitute a central part of the treatment. In this chapter, the basic principles of a pragmatic approach to treatment directed at self-disturbances have been proposed and outlined. The next, and last, chapter suggests taking some steps towards a systematic use of the Subjectivity Model, in clinical assessment, treatment, and follow-up. The chapter briefly discusses some central aspects relating to implementation processes in general, and to the present model in particular.

Reference Møller, P., & Husby, R. (2000). The initial prodrome in schizophrenia: Searching for naturalistic core dimensions of experience and behavior. Schizophrenia Bulletin, 26(1), 217–232.

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17 IMPLEMENTING THE SUBJECTIVITY MODEL

Implementing and establishing new forms of assessment and treatment as standard clinical practice, not least in the field of mental health, are demanding and time-consuming processes. Implementation is extra challenging when we are also concerned with new scientific perspectives on understanding mental disorders. This is normal and expected, and to some extent desirable, but may also result in a hindrance to a much needed development. It is essential to remember that the present book seeks to highlight a supplementary model for the understanding of psychotic disorders, not a competitive one. After the millennium, the Subjectivity Model has gradually become well known internationally. The stage is thus set to take some steps forward towards more systematic use, in clinical assessment, treatment, and follow-up. This chapter briefly outlines some central aspects relating to implementation processes in general, and to the Subjectivity Model in particular.

The implementation of new models is always opposed From considerable direct contact with clinical communities and mental health professionals in teaching and seminars spanning more than 25 years, I have consistently experienced that the Subjectivity Model has been received as relevant, useful, and clinically inspiring. Phenomenology helps to support a scientific, subjective perspective on pre-psychotic and psychotic experiences, a perspective often sought for by clinicians. Professionals in the field of psychosis already work within many different models, and (again) the statistician George Box neatly reminds us that ‘all models are wrong, but some are useful’ (Box, 1976). Operating with several models will in any case provide us with what the American novelist Siri Hustvedt, in an interview for the Journal of the Norwegian Psychological Association, has called a focused zone of multi-disciplinary ambivalence (Hustvedt, 2017). She claims that this can be a highly productive zone to work and research from, as there are DOI: 10.4324/9781003127895-18

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fewer clearly defined boundaries between academic disciplines. In this context, ambivalence implies that phenomena which are observed in the realm of human nature have several meanings at the same time, and that the picture to be drawn by researchers to understand a given phenomenon must gather inspiration from several disciplines and models. Hustvedt aimed to build bridges between natural science and the humanities. It is important to get the two cultures in dialogue, she maintained, precisely because major breakthroughs are so rare. Psychology, psychiatry, philosophy, literature, psychoanalysis, neuroscience, cognitive science, consciousness research, and phenomenology are all fields of study that can provide elucidating and useful models if we avoid claiming to have the final answer, for example to the puzzle of schizophrenia. Professor of economics George Akerlof at the University of Berkeley, who was awarded the ‘Central Bank of Sweden’s memorial prize for Alfred Nobel’ in 2001, shared the same concerns. He highlights a worrying mechanism within academia: when leading researchers and academics, who review publications and decide promotions, are biased towards researchers who favour the same models as themselves, researchers with alternative models will become ‘extinct’. This can be despite the availability of alternative research which can provide explanations of observed facts in a superior way (Akerlof & Michaillat, 2017). However, there must exist solid theoretical and empirical evidence for a new model before it is put forward, implemented, and tested. When it comes to the Subjectivity Model for the understanding of psychosis, a significant amount of interdisciplinary theoretical and empirical evidence already exists (Nelson et al., 2016; Henriksen et al., 2021; Nordgaard et al., 2021), so that the stage is now set for more systematic practical clinical use in assessment, treatment, and follow-up.

The Subjectivity Model has been clinically tested What constitutes a practical-clinical implementation or trial? As was evident in the suggestion for a treatment module presented in the previous chapter, the model can be readily integrated in a wide range of settings: outpatient clinics, day- or in-patient clinics, and, if necessary, ambulatory treatment. Much experience has been previously acquired from our own specialised in-patient assessment clinic, as well as from psychoeducational family interventions, in both cases over several years. In the following, these experiences will be briefly summarised. From 2000 to 2008, an ‘assessment unit for psychosis’ was in operation at Division of psychiatry at the former Lier Psychiatric Hospital in Norway, shortly outside Oslo. In the first years, the unit was run as a seven-day/night treatment service, being reduced later to a five-day service. All assessment, diagnostics, and treatment were consistently based upon the experiential and subjective reports of the clients. The referential background was emerging drafts to the EASE manual, which at that time was under construction, as well as early thoughts about what would become the Subjectivity Model (or Ipseity Disturbance Model). The manual was designed and tested out in parallel at the unit, and finally published in 2005. The 190

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new way of working and the model were strikingly well received by the service users, their parents, and families. They expressed surprise that the service was not a mainstream model. One client said it this way: ‘The method kind of gets straight to what this is all about, everything that I actually experience day-in and day-out’. The design, processes, and content of the assessment unit were gradually developed along the way, as in a trial, and with an open view by integrating the focus on self-disturbances with the usual procedures that were already in place. We also experienced it was fully possible to combine this understanding – the consistent subjective point of departure – with diagnostic procedures according to ICD or DSM. We worked with the official diagnostic criteria in a form that was only modified in the way of individualised client-centred (personal) language and terminology. That is to say that the ‘objective’ criteria were reformulated to fit a subjective frame of reference (mediated digitally by a ‘diagnostic working diagram’ [DWD]). In this way, the diagnostic process could be turned ‘upside down’. A diagnosis was therefore not something professionals ‘gave’ the client, but rather a (clinical) term or name for something that already existed, that is, the client’s own, self-reported inner mental landscape. We are referring here to a form of ‘bottom-up’ diagnostics based on close adaptation to the clients’ universe: a written clarification of the central experiences, and a presentation and description of these in a way that the main person can fully accept. This way of working in relation to diagnostics worked perfectly well at the unit, even as written documentation for health authorities, and as information for clients and families. A corresponding, digitally based ‘chronological life-span diagram’ (CLD) was developed, which in the same way is a simple tool which helps clients become more aware of their own life- and illness story. They draw up their own story themselves, systematically, chronologically in written form, together with their professional primary contact at the unit. The core of the diagram is a vertical, centralised time-line column, with descriptions of important events and milestones in a left-hand side column, and descriptions of the client’s own thoughts, reactions, and feelings tied to these events in a right-hand side column. This then becomes a selected extract of the client’s own subjective life story (which of course could be told in a very different way by others in the family). The diagram also functioned as a useful, general document for any necessary exchanges of background information inside or outside of the unit. In 2008, for financial reasons, the assessment unit was joined with another unit (with a completely different treatment profile) and the Subjectivity Model could not be carried on further within the new merged unit.

Current status of the Subjectivity Model (also called Ipseity Disturbance Model) •

In the international scientific community, a multitude of theoretical and empirical, quantitative and qualitative scientific papers concerning this model have been published, also in the highest ranked general

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and specialised psychiatric and psychological journals (see editorial in World Psychiatry: Sass, 2022). • Comprehensive systematic reviews have been published and initial reflections and proposals for treatment approaches have emerged in the literature. • The EASE checklist (Examination of Anomalous Self-Experience) has been made available in 11 languages and is being used across the globe. Its publication is being increasingly cited (>900 citation as per 03/23 in Google Scholar), and international and national EASE courses are currently running. • Several prominent clinical research communities for the early identification of psychosis, mainly based in Denmark, Norway, Italy, Australia, Israel, Germany, Poland, Slovenia, South America and North America, are running research projects, based on this phenomenological perspective of psychosis. • Basic Self-disturbances (the SQuEASE-11) is for the first time incorporated in a large, long-term (2016–2022) UHR intervention study, the STEP study in Melbourne, Australia, a sequential multiple assignment randomized trial, to investigate the predictive properties of the phenomena in treatment. In summary, the Subjectivity Model now has a world-wide support and a recognised scientific status, as a client-centred, evidence-based, and ‘fromwithin’ perspective on the understanding of early psychosis phenomena and development.

Elements of implementation, teaching, and training The seven-step treatment module outlined in Chapter 16 is presented as highly flexible with the aim of being easily integrated into a broader course of treatment or a standardised treatment package. Successful integration of new models always rests on general demands regarding a solid local supporting foundation, at the level of senior administrative management and among clinicians in the organisation concerned. It is also important to have detailed plans regarding the specific knowledge and skills required for implementation, broad involvement of all staff in the relevant units, and the provision of systematic training, supervision, and evaluation over time, linked to the field concerned. The role of clinical leadership It is not possible to implement new clinical routines in entire, or larger sections of, clinical units without a robust prior ‘anchoring’ process. Among the 192

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essential criteria that must be fulfilled for a successful and broad implementation process are: consensual clinical needs and motivation, clear operationalised implementation aims, secure links to administrative and clinical leadership and organisation, financial backing, and plans for teaching, supervision, and evaluation. To make room for such pre-conditions, senior administrative management must provide their full support to both the aims and implementation process in advance, and preferably participate in steering committees and the operative team. Today, larger health authorities often have their own internal support resources for carrying out such implementation work, through their own departments for quality and organisational development. The role of clinicians Even when solid administrative support is in place at all levels, implementation is difficult or impossible to carry out if there is no corresponding support within the body of clinicians who are to use the new models and systems. Clinicians usually have their preferred methods and clinical approaches when it comes to assessment and treatment. Such preferences should not be taken lightly when looking towards a new, common approach. It is necessary to strike a respectful balance if one is to gather support for new procedures in the clinical community. Sometimes a workable solution, in a transitional phase, is to accept the use of earlier and new instruments at the same time. New and overarching guidelines will, in any case, establish themselves over time in a natural way when the implementation process has generally been good. Requirements for knowledge and competence Because the Subjectivity Model to a large extent builds on phenomenology, a scientific discipline which still is not widely known and applied within mental health, the requirement of having basic knowledge is a decisive point in its implementation. The main theoretical sections of this book (Chapters 1–9), supplemented by some of its most central references, will provide an adequate theoretical knowledge background. The disposition of chapters provides concrete indications of what should be covered, and what thematic progression is appropriate with a view to training. In some European countries, phenomenology is a natural part of the knowledge base for psychiatry, psychology, and mental health in general. This discipline is now gaining ground in health-related and psychological/psychiatric research in increasingly more countries. Certification in the use of EASE Certification procedures are established for the qualified use of the EASE instrument, to meet minimum standards for a common knowledge and experience base ensuring good practice. On the web pages www.easenet.dk is an overview of certification criteria, and approved EASE instructors and EASE raters. Briefly, 193

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approved EASE instructors are the authors of the EASE manual and their closest co-operators, who are well-trained in both clinical and research uses of the instrument. To be approved as an EASE rater, it is required either to be able to use the instrument properly and responsibly in the clinic (usually together with skilled co-workers), or that one can carry out independent research with the EASE. To be approved for research purposes, three demands must be met: (1) completion of an introductory course over at least two days (arranged most years in Copenhagen, the courses are advertised on the aforementioned website), (2) completion of an advanced course, or its equivalent, that is, course material and training with approved instructors (being able to carry out one’s own interviews), and (3) training in reliability with approved instructors. The first two demands should be met before using the instrument in the clinic. For non-certified clinical use of the EASE manual, the instrument must be used and interpreted in the context of supervision, in collaboration with experienced specialists in the field of psychosis. The clinician’s workplace should in all cases arrange teaching and training in advance, which is the general norm before new clinical instruments are employed. It must be emphasised that EASE is not a diagnostic instrument, but rather an aid to an in-depth assessment, and rich clinical descriptions of risk phenomena. Shared databases At clinical units where EASE is employed after systematic teaching and training, an electronic database should be established of a minimum common set of collected data, which will typically be ordinary, relevant measures of symptoms, functioning, and life quality, in addition to EASE ratings. In the first instance, this can be an internal ‘anonymous’ approved quality register. These can also later be used for limited research purposes, as the data should be non-identifiable regarding clients, using only anonymous data such as age and gender, in addition to clinical parameters. Quality registers are usually regarded as internal evaluations of ongoing health service activities. Approval by committees for medical and health research ethics will then not be necessary, but all registers should be approved by the relevant authority for general data and person protection in the institution in question. When one has established a quality register that functions well, it is usually possible to convert this to a standard research database later, upon required application.

References Akerlof, G., & Michaillat, P. (2017). Beetles: Biased promotions and persistence of false belief (No. w23523). Cambridge: National Bureau of Economic Research. (A working note, www.pascalmichaillat.org) Box, G.E.P. (1976). Science and statistics. Journal of the American Statistical Association, 71(356), 791–799.

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Henriksen, M.G., Raballo, A., & Nordgaard, J. (2021). Self-disorders and psychopathology: A systematic review. The Lancet Psychiatry, 8(11), 1001–1012. Hustvedt, S. (2017). Tvetydighetssonen (The ambiguity zone. We must know what we do not know. This also applies to therapists). Journal of the Norwegian Psychological Association, 55(4), 370–375. Nelson, B., Sass, L.A.,  & Parnas, J. (2016). Basic self-disturbance in the schizophrenia spectrum: A review and future directions. The Self in Understanding and Treating Psychological Disorders, 158. Nordgaard, J., Henriksen, M.G., Jansson, L., Handest, P., Møller, P., Rasmussen, A.R., . . . & Parnas, J. (2021). Disordered selfhood in schizophrenia and the examination of anomalous self-experience: Accumulated evidence and experience. Psychopathology,  54(6), 275–281. Sass, L. (2022). Subjectivity, psychosis and the science of psychiatry. World Psychiatry, 21(2), 165–166.

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APPENDIX

Screen Questionnaire for EASE – six items (SQuEASE-6) A preliminary (under testing) screening tool for basic self-disturbances, for individuals at suspected increased risk for psychosis. The item selection is based on overlapping frequency findings in six empirical studies (Møller & Husby, 2000; Haug et al., 2012; Nelson et al., 2012; Koren et al., 2013; Nordgaard et al., 2017; Værnes et al., 2018) © Paul Møller, 2014–2018 1.  Strongly exaggerated rumination Last Occasionally (or often) I ruminate so much that I am   month: hardly able to do other things. It is almost impossible to YES NO stop it and I can become entirely stuck. I may ruminate like Earlier:   this about anything; myself as a person, things that have YES NO happened, or something in the world around me. An example: The rumination takes over completely and decides everything. If YES last month, how distressful is it?  Not distressful  A bit distressful  Quite distressful  Very distressful

2.  Strong feeling of unreality or alienation Last month: Occasionally (or often) I feel very strange, alienated,   unreal or somehow artificial, almost as if in a movie. YES NO This strange feeling can also apply to my thoughts or to Earlier:   the world around me. It can seem like what I experience YES NO or think does not belong to me, or does not apply to me. An example: I loose myself entirely, I don’t understand who I am anymore. If YES last month, how distressful is it?  Not distressful  A bit distressful  Quite distressful  Very distressful

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3.  Examine oneself intensely in the mirror Occasionally (or often) I have an intense urge to study myself thoroughly in the mirror, to see if something has changed in my face or body, or because I become unsure about whether I do exist at all. If YES last month, how distressful is it?  Not distressful  A bit distressful

Last month: Earlier:

 Quite distressful

 YES  YES

 NO  NO

 Very distressful

4.  Extremely preoccupied with new interests or themes Last month: At some point of time my interests very clearly   have changed. I have become extremely busy with YES NO new themes, for example, religious, philosophical, Earlier:   existential, psychological, or supernatural themes. YES NO An example: Thoughts about supernatural things took over my entire life. If YES last month, how distressful is it?  Not distressful  A bit distressful  Quite distressful  Very distressful 5.  Audible or loud thoughts (“sound on thoughts”) Occasionally (or often) my thoughts have become so loud as if I can hear them, like they have got sound on them (acquired acoustic quality). NB. Does not apply to reading a text

Last month: Earlier:

If YES last month, how distressful is it?  Not distressful  A bit distressful  Quite distressful

 YES  YES

 NO  NO

 Very distressful

6.  Hidden messages to me Occasionally (or often) it is as if there are hidden Last month:   messages or particular announcements to me YES NO personally, through the social media, smartphone, Earlier:   radio, TV, newspapers or through the way things YES NO around me are placed and arranged. If YES last month, how distressful is it?  Not distressful  A bit distressful  Quite distressful  Very distressful Functional consequences Finally, think about the YES-answers you have given above, for the last month (if any). Do you feel, all together, that the experiences you have confirmed make it difficult for you to function well, when it comes to school, friends and leisure activities?  Not difficult  A bit difficult  Quite difficult  Very difficult

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The questions partly cover these 11 EASE-items: Q1: 1.6; 2.6. Q2: 1.2; 2.1; 2.2; 2.5; 5.5. Q3: 3.2. Q4: 5.7. Q5: 1.7. Q6: 5.1 The instrument may be applied as a self-rating tool, but preferably as part of an interview. There is no cut-off. Any clear and confirmed positive finding should lead to a more thorough assessment, at best a full interview with the EASE manual. Findings should always be discussed in a specialist team, together with experienced clinicians.

References Haug, E., Lien, L., Raballo, A., Bratlien, U., Øie, M., Andreassen, O.A., . . . & Møller, P. (2012). Selective aggregation of self-disorders in first-treatment DSM-IV schizophrenia spectrum disorders. The Journal of Nervous and Mental Disease, 200(7), 632–636. Koren, D., Reznik, N., Adres, M., Scheyer, R., Apter, A., Steinberg, T., & Parnas, J. (2013). Disturbances of basic self and prodromal symptoms among non-psychotic help-seeking adolescents. Psychological Medicine, 43(7), 1365–1376. Møller, P., & Husby, R. (2000). The initial prodrome in schizophrenia: Searching for naturalistic core dimensions of experience and behavior. Schizophrenia Bulletin, 26(1), 217–232. Nelson, B., Thompson, A., & Yung, A.R. (2012). Basic self-disturbance predicts psychosis onset in the ultra-high risk for psychosis “prodromal” population. Schizophrenia Bulletin, 38(6), 1277–1287. Nordgaard, J., Handest, P., Vollmer-Larsen, A., Sæbye, D., Pedersen, J.T., & Parnas, J. (2017). Temporal persistence of anomalous self-experience: A 5 years follow-up. Schizophrenia Research, 179, 36–40. Værnes, T.G., Røssberg, J.I., & Møller, P. (2018). Anomalous self-experiences: Markers of schizophrenia vulnerability or symptoms of depersonalization disorder? A phenomenological investigation of two cases. Psychopathology, 51, 198–209.

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INDEX Indexer: Dr Laurence Errington.

Acceptance and Commitment Therapy (ACT) 117 acute phase (of psychosis) 165–6; medication 111, 166; see also development of psychosis administrative management and officers 164, 193 adolescents see children and adolescents/ youths Akerlof, George (Professor of economics) 190 alienation 28, 32, 77, 79, 99, 143, 159, 166; destructive 51 alive and vital, feeling 72 ambivalence 90, 189–90 ambulatory treatment 109, 176, 190 amodal perception 152 anchoring: healthy mental functioning 26; to individual/personal core 130, 145, 175 Anglo-American (US and UK) scientific tradition 57, 162; prodromal phase concept 40, 43, 44, 48, 49, 50 anomalous self-experience see basic self-disturbance antipsychotics see medication Antonovsky, Aaron 25, 145–6 apocalypsis 42 apophany 42 art, the self in 78–80 ‘as if’ experiences/phenomena 33, 84, 179, 180, 185 at-risk mental states and phenomena 2, 4, 12, 39, 88–9, 113, 157, 170 atmosphere 136–7 attention: clinician’s 137; directed to self-disturbances 159–60 attenuated delusional ideas or perceptions 42

attenuated positive symptoms syndrome (APSS) 48, 49, 50 attenuated psychosis syndrome 88 attribution 102; of meaning 31–2, 177; in seven-step treatment module 182–3, 184; see also re-attribution audible thoughts 197 Australia (Melbourne): STEP UHR intervention study 104, 192 awareness of self see self-awareness basic self-disturbance/BSD (anomalous self-experience/ASE; self-disorder/SD) 1, 2, 7, 18, 76–87, 90, 106–8, 156–73; approaches and settings in treatment directed at 156–73; clinical availability 141–4; clinical work building understanding and alliance 110–11; entire individual sum of 91; preliminary screening tool 196–8; Subjectivity Model and 192 basic symptoms (concept) 40, 44, 49, 51, 52 behaviour 57–8; experiences preceding 16–17; motor, disorganised/abnormal 17; prodromal 42; in seven-step treatment module 178, 185–6; see also cognitive behavioural therapy beliefs (false/impossible/irrational) 41, 43, 102; seven-step treatment module and 177 Binswanger, Ludwig 121 bipolar disorders 3, 11, 41, 162 BIPS (brief intermittent psychotic symptoms syndrome) 49, 50 Blankeburg, Wolfgang 24, 51 Bleuler, Paul Eugen 1, 6, 8 body: experience 65–6, 69, 99–100; mind and, intertwining and 65–6, 67, 69

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Bonn Scale for the Assessment of Basic Symptoms (BSABS) 51 Box, George 29–30, 187, 189 brain (and neurobiology) 18, 96, 122–3, 135, 152; nerve cells 18, 23; see also neurocognitive perspective brief intermittent psychotic symptoms syndrome (BIPS) 49, 50 BSABS (Bonn Scale for the Assessment of Basic Symptoms) 51 CAARMS (Comprehensive Assessment of At Risk Mental States) 49, 50, 90 CBT (cognitive behavioural therapy) 117, 129, 169 certification in the use of EASE 193–4 children and adolescents/youths 112–13; ‘central conversation’ with a boy xiv-xv, 145, 166–9; prodromal phase 52; Schizophrenia Proneness Instrument for (SPI-CY) 52; schizophrenia spectrum disorders 4; treatment 112–13, 166–9 chronological life-span diagram (CLD) 191 client (service user/patient): essential involvement in treatment 108, 170; quotations see quotations; talking with see talking; therapist relationship with see therapeutic alliance; as under-utilised source of knowledge 60 clinical experiences, 7-step treatment module building on 174–5 clinical high-risk (CHR) 2, 39, 192 clinical leadership 192–3 clinical practice/work 59, 110–11; phenomenology in 14–15 clinical research see research clinicians: attention 137; role in implementation of Subjectivity Model 193; talking with client see talking coercion (treatment), reduced 171 cognition: in EASE manual 96–7; social 118 cognitive behavioural therapy (CBT) 117, 129, 169 Cognitive Disorders (COGDIS) (in BSABS) 51, 52 Cognitive Perceptual Basic Symptoms (COPER) (in BSABS) 51, 52 cognitive perspectives 117; see also neuromotor functions, disorder Cohen’s kappa 92

coherence (sense of) (Antonovsky) 25, 69–70, 129; inner/internal 8, 25, 145–6, 175 comforting 151, 153, 154, 162, 163 common ground/commonality and building understanding 110, 128, 146 common sense 51, 72, 82, 108, 143, 160 communication see talking competence in implementing Subjectivity Model 193 Comprehensive Assessment of At Risk Mental States (CAARMS) 49, 50, 90 consciousness 24–5, 32–3, 65; identity and levels of 82–5; meaning 24–5, 31–2, 32–3; new clinical phenomena and research 39–40; stream of 15, 96–7, 99; subjectivity and 38–9, 69, 83 consistency, internal, EASE manual 92 containing 41, 109, 120, 150, 153 continental psychiatry see European psychiatry conversation see talking COPER (Cognitive Perceptual Basic Symptoms) (in BSABS) 51, 52 coping in relationships 24–7 core (personal): anchoring to 130, 145, 175; feeling of having/not having a 69–70 core experiences 18, 37–8, 41, 183 core phenotype 127, 128 core self (minimal/experiential self) 73, 80, 81, 83, 91 correlation, interrater, EASE manual 92 countertransference 119, 120 crisis management (case example) 167 Cronbach’s alpha 92 da Vinci, Leonardo 23 daily functioning see functioning day (outpatient) treatment 156, 165 delusions 17 see attenuated delusional ideas demarcation in EASE manual 100–1 development of psychosis: stages in early development 26–7; three-phase model (Conrad’s) 42; see also acute phase diagnosis and diagnostics 88–93, 191; adolescents, cautions 113; diagnostic criteria 1, 16–17, 57, 59, 191; historical perspectives 6–9; risk and 88–93; see also DSM; ICD dialogue see talking directionality 16

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disintegration 8; bodily 99; of meaning 51 dopamine hypothesis 122–3 drugs: misuse/dependency 123; therapeutic see medication DSM: DSM-III 56, 57; DSM-IIIR 39; DSM-IV 39, 42; DSM-IV-TR 11, 19, 58; DSM-5 1, 2, 9, 17, 88 early interventions and treatment 108, 109 EASE (Examination of Anomalous Self-Experience) 2, 4, 91–2, 95–105, 190–1, 192, 194; certification in the use of 193–4; five phenomenological domains 95–105; pragmatic approach to the use 103–4; psychometric properties 4, 92; Screen Questionnaire for see SQuEASE ego psychology 119–20 embodiment 66, 69 emotions, sciences of 118 empathy 4, 150, 153 endophenotypes 142 energising effects of activating the self 151–2 European (continental) psychiatry 42, 56, 121, 141, 153, 193; philosophy and 14; prodromal phase 40, 44, 48–9, 50–2 Examination of Anomalous Self-Experience see EASE existence (and existentialism) 37–46, 69, 77, 101–3, 121, 144; client quotations 69–73, 103; in EASE manual 101–3; philosophy 57, 77, 121, 151; six fundamental existential functions in consciousness 69; subjectivity and 38–9 experience(s) 16–19; behaviour preceded by 16–17; bodily 65–6, 69, 99–100; clinical, building on 174–5; core 18, 37–8, 41, 183; life 15; of oneself (self-experience) 29, 31, 32, 56, 66, 67, 81, 102, 112, 120, 121, 149, 181, 182, 183, 184; owning one’s (feeling of) 71; prodromal 42, 43, 143; recognised as one’s own 145, 175; science and 17–18, 17–19, 56, 60; talking/ conversations/dialogue and 133, 134, 135–9, 142, 146–7; therapy and 19, 145, 146–7, 175–88; understanding of see understanding experiential phenomena 1, 2, 10, 30, 41, 110, 178, 186–7

experiential self (minimal/core self) 73, 80, 81, 83, 91 explanation and understanding (differences between two concepts) 10–11 factor analysis, EASE manual 92 family interventions 188; psychoeducational 26, 109, 112, 112–13, 160–3, 164, 165, 190 flexible practice in seven-step treatment module 176 formal thought, disturbance of 117 Freud, Sigmund 119 friends 164 Fröding, Gustav 78–80 functioning (daily) 90, 166; in seven-step treatment module 178, 181, 185–6; SQuEASE-6 197 genetic risk and deterioration syndrome (GRDS) 49, 50 genotypes 142 GRDS (genetic risk and deterioration syndrome) 49, 50 Gross, Gisela 51 hallucinations 17 Hawking, Stephen 23 health professionals and authorities, changing views on treatment 106–7 Hellberg, Mauritz 79 hidden messages to me (self-reference) 197 high-risk: clinical (CHR) 2, 39, 192; ultra see ultra high-risk historical perspectives in schizophrenia diagnosis of 6–9 home working 181; see also living environment ‘how’ versus ‘why’ questions 138 Huber, Gerd 51 human being, existentialism and what it is to be a 77 Husserl, Edmund 14, 15, 19, 24, 67 Hustvedt, Siri (American novelist) 189–90 hyper-aggregation (of self disorders) 2, 3 hypo-psychosis 39 ICD (International Classification of Diseases) 1, 8–9, 58, 191; ICD-9 56; ICD-10 12, 58, 59, 89; ICD-11 1 identity (sense of) 32, 82–5, 147, 175–80; conscious and unconscious levels and

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82–5; disturbed/compromised 67–8, 84, 122; treatment involving 144, 149–50, 175–80 identity diffusion (concept) 119 incipient psychosis phenomena, instability and changeability 143–4 individuality, disturbed 58, 59 inner/internal coherence 8, 25, 145–6, 175 inner/internal language 134 inner/internal phenomena 27–8, 128 inner/internal scripts 182, 185 inner/internal world 24, 179 inpatient (incl. confined and secure unit) clinics 165, 190; milieu therapy in 165–6 insanity, historical use of term 7 insecurities (and feeling unsafe) 179–80; pervasive and harrowing 130 insight (self-insight) 43, 143, 148, 159, 180, 185, 187 instinct (basic human), understanding as 23–4 integration, failure of 152; see also disintegration intentionality 8, 15, 24, 67 intermodal perceptual integration 152 internal . . . see inner . . . International Classification of Diseases see ICD interpersonal relationships see relationships intersubjective issues (sharing and communication) and impact 107, 109, 146–7, 148–9, 159; in seven-step treatment module 175 intrasubjective issues and impact 147, 148 Ipseity Disturbance Model see Subjectivity Model isolation, comforting a unique sense of 153 Jaspers, Karl 51, 61, 150, 153 Kierkegaard, Søren 37–8, 43, 77, 147, 181 Klein, Melanie 119 Knausgård, Karl Ove 23 knowledge: about the mind, main source of 12; client as under-utilised source of 60; requirements (for implementing Subjectivity Model) 193; sharing see sharing; see also understanding Kraepelin, Emil 8, 11

Lancet, systematic review of empirical studies 3 language 28, 133–4, 135; inner 134 leadership, clinical 192–3 Leonardo da Vinci 23 Lier Psychiatric Hospital 190 life, being the centre of one’s 152 life experience 15 life-story see self-narrative listening 12–13 living environment: milieu therapy and 165; psychoeducational family interventions and 160; see also home working loneliness 79, 153, 162 meaning 24–7, 31–2; attribution of 31–2, 177; consciousness and 24–5, 31–2, 32–3; in conversation, subjective understanding 138; disintegration of 51; finding 10, 15, 25; personal 145–6, 175, 177, 178, 182; relationships and 24–7; self-understanding and 31–2; in seven-step treatment module 175, 177, 178, 182–3, 184, 184–5, 187 medication (antipsychotics) 110–11, 166–70; in acute phase 111, 166; clinical case 166–70; restraint in use 170; talking therapy versus 169–70 Melbourne (Australia), STEP UHR intervention study 104, 192 mental functioning, healthy, anchoring points 26 mental health (psychiatric health) services 110; client as under-utilised source of knowledge in 60; engagement with 128; milieu therapy and psychosocial support in 164 mental health disorders (psychiatric illness): psychoeducational family interventions 162; treatment ‘packages’ 157; words and language as therapeutic tools 133–4 mental life 71–2, 90; therapeutic effects on 147 mental phenomena and diagnostic definitions 89 mental scripts (inner/internal scripts) 182, 185 mental states: at-risk phenomena and 2, 4, 12, 39, 88–9, 113, 157, 170; in EASE manual 96, 98, 100

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Merleau-Ponty, Maurice 97 Meta-Cognitive Therapy (MCT) 117 milieu therapy 164–6 mind 12, 15–16, 17–19, 65–6; body and, intertwining of 65–6, 67, 69; learning about see psychoeducation; main source of knowledge about 12; object and 15; science and 17–19 minimal (core) self 73, 80, 81, 83, 91 Minkowski, Eugene 24, 51, 121 mirror, examining oneself intensely in 197 mirroring a sense of self 149–50 models (of understanding) 28–33, 114–25; ‘all models are wrong but some are useful’ 29–30, 189; opposition to implementing new models 189–90 momentary nature of sense of self 81 motor behaviour, disorganised/abnormal 17; see also neuromotor functions; sensory-motor feedback response multi-disciplinary ambivalence 189–90 multi-disciplinary approach 170–1 Munch, Edvard 78 narrative see self-narrative naturalistic core dimensions of initial prodromal experience and behaviour 42 need (universal human), understanding as a 23–4 negative symptoms 3, 17, 49, 59 nerve cells (brain) 18, 23 networks/networking 164, 165 neurobiology see brain neurocognitive perspective 117–18 neuromotor functions, disorder 117–18 neuropsychological examinations 118 normality, schizophrenia and subjectivity disturbances shedding light on 65 Norway 43, 104, 157; Lier Psychiatric Hospital 190 object (and objectivity) 56, 58; mind and 15 obvious, understanding/not understanding the 51, 72–3 oneself see self onset of psychosis 43–4, 169, 169 open-ended questions 40, 139 opening setting 136 opening talks 139 operationalisation and operationalism 17, 56, 57–8; prodromal phase 49, 51

others: acknowledgement from 150; empathy from 4, 150, 153; weakened boundaries to 101–3 ourselves see self outpatient (day) treatment 156, 165 Parnas’ (Josef) research group, author’s collaboration with 43 patient see client peer-support, family-based 160 perceptions: amodal 152; attenuated delusional 42; integration 152 personal core see core personal meaning 145–6, 175, 177, 178, 182 pharmacological treatment see medication phenomena 7–8; ‘as if’ 33, 84, 179, 180, 185; at-risk (and at-risk mental states) 2, 4, 12, 39, 88–9, 113, 157, 170; core 6, 9, 32, 41, 127; in EASE 95–105; experienced (experiential phenomena) 1, 2, 10, 30, 41, 110, 178, 186–7; incipient, instability and changeability 143–4; inner/internal 27–8, 128; mental, diagnostic definitions and 89; overlapping 136–7; prodromal 37–46; in seven-step treatment module 175–88 phenomenology 6–7, 13, 14–15, 57, 134–9; in clinical research and practice 14; EASE five phenomenological domains 95–105; feeling of presence in 70; self in 80–2, 120 phenotypes 141, 142–3; core 127, 128 philosophy 13, 14, 24, 57, 61; existential 57, 77, 121, 151 polyvalence 96 positive symptoms 49, 56; attenuated positive symptoms syndrome (APSS) 48, 49 pre-reflexive/prereflective level 65, 66, 80, 81, 83–4, 147 presence (and feeling/not feeling present) 70–1, 81, 97–9 prevention 161, 163, 168, 169–70; of further negative developments 151, 163, 166; prodromal phenomena and 49–50 problem solving 163 prodrome/prodromal phase 37–54, 84, 157; author’s studies 41–3, 134; concept (incl. conceptual difficulties) 39, 44; foundation stone 38–9; initial 10, 41–3, 44, 157, 168; problems of defining 48–54

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psychiatric health see mental health psychoanalytic perspectives and therapy 118–21 psychodynamic perspectives and therapy 118–21, 129 psychoeducation (and learning about the mind): family interventions 26, 109, 112, 112–13, 160–3, 164, 165, 190; in sevenstep treatment module 177, 181, 182 psychometric instrument(s) 139; EASE as 4, 92; short versions 104 psychopathology 2, 3, 12, 13, 41–2, 48, 57, 104; subjective 51, 57, 69 psychopharmacological treatment see medication psychosis and psychotic disorders (basics): acute phase see acute phase; development see development; diagnosis see diagnosis; onset 43–4, 169, 169; prodromal phase see prodrome; psychopathology see psychopathology; relapse risk/vulnerability 157, 169, 186; schizophrenia versus 11; from self-disturbance to 33; treatment see treatment; understanding of 27–8; use of the terms 1–5 psychosocial support 164–6 psychotherapy (talk therapies) 112, 114–26, 129–31, 144–7, 157–9; individualised 157–9; medication versus 169–70; therapeutic preconditions 130, 141, 144–7, 163, 175 qualitative studies/methods/research 13, 40, 42, 44; combined quantitative and 91 quantitative studies/methods/research 13, 40; combined qualitative and 91 quotations (from client and others) 137–8; cognition 97; EASE manual 95, 96, 97, 98–9, 100, 101, 103; existential functions 69–73, 103; feeling like oneself (or not feeling) 85; feeling of presence or not being present 70–1, 98–9; other individual’s, use 137; self-awareness 98–9; stream of consciousness 97; weakened boundaries to others and to the world 101–3 reality (sense of) 109, 179; loss of (unreality) 28, 32, 51, 77, 134, 143, 159, 167, 168, 196 re-attribution 178

reductionistic review 115–16 reflexive level 66, 83 re-labelling 60 relapse, risk of/vulnerability for 157, 169, 186 relationships (interpersonal) 148; breakdown 25–7; social see social relationships; therapeutic see therapeutic alliance reliability (instrument measurements) 18, 58, 92; EASE manual 194; interrater 92 training 94 reorientation, existential 101–3 research (clinical) 39–43, 59, 60–1; author’s 41–3, 134; doing things once again in 60–1; EASE manual and 194; on the mind 16; phenomenology in 14; prodromal phase 39–43, 44; qualitative and quantitative see qualitative studies; quantitative studies; searching once again (re-search) in 60–1; see also science respect (concept of) 60 re-thinking 60 rumination, strongly exaggerated 186 safety: conversation in safe setting 136; need for 23, 183; see also insecurities Scale for the Assessment of Prodromal Symptoms (SOPS) and SIPS/SOPS 2–3, 48, 49, 50, 90 schizophrenia (basic references): historical perspectives 6–9; lack of comprehensive model to understand 9–10; psychosis versus 11; shedding light on normality 65; subjectivity disturbances and 65; use of the term 1–5, 6 Schizophrenia Proneness Instrument (SPI): adults (SPI-A) 51; for children and youths/adolescents (SPI-CY) 52 schizophrenia spectrum disorders (SSDs) 2, 3, 11; childhood and adolescence and 4; subjectivity in 68 schizotypal disorder 2, 3, 7, 12, 89 science(s) 14, 56–62; culture in 58–9; of emotions 118; experience and 17–19, 56, 60; mind and 17–19; see also research Screen Questionnaire for EASE see SQuEASE scripts, inner 182, 185 ‘sealing over’ 108

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INDEX

self (oneself/ourselves) 6, 32, 76–86, 181–2; activating the, and energising effects 151–2; art and the 78–80; becoming ourselves 76–7; concepts of 30, 37, 44, 73, 76, 80, 81, 85, 120, 181–2; disorder of see basic self-disturbance; experiential/ minimal/core 73, 80, 81, 83, 91; feeling like being oneself/ourselves 2, 65, 69, 82, 85, 149, 177, 181–2; losing the self/oneself 37–8, 84–5, 120, 150; minimal/core 73, 80, 81, 83, 91; mirroring sense of 149–50; momentary nature of sense of 81; in phenomenology 80–2, 121; in self psychology 120; sensing of 14, 31; in seven-step treatment module 177, 183–4; spontaneous non-thematic basic experience of 31; story of see self-narrative; strengthening and supporting a sense of 112, 149–50; subjectivity as basic element of 66 self-awareness 14, 31, 37, 44, 51, 59, 65, 77, 91, 97–9; concept and definition of 38, 41, 97 self-direction, disturbed 58, 59 self-experience (experience of oneself/ ourselves) 29, 31, 32, 56, 66, 67, 81, 102, 112, 120, 121, 149, 181, 182, 183, 184; see also EASE self-insight 43, 143, 148, 159, 180, 185, 187 self-narrative and life story 10, 78, 121, 191; obstacles to 179–80 self psychology 37, 78, 81, 120–1 self-understanding 31–2, 54, 118, 131, 164; as conscious and deliberate attribution of meaning 31–2; disturbed/ altered/alternative/inappropriate 32–3, 67, 102; in seven-step treatment model 178, 182, 184, 186–7 sensory-motor feedback response 152 service user as under-utilised source of knowledge 60 settings: safe and opening 136; in seven-step treatment module 176 shame, reducing feelings of 154 sharing (databases) 194 sharing (of knowledge and understanding) 129; experiences 146–7; in family interventions 160–3; in seven-step treatment module 177, 180–1

SIPS and SIPS/SOPS 48, 49, 50, 90 social cognition theory 118 social relationships/contacts (and isolation/ withdrawal) 179; comforting a unique sense of isolation 153 SOPS and SIPS/SOPS 2–3, 48, 49, 50, 90 “sound on thoughts” 197 Spearman’s rho 92 SPI see Schizophrenia Proneness Instrument SQuEASER (Screen Questionnaire for EASE): SQuEASE-6 91, 104–5, 196–8; SQuEASE-11 104, 192 STEP UHR intervention study (Melbourne, Australia) 104, 192 stigma 11 story of self see self-narrative stream of consciousness 15, 96–7, 99 stress-vulnerability model 116–17, 123 Structured Interview of Psychosis-risk Syndromes (SIPS) and SIPS/SOPS 2–3, 48, 49, 50, 90 subjectivity 28–9, 99, 120, 146–7, 159; compromised, affecting sense of identity 67–8; concept of 29, 40, 61, 66, 73, 117, 182, 183; consciousness and 38–9, 69, 83; definition 64; existence and 38–9; intact 38, 65, 67, 72, 98, 149, 151; normality and disturbances in 65; phenomenology and 15; prototypical 68, 91; source of 67; subjective psychopathology 51, 57, 69; therapy and 144, 150, 153, 177, 183–4; trivialisation of subjective aspects 59–60; weakened 144, 145, 146–7, 183, 184; see also intersubjective issues; intrasubjective issues Subjectivity Model (Ipseity Disturbance Model) 3–4, 12, 28–33, 40, 60, 83, 114, 115–16, 163, 174, 188, 189–95, 190; aspects of 30–3; clinical testing 190–1; current status 191–2; implementing and establishing 189–95 substance (drug) use 123 sympathy 150, 186 symptoms: basic (concept) 40, 44, 49, 51, 52; negative 3, 17, 49, 59; positive see positive symptoms; relief with antipsychotics 111 systematic reviews 192; of empirical studies (Lancet) 3

205

INDEX

talking (communication/conversation/ dialogue) 134–9, 141–2, 146–7; avoidance with difficult feelings 180; ‘central conversation’ with a boy xiv-xv, 145, 166–9; medication versus 169–70; phenomenology and 134–9; previous (pre-2000) discouragement of talking about experiences 108–9; in psychoeducational family interventions 163; supporting the dialogue 150 talking therapy see psychotherapy target group in seven-step treatment module 176, 178–9 teachers (for clients) 164 teaching and training, seven-step treatment module 192–4 therapeutic alliance/relationship 4, 43, 110, 110–11, 148, 159; approaches and settings at 156–73; many/wider contexts 106–7, 127–31; new directions 107–8 therapy see medication; psychotherapy; treatment thinking, disorganised 17 thoughts (inner language) 134; audible/ loud 197; formal, disturbance of 117 three-phase model of psychosis development (Conrad’s) 42 training, seven-step treatment module 192–4 transcendalised (use of word by Mauritz Hellberg) 79 transference 118, 119 transforming 151, 154, 163 transitivism in EASE manual 100–1 trauma (traumatic experiences) 122, 145, 158–9, 162, 186 treatment/therapy 106–31, 141–88; changing views of professionals and health authorities on treatment 106–7; coercion, reduced 171; contexts 106–7; experiences in 19, 145, 175–88; general impact 147–9; ‘packages’ (in mental health) 157; pervasive principles 170–1; pragmatic approach (using seven-step treatment module) 174–88; preconditions 130, 141, 144–7, 163, 175; primary effects 151–5; psychosis-specific 149–50; words and language as tools 133–4; see also clinical practice/work; medication; psychotherapy trema: in Conrad’s three-phase model 42

UK see Anglo-American scientific tradition ultra high-risk (UHR) 39, 49, 90, 170; STEP study (Melbourne, Australia) 104, 192 unconscious and identity 82–5 understanding 4, 23–35, 110–11, 151, 153, 163; alternative/new (in seven-step treatment module) 177, 183–4, 187; building 110–11; common 110, 128, 146; deep-seated desire to understand 13; empathy and 153; explanation and (differences between two concepts) 10–11; lack of comprehensive model to understand schizophrenia 9–10; models see models; the obvious 51, 72–3; onset phase in understanding of disorders 43–4; of psychosis 27–8; of self see self-understanding; shared see sharing; see also knowledge uniqueness (feeling like unique individuals) 29, 64; disturbed 58, 59 United Kingdom see Anglo-American scientific tradition United States see Anglo-American scientific tradition unreality 28, 32, 51, 77, 134, 143, 159, 167, 168, 196 US see Anglo-American scientific tradition validity (instrument measurements) 18, 58, 60 vitality: feeling vital 72; re-establishing elements of a vital dialogue 150 vulnerability: for relapse 157, 169, 186; stress and (model) 116–17, 123 warning phenomenon, self-disturbance as 127–8 wholeness (feeling whole) 69–70, 105, 127, 149, 152; seeking 129; weakened 146 ‘why’ versus ‘how’ questions 138 words 28, 133–4, 179 world: internal/inner 24, 179; weakened boundaries to the 101–3 writing (as part of treatment); in seven-step treatment module 180 youths see children and adolescents/youths

206