Subjectivity, psychosis and the science of psychiatry
Authors: Louis Sass
Journal: World Psychiatry (2022)

The significance for psychiatry of a patient's subjective or "lived" experience seems obvious even on casual reflection, especially in cases of severe mental illness. It is likely that curiosity and concern about what a patient is experiencing is a prerequisite for building trust or a therapeutic alliance, particularly when the experiences seem highly unsettling and unusual. Few would deny that grasping something of the patient's viewpoint should play a role both in developing and selecting therapeutic techniques. Beyond this, it seems likely that some understanding of patients' subjective life is relevant to psychopathology as a scientific enterprise. The explanandum at issue in what we term "delusion", "hallucination" or "thought disorder" may, for instance, be found to involve quite different experiences across different individuals, diagnoses or subgroups, and such knowledge can improve the pathogenetic modelling of mental disorders. It is possible, in fact, that the lackluster results of neurobiological research on severe mental illness in recent decades (widely acknowledged) be in part due to neglect of this subjective dimension and the distinctions it would allow. Given all this, it is striking to note how limited the study of patients' experiences has been in the mainstream of psychiatry and clinical psychology. One may wonder why. An obvious reason is the influence of exclusionary and reductive forms of empiricism and materialism, which have stressed the difficulty both of observing subjective life and of incorporating it into the causal order of the universe. Subjectivity can indeed seem what phenomenological philosopher M. Merleau-Ponty termed "the flaw in the great diamond of the world"1 – a recalcitrant explanatory outlier, albeit one that is lodged at the center of each one of us (our consciousness) and is the condition for whatever knowledge we possess. A second reason is a widespread discomfort with and incomprehension of the states of mind that characterize severe forms of mental or emotional disorder, especially psychoses. Though many scientists and scholars are fascinated by the limit-experiences that can occur in psychotic conditions, many are ready to accept what are, in scientific terms, extremely vague and potentially misleading characterizations, often involving defect and deficit assumptions that do little more than register the absence of a norm (e.g., "inappropriate affect", "false belief"). Deficit models are often criticized on ethical grounds as being condescending or even insulting to the patient's dignity, but their modes of objectification may also be scientifically inadequate, since they fail to register what may be qualitatively distinct about the condition being studied2. Conventional approaches also tend to downplay the agentic role of the patient – i.e., the subtle ways in which a patient's orientation or attitude, partly under his/her control, can impact the nature of delusions, hallucinations or "thought disorder"3. The study by Fusar-Poli and numerous co-authors publish­ed in this issue of the journal4 is an exceptionally important contribution. There have been previous attempts, especially by phenomenologists and qualitative researchers, to collaborate intensively with patients whose experiences they study, but never on such a broad-based, quantitative scale. As the authors note, their results are in fact consistent with the rich phenomenological tradition which stemmed from K. Jaspers and the Heidelberg school and included, among the others, K. Schneider, K. Conrad, W. Blankenburg, E. Minkowski and the various contemporary experts cited in the paper. Phenomenological psychopathology did influence mainstream British psychiatry in the 1950s through a textbook by the German-Jewish émigré W. Mayer-Gross, and penetrated North American consciousness with the anthology Existence in 19585 and Laing's Divided Self of 1960; but then it languished for several decades prior to its more recent renaissance beginning in the 1990s. Fusar-Poli et al's study vindicates this most venerable approach to a rigorous understanding of mental life in psychiatric illness. The present study is mainly in the tradition of descriptive phenomenology, offering diverse accounts largely in the vocabulary of everyday language, eschewing attempts at explanatory synthesis5. Another type of phenomenology, more speculative and theoretical, does try to account for the heterogeneity of some subsets of symptoms by identifying a core or generating disorder, thereby providing models for pathogenetic research that can account for the variety and variability of certain psychotic conditions – e.g., "loss of vital contact"6 or altered "basic-self experience"7. There is much to be learned from Fusar-Poli et al's report, a su­perb compendium of all the major experiences characteristic of psychosis, and perhaps especially of the contested category of schizophrenia. Like earlier phenomenological work, their research shows that signs and symptoms can seem very different from within a mental condition compared to what common sense or standard psychiatry often claims. Hallucinated voices may not exactly be "heard". What we call "delusions" may or may not be taken literally and, rather than being "erroneous beliefs", may sometimes involve withdrawal into a private or subjective world that the pa­tient himself actually recognizes as such8. So-called "poverty of con­­tent of speech" – a type of "formal thought disorder" – may somet­imes contain profundities. Among the many insights to be gleaned is the prominence (at least for some patients some of the time) of the experience of insight and illumination. Confronted with "madness", the academic observer or man-on-the-street stresses metaphors of darkness, confusion, and subterranean journeys, and this sometimes accords with the patient's viewpoint. But, as Fusar-Poli et al4 report, patients may describe some "psychotic" states as shot through with a sense of almost blinding clarity and revelation. We must beware of projecting our own yearnings and value judgments onto the patients. They, at least, can sometimes feel not beneath, but far above the quotidian realities of "normal" people, who neglect more encompassing and foundational though ineffable truths – truths perhaps accessible only to forms of self-conscious or hyperreflexive awareness unavailable to most of us3. In closing, one must acknowledge some gaps in our grasp of subjectivity and its significance for psychiatry. It may be obvious to common sense that the exercise of free will, together with a person's experience of meaning or significance, do play a role in human behavior and thereby affect the material plane of brain functioning (if I choose to close my eyes, in prayer, patterns in visual cortex are altered). But it is also true that we have difficulty incorporating the domains of conscious life and its physical substrate within a single explanatory account (the mind/body problem). In particular, we have difficulty integrating "act" with "affliction" aspects of psychological existence3 – that is, appreciating the subtle but decisive ways in which defensive or other goal-directed forms of thought or behavior can interact with aspects of mental life over which the person has little or no control. Even more basic is the challenge of observing and describing consciousness itself, whose ever-changing, all-encompassing flow we, as human beings and language speakers, are constantly tempted to misperceive or misdescribe. We succumb to this temptation by using words that stress the substantive over the transitory aspects of experience, or by focusing on particular objects of awareness while ignoring subtle alterations in, for example, the experience of space, time, or the overall atmosphere of reality. In fact, no approach can be fully "bottom-up" in the sense of being purely empirical or a-theoretical: when it comes to describing experience, patients as well as professionals are burdened (though also blessed) with the objectifying prejudices of their language and their worldview. The study of "lived experience" may then be impossible as a foolproof, quasi-empiricist venture. It is, however, also indispensable – and to both the ethical and the scientific enterprise of psychiatry9.