FACULTY OF HUMANITIES

UN
       I V E R S I T Y O F C O P E N H A G E N
   
 
 
 
 
 

Author
Ulla Stensdal Larsen

Phenomenology
Schizophrenia and Gestalt-therapy  
Is gestalt-therapy a relevant  treatment for schizophrenia?
 

Master thesis in philosophy - Specialisation in “Phenomenology and Philosophy of Mind”

Academic advisor
Institut for Medier, Erkendelse og Formidling Mads Gram Henriksen
February 2014

Studie nr.: bpr622 - Mobil: 2621 1202 - E-mail: ulla@zyk.dk - Modul: 10 -

Monografispeciale - Studieordning: 2008 - Grenspecialisering: Teoretisk filosofi:
Phenomenology and Philosophy of Mind Antal tegn: 161.350 - Antal sider: 67
Abstract

By bringing topics of phenomenology, phenomenological psychiatry and gestalt-

therapy together, I wish to examine if there is any indication that gestalt-therapy might
be an adequate therapeutic method in relation to self-disorders like schizophrenia.

In the first chapter, I introduce the phenomenological conceptions of the “intentional

act” and “operative intentionality”, reflective and pre-reflective consciousness, “motor
intentionality” and “empathy”. Then I proceed to an investigation of the self that
involves the “minimal-self,” “act transcending self,” “embodied-self” and the
“personal-self.” I also investigate what kind of reflective access the subject has to itself.
Finally, I end the chapter by contrasting the “natural attitude” to the “phenomenological
attitude” that is attained by the “epoché”. In the second chapter, I expose the
phenomenological take on schizophrenia, according to which schizophrenia is a self-
disorder that contains two main features: a diminished sense of self and
“hyperreflexivity.” The self-disorder elicits an inadequately functioning of “operative
intentionality”, which means that the natural attitude is not fully executed. Therefore,
the bestowal of sense in relation to the self, others and the world is limited.
Hyperreflexivity may be an attempt to compensate for the diminished sense of self, and
it contains two components: an access of operative reflexivity and an access of
reflection. Hyperreflexivity creates a distorted sense of self, and it also turns attention
towards the inner mental states creating a solipsistic attitude. Following the exposition
of the self-disorder, I account for the main symptoms that are subtyped into the positive,
negative, basic and disorganisation syndromes. These symptoms relate back to the self-
disorder. I furthermore describe how the “solipsistic attitude” becomes an integrated
part of the self and that this might explain why many patients are reluctant to comply
with treatment. The third chapter on gestalt-therapy starts with a description of how the
neurotic character develops when society impinges to heavily upon the subject. This
elicits a fixation of defence mechanisms instigating a diminished self-awareness, which
refrains the person with neurosis somewhat from organizing meaningful gestalts. The
self is revealed in the way it is contacting the world. To accomplish contact the self
must be able to distinguish between self and other. Without this ability the self is in a
chronic state of confusion. I describe the defence mechanisms that instigate the
diminished self-awareness, which also entail muscular contractions. Following I attend
to the phenomenological method that founds the therapeutic encounter. Finally, I
describe some of the techniques and experiments used in the therapeutic encounter to
facilitate a re-experiencing process that enhance experiential self-awareness. In the
fourth chapter, I compare the approach of cognitive-behavioral therapy to that of
gestalt-therapy, because today in mainstream psychiatry cognitive-behavioral therapy is
the first choice of therapeutic treatment for schizophrenia. I argue that from the
perspective of gestalt-therapy the approach of cognitive-behavioral therapy might in
fact increase the distress of the patient with schizophrenia rather than weakening the
distress. I suggest the importance of a therapeutic approach that understands the self as
being both experiential and narrative. Finally, I suggest the importance of implementing
the phenomenological perspective on empathy and the phenomenological attitude into
gestalt-therapy to assist the therapeutic process.

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Contents

Introduction 3  
Aim 3  
Situating the project 3  
Methodology 3  
Constraints 3  
1. Chapter: Phenomenology 4  
Introduction to Phenomenology 4  
Intentionality 5  
Functioning Intentionality 6  
Motor Intentionality 7  
Empathy 8  
The Minimal-Self 11  
The Embodied-Self 13  
Time-consciousness 13  
The Act-transcendent Self 14  
Reflection and Pure Reflection 15  
The Personal-self 16  
The Phenomenological Attitude and the Epoché 17  
2. Chapter: Schizophrenia 18  
Introduction to Schizophrenia 18  
The Ipseity-disorder 19  
The Negative, Basic, Positive and Disorganisation Syndromes 22  
Negative and Basic Syndromes 22  
Positive Symptoms 25  
Disorganisation 26  
Coexistence of the Natural and the Solipsistic Attitude 27  
3. Chapter: Gestalt-therapy 31  
Introduction to Gestalt-therapy 31  
Neurosis and Self-awareness 32  
Contact and Contact Boundary 35  
Defence mechanisms 37  
Projection   37  
Retroflection   38  
Confluence   38  
The Body-armour 39  
The Phenomenological Method 39  
Practising Gestalt-therapy and Techniques 41  
4. Chapter: Discussion 47  
Introduction 47  
The Vitality of Recognising the Experiential-self 47  
Empathy and the Phenomenological Attitude 50  
Conclusion 53  
Bibliography 54  

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Introduction
Aim
The phenomenological movement founded by Edmund Husserl (1859-1938) has
contributed to the understanding of the structures of consciousness and of subjectivity
and intersubjectivity. From the phenomenological perspective, schizophrenia is
conceptualised as a specific disorder of the self; this idea dates back to Kraepelin (1856-
1926), Bleuler (1857-1930) and Jaspers (1883-1969) (Sass and Parnas, 2003). This idea
has been dormant, but it was revitalized within phenomenological psychiatry in the
works of Sass, Parnas, Fuchs, and others. The founder of the psychotherapeutic
movement of gestalt-therapy, Fritz Perls (1893-1970), also seems to have approached
psychotherapy from the phenomenological perspective. By bringing these three areas
(i.e., phenomenology, phenomenological psychiatry and gestalt-therapy) together, I
wish to examine if there is any indication that gestalt-therapy might be an adequate
therapeutic method in relation to self-disorders like schizophrenia.

Situating the project

This thesis exposes topics that are relevant within contemporary philosophy, psychiatry,
psychology and psychotherapy. The exposed phenomenological theories are important
to consider in the community’s responsibility to provide care or treatment to children
and people in need of special care. If these founding theories are not acknowledged, the
efforts to help the child or the mentally ill may to some extent be in vain.

Methodology
The phenomenological theories are founded on descriptions of subjectivity, but they are
also based on logical conclusions. Some of the theories and conclusions that I expose
are also based on empirical trails, but I do not value any data. The thesis is purely
theoretical in nature.

Constraints
One of the main conceptions that is exposed in this thesis argues that the experiential-
self founds the narrative-self, i.e., the self is not solely a rational accomplishment. This
conception could have been further emphasised by involving contemporary
developmental psychology, which clearly indicates that the infant is self-aware and
interacts with its caretakers. The chapter on gestalt-therapy argues that mental illness
not only resides in the mental apparatus, i.e., there is a functional identity between the
physical body and the mental. This could have been explained more detailed by
including the perspective of “bioenergetics” by Alexander Lowen (1988) and
contemporary body-therapy. In that context, it would also have been interesting to
examine the bodily features of schizophrenia. Even though the theory of perception
relating to figure and background formation is implicit in the topics of this thesis, I have
chosen not to give a thorough review here, because the theory of perception in both
phenomenology and gestalt-psychology (that founds gestalt-therapy) is very much in
alignment (there probably is disagreements, but they are not important in this context).
The description of gestalt-therapy mainly draws on Perls’ theories to stick to the roots
and is limited to the most fundamental themes in gestalt-therapy.
   

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1. Chapter: Phenomenology

Introduction to Phenomenology

The topics of phenomenology that are interesting to explore in an attempt to understand

the self are multiple. All these topics are intermingled, and it requires knowledge of
other topics to get the full grip of any topic. This makes it a difficult task to approach
phenomenology. Also the matter studied by phenomenology is new terrain to most
people, because the phenomenological findings tend to be in opposition to the general
paradigm of the western world, i.e., when study phenomenology our perspective is part
of a paradigm that understands the mind (or consciousness) and the body as separately
functioning entities termed the Cartesian divide. Therefore, it is not only a matter of
assimilating the phenomenological understanding but also a matter of
dismantling/deactivating the general inherited paradigm in the process.

The phenomenological understandings of the structures of consciousness in this thesis

are basic phenomenological theories. My exposition is to a large extent based on the
work of the contemporary Husserl interpreter and phenomenologist Dan Zahavi, but his
work also exposes the ideas of other main figures within phenomenology, such as
Maurice Merleau-Ponty (1908-1961), Jean Paul Sartre (1905-1980) and Max Scheler
(1874-1928). Zahavi writes that phenomenology is an investigation of subjectivity and
its relation to the world as it is experienced from a first person perspective.
Phenomenology is not idealistic; subjectivity is worldly in the sense that it cannot be
separated from the world, and further the subject is embedded in a social context, and
the subject’s self-understanding entail others. Thus, the investigation of subjectivity is
also an investigation of intersubjectivity (Zahavi 2007, 36-37). The mark of
phenomenology is that it concerns itself with the working of consciousness often
expressed as the “how of consciousness” and not with the intentional object, i.e., the
“what”. However, they can only be separated conceptually. When phenomenology
argues that the subject constitutes the world, one must bear in mind that the constituting
subject is situated in the world, and it is not the world that is situated in the subject.
Phenomenology is not solipsistic, the subject, intersubjectivity and the world together
found the constituting process (Zahavi 2011, 114-115).

Even though non-mental factors, such as neurophysiological processes, are involved in

cognition, they are not the topic of phenomenology, because the neural brain processes
are not conscious (Zahavi 1999, xiii). This is not to say that phenomenology does not
find inspiration from other sciences, it is only to point out that the phenomenological
investigation concerns itself with the phenomenon as it is experienced from the first
person perspective.

In this chapter, I first introduce intentionality starting with the “intentional act”, how we
are consciously directed towards the world. Then I proceed to “operative
intentionality”, which is a manner of being merged with the world that precedes and
founds the intentional act. After that, I continue with “motor intentionality”, which is a

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manner in which the subject engages with the world in an automatic fashion without
actually attending to the task at hand. Then I proceed to “empathy”, which is a peculiar
manner of being directed towards and understanding the other that is based on the “life-
world”. Then I proceed to an investigation of the self that entails the “minimal-self,”
“act transcending self,” “embodied-self” and the “personal-self.” I also investigate what
kind of access the subject has to itself. Finally, I end the chapter by contrasting the
“natural attitude” to the “phenomenological attitude” that is attained by the “epoché”.

Intentionality

In approaching the basic phenomenological theories, I start with Husserl’s analysis of

act intentionality. The topic of act intentionality is about the directedness of
consciousness. The conscious act is directed towards the intentional object (Zahavi
2007, 38). When I think, then I necessarily think of something, and the same is valid in
perception, hearing, tasting, remembering, imagining, desiring, contemplating and so
on. It makes no sense to talk of these conscious acts devoid of the intended object; the
act of love entails the beloved, the act of perception entails the perceived and the act of
judging entails the object that is judged.

Husserl’s initial analysis of act intentionality was inspired by Franz Brentano (1838-
1917), but Husserl disagreed with Brentano on the question of how to account for the
fact that we are not only conscious of the intentional object but also of the conscious
act. It is often posed as the question of “how consciousness experiences itself, how it is
given to itself, how it manifests itself” (Zahavi and Parnas 1999a, 255). Brentano
proposed that intentional consciousness is directed both at the intentional object and at
the inner mental state (the act) itself (Zahavi 2005, 38). The unfortunate implication of
Brentano’s account is that the act and the intentional object are both perceived in an
objectified manner, but we are not aware of the act in the same manner as we are aware
of the intended object. Husserl’s contribution was to point out that the act is
experienced and the intentional object is perceived (Zahavi 2005, 40). The kind of
consciousness that is directed towards and perceives the object is an explicit kind of
consciousness, whereas the act is experienced by pre-reflective consciousness which is
an implicit and non-objectifying kind of consciousness. Pre-reflective consciousness is
a constant feature of consciousness. This means that the subject is pre-reflectively
aware of subjectivity when intentional consciousness is directed towards the object. Pre-
reflective consciousness (the act) is also described as simply being “lived through”
(erlebt) (Zahavi 2005, 40). “In contrast to Brentano, Husserl did not seek to identify the
(self-)givenness of our experiences with the givenness of objects” (Zahavi 2005, 40-41).
Phenomenology distinguishes between pre-reflective consciousness and intentional
consciousness, i.e., between experiencing (Erleben) and perceiving (Wahrnehmen)
(Zahavi 1999, 55; 2005, 41). With attention firmly focused on the object, I am aware of
the act, and even though pre-reflective consciousness is defined as being an implicit
kind of awareness, I am aware of the act.

According to phenomenology, it feels different to perceive and to recall a magnolia tree.

The phrase “what it is like” refers to the experiential phenomenality of the act. “[We]

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are never conscious of an object simpliciter but always of the object as appearing in a
certain way (judged, seen, feared, remembered, smelled, anticipated, tasted, etc.)”
(Zahavi 1999, 23). It is not only sensations and emotions that have a phenomenal feel
but also cognition (Gallagher and Zahavi 2008, 115). “What it is like to be in one type
of conscious intentional state differs from what it is like to be in another type of
conscious intentional state” (Gallagher and Zahavi 2008, 115).

Gallagher and Zahavi write that to the phenomenologists intentionality is about

meaning, “We intend an object by meaning something about it” (Gallagher and Zahavi
2008, 116), to understand the full scope of meaning we must turn to functioning
intentionality.

Functioning Intentionality

We perceive our self, others and the world by intentional consciousness, but for this to
be possible the subject is already merged with the world, i.e., the world is given pre-
reflectively to the subject prior to any analysis of the world (Zahavi 2007, 38). The way
the world is given pre-reflectively precedes language and is non-theoretic and non-
objectifying in nature, i.e., in the same manner as the implicit awareness of the
intentional act.

Husserl distinguishes between act intentionality – which is the intentionality of

our judgements and of our voluntary decisions […] – and operative intentionality
(fungierende Intentionalität) the intentionality that establishes the natural and pre-
predicative unity of the world and of our life, the intentionality that appears in our
desires, our evaluations, and our landscape more clearly than it does in objective
knowledge. (Merleau-Ponty 2012, xxxii)

Merleau-Ponty describes in Phenomenology of Perception that the life of consciousness

is “underpinned by an “intentional arc” that projects around us our past, our future, our
human milieu, our physical situation, our ideological situation, and our moral situation”
(Merleau-Ponty 2012, 137). The analysis of intentionality describes the subject as “an
embodied and socially and culturally embedded being-in the-world” (Zahavi 2008,
662). I refer to operative intentionality when using the term “functioning subjectivity”
(Zahavi 1999). Functioning subjectivity brings things into existence for us prior to
being explicitly known or seen by intentional consciousness. Phenomenology
understands consciousness as being transcendent in the sense that it reaches out into the
world; the world already makes sense because the intentional arc underpins perception.
This means that the subject is rooted in this non-theoretic and multi facetted manner of
existence, and that the subject is always in a situation even when the subject does not
pay special heed to anything. The subject is always pre-reflectively aware of being in a
world that is saturated with sense. In a reflection, we are able to partially objectify the
functioning intentionality that constitutes the intentional act but not functioning
intentionality as such. Merleau-Ponty writes that in order to understand operative
intentionality we must understand that it encompasses everything (all our experiences,
history, morals, milieu, the scientific perspective and so on), and that sense does not

  6  
derive from a single incident. The fuller perspective we have on a matter, the more
likely we are to understand the proper sense of the matter (Merleau-Ponty 2012, xxxiii).
Functioning subjectivity is described as an “invisible manifestation,” because it does not
manifest itself in the same manner as the objectified intentional object; it is an absolute
immanence that is non-objectifiable in its core, but we can in a reflection thematize part
of subjectivity (Zahavi 1999, 192-194).

Operative intentionality is the one that provides the text that our various forms of
knowledge attempt to translate into precise language. The relation to the world,
such as it tirelessly announces itself within us, is not something that analysis
might clarify: philosophy can simply place it before our eyes and invite us to take
notice. (Merleau-Ponty 2012, xxxii)

Every subject is situated in an individuated setting that is constituted by many factors,

such as a particular world-history including scientific beliefs, the family’s history, the
subject’s own life story and the environment’s ideology, morals, norms and the
subject’s present life circumstances, the possibilities the future holds for a particular
subject, which is also determined by physical abilities and intelligence.

Motor Intentionality

The primary manner of interacting with the world is not objectifying in nature.
Ordinarily, we deal with the world in a familiar and meaningful manner. According to
Merleau-Ponty, certain objects afford certain actions, for instance when “I see my car as
drivable” (Gallagher 2008, 537), it affords me to drive. When I approach the car to
drive somewhere, I most likely do not perceive the car as an objectified image; I only
notice the car in an implicit manner as a means to go somewhere: “the drivability of my
car is built into my direct perception of it” (Gallagher 2008, 537). The
phenomenological study of “embodiment” suggests that the mind is embodied, and even
though attentional consciousness is not involved, we are able to execute implicit
intentions due to “motor intentionality”. Motor intentionality directs me towards the
world and handles tasks depending on how familiar I am with a certain task, such as
driving a car. For example when a trained driver suddenly wakes up to realize that he
has no recollection of driving the car for a long stretch - a feeling of having been absent.
Such an experience is disturbing for some people, but really it is not different from
other automatic actions like getting out of bed, getting dressed or eating breakfast. We
experience these habitual actions pre-reflectively, and even though they are easily
forgotten, we are conscious of them as we execute them. We can function in the world
without being explicitly aware of the actions that we execute because our primary
bodily sensitivity is part of functioning intentionality (Zahavi 1999, 98).1 We are
already familiar with and aware of the world before we stop to take a look at it.
“Attention does not define consciousness” (Zahavi 1999, 217).

                                                                                                               
1
People with certain kinds of neurological afflictions have lost this pre-reflective body-
awareness, and they therefore rely on attentional consciousness to control the body
(Zahavi 1999, 101).

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Empathy

We have seen that the world is given before it is thematized by attentional

consciousness, and the same is the case in relation to the other. Zahavi states that the
way the other is given “is of a most peculiar kind” (Zahavi 1999, 192). When attention
is directed towards another person in a face-to-face encounter, we are usually not aware
of the physiological details  of the other’s face, such as muscle contractions. As Scheler
writes in The Nature of Sympathy:

I can tell from the expressive ‘look’ of a person whether he is well or ill disposed
towards me, long before I can tell what colour or size his eyes may be. (Scheler
2009, 244)

When confronted with another person in a face-to-face encounter, I understand at least

part of the other’s mind. I may perfectly well understand that the other has lost all
patience with me, without being able to describe what I actually saw in terms of
mimicry, bodily posture and movements. Intersubjective understanding occurs
automatically in a similar manner to that of motor intentional activity. “In fact, we
hardly perceive any objects at all, just as we do not see the eyes of a familiar face but
rather its gaze and expression” (Merleau-Ponty 2012, 294). Just as the intentional arc
merges the subject in relation to the world, the subject is also already merged in a
familiarity with the other before actually attending to the other in an objectified manner.

[The] essential character of human consciousness is such that the community is in

some sense implicit in every individual, and that man is not only part of society,
but that society and the social bond are an essential part of himself.
(Scheler 2009, 229-230)

Scheler claims that all living creatures share a “universal grammar” enabling us to
understand expressivity. Therefore, we do not only understand the expressivity of our
fellow man but also the expressivity of the dog and even the fish (Scheler 2009, 11).
Observing a fish caught on a fishhook, one directly perceives that the fish is in distress,
i.e., we do not infer but rather perceive the mental state of the fish. According to
phenomenology, the mind is expressed through the body, and we are not originally
directed towards the other’s body in the same manner as when a doctor examines a
body. We perceive intentions and emotions due to the expressivity of the other’s body
which is distinct to a perception of the other’s body as an object. Phenomenology
distinguishes between the lived-body (Leib) and the body as an objectified thing
(Leibkörper) (Zahavi 2007, 58-59).

The philosophical topic of “other minds”; how we come to know that others are minded
creature like ourselves, is approached from different perspectives in the philosophical
tradition. Some accounts are based on non-conscious cognitive processes that are
inferential in nature, i.e., “simulation theory of mind” and “theory of mind” (Gallagher
and Zahavi 2008, 172). The phenomenological conception of empathy is opposed to any
theory that is inferential in nature (Gallagher and Zahavi 2008, 183). This does of

  8  
course not mean that rational deliberations, inferences and projections are not part of an
encounter, but just that they are not the primary means we have of understanding the
other.

The relation between self and other is not established by way of an inference to
best explanation; on the contrary, we should recognise the existence of a
distinctive mode of consciousness, often called empathy or “Fremderfahrung,”
that allows us to experience behaviour as expressive of mind. This is what allows
us to access the feelings, desires, and beliefs of others in their expressive
behaviour. (Zahavi 2005, 155)

Empathy is a basic, irreducible, form of intentionality that is directed towards the

experiences of others. It is a question of understanding other experiencing
subjects. But this does not entail that the other’s experience is literally transferred
to us. (Zahavi 2010, 180)

Zahavi writes in the above quotation that in empathy the other’s experience is not
literally transferred. This is because the phenomenological account of empathy entails
asymmetry. In experiencing a friend’s grief, we do not share the same object. He is in
grief because he has lost a child, and his object is the dead child. My object is not the
child but my friend’s despair (Zahavi 2010, 179). Zahavi further writes that the distance
between self and other is upheld in both empathy and sympathy (Zahavi 2010, 179). I
do not put myself in his shoes, so to speak, to experience the grief in the same way that
he does. When the phenomenologist states that one experiences the mental states of the
other, this asymmetry is implied. Scheler writes that to perceive the mental state of a
drowning man is not to have the same experience as the drowning man. The observer
directly understands the mortal terror expressed by the drowning man, and this
understanding leads to a different experience in the observer (Scheler, 2009, 11). This,
however, does not mean that the other’s emotions cannot be transferred to me, it only
means that it is not the case in empathy, but it is in “emotional contagion” (Zahavi
2010, 179). This happens when one for example enters a bar and is infected with the
cheerful emotions of the others.

We do not have full access to the other’s mind. Scheler writes that a person is able to
conceal his/her thoughts, but that nature “at the vital level of mentality” cannot conceal
itself in this manner and is “in principle at least, open to spontaneous scrutiny” (Scheler
2009, 225).

For we certainly believe ourselves to be directly acquainted with another person’s

joy in his laughter, with his sorrow and pain in his tears, with his shame in his
blushing, with his entreaty in his outstretched hands, with his love in his look of
affection, with his rage in the gnashing of his teeth, with his threats in the
clenching of his fist, and with the tenor of his thoughts in the sound of his words.
If anyone tells me that this is not ‘perception’, for it cannot be so, in view of the
facts that a perception is simply a ‘complex of physical sensations’, and that there
is certainly no sensation of another person’s mind nor any stimulus from such a
source, I would beg him to turn aside from such questionable theories and address
himself to the phenomenological facts. (Scheler 2009, 260)

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According to Scheler, behaviour is “a psychophysical undifferentiated concept” (Zahavi
2010, 181). To understand the functioning of empathy, which Scheler terms
“Nachfühlen” (Zahavi 2010, 178), the right understanding of the connection between
mind and body is required. We can perceive the other’s mind because it is not hidden in
the head. As already stated, the mind is embodied (Zahavi 2005, p. 154). The essence of
an affective state is revealed through the expressivity of the other’s gaze and/or the
sound of the voice, by gestures, posture, gait and so on (Merleau-Ponty 2012, 294). Our
own lived-body is a constant feature of pre-reflective consciousness, and it underpins
the perception of the other’s mind. The manner in which I experience some of my own
mental states is similar to how I experience the other’s mental states. Unless anger
reveals itself in expressive tendencies, there is no awareness of being angry. When the
expressivity of anger is repressed, it evaporates from the internal point of view (Scheler
2009, 251). This is valid for many mental states. Unless “it discharges itself in intended
movements, or at least in expressive tendencies” (Scheler 2009, 251), we are not able to
attend to it. It is through my own actions, movements and expressivity that I experience
myself, and I understand the other’s mind through his/her actions, movements and
expressivity. “In this respect, therefore, there is at bottom, no very crucial difference
between self-awareness and the perception of mind in other” (Scheler 2009, 251).
According to Zahavi, “Scheler consequently denies that our initial self-acquaintance is
of a purely mental nature, as if it anteceded our experience of our own expressive
movements and actions, and as if it took place in isolation from others” (Zahavi 2010,
181). “I must be my exterior, and the other’s body must be the other person himself”
(Merleau-Ponty 2012, xxvi). If my own mind were not embodied, how would I ever
come to think that the other’s body had a mind. “If my own self-experience, in the first
place, is of a purely mental nature…we need to understand how I will ever be inclined
to attribute selfhood to others” (Zahavi 2004, 51).

The givenness of the other evades perception, but that does not mean that the other is
not given, i.e., we are not able to objectify the givenness of the other, but “We are
empathically able to experience other minds” (Zahavi 2010, 180). Likewise does our
own functioning subjectivity evade perception, but it is still experienced pre-reflectively
(Zahavi 1999, 193).

There seems to be a profound analogy between reflection (understood as a

thematic experience of myself) and empathy (understood as a thematic experience
of the other). In both cases we are dealing with a thematic experience of
something which is already pregiven and functioning prior to the thematization,
and which can never be exhaustibly grasped since it remains nonobjectifiable in
its core. (Zahavi 1999, 192)

Empathy is founded in the life-world, i.e., we share a universal horizon of meaning.

Husserl speaks of an “intersubjectively identical life-world-for-all” (Husserl 1970, 172).
Functioning subjectivity already includes the other. Empathy furthermore always takes
place in a given context. Different environments have different meaning horizons, and
thus the other is understood on the basis of the context (Gallagher and Zahavi 2008,
191).

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 In the experience of dialogue, there is constituted between the other person and
myself a common ground; my thought and his are inter-woven into a single fabric,
my words and those of my interlocutor are called forth by the state of the
discussion, and they are inserted into a shared operation of which neither of us is
the creator. We have here a dual being, where the other is for me no longer a mere
bit of behaviour in my transcendental field, nor I in his; we are collaborators for
each other in consummate reciprocity. Our perspectives merge into each other,
and we co-exist through a common world. (Merleau-Ponty, 2012 p. 413)

Within phenomenology, it is not a resolved matter how operative intentionality is

acquired. Scheler argues that all higher forms of social interaction have developed from
and are based on an innate ability to absorb other minds. “The mental content of
experiences that is virtually absorbed ‘with one’s mother’s milk’ is not the result of a
transference of ideas, experienced as something ‘communicated’” (Scheler 2009, 247).
Especially the child has a herd mentality that integrates the mental content of the group
that it is part of, and according to Scheler this “mode of transference” is not to be
thought of as communication. “For in this case we do not primarily ‘understand’ the
passing of a judgement or the expression of an emotion, or regard it as the utterance of
another self” (Scheler 2009, 247). The idea is that what has previously been thought of
as knowledge gained purely through learning, can also be thought of as knowledge
gained through this ability to “tap” into the other’s mind. This means that we are not
explicitly aware of what norms and other ideas that are absorbed into operative
intentionality, and we are not explicitly aware of the operative intentional sense that
shapes our being in the world. This only happens in a further thematization.

The Minimal-Self

The next topic is self-awareness, and it is related to the analysis of intentionality. We

have already seen that we are pre-reflectively aware of the experienced act, but the
question is if that awareness entails self-awareness. Husserl realised that he had to
define an experience as entailing self-awareness (Zahavi 2000, 69). How else would he
know if an experience belonged to him or to the other, i.e., he would be faced with the
problem of free-floating experiences, which is problematic in relation to
intersubjectivity (Zahavi 2005, 45). If consciousness does not entail some kind of self-
awareness, the problem is basically how consciousness is able to distinguish between its
own conscious states and the conscious states of the other. Ordinarily, I never
experience sadness without knowing if it is me or somebody else who is sad. I
experience my sadness from a first person perspective, which is a unique access that
only I have to my consciousness. When I experience the other’s sadness from a second
person perspective, it is not experienced as my sadness. If I had a first person access to
the other, as I have to myself, I would not be able to distinguish between self and other.
Therefore, the first person perspective is the perspective of the “minimal-self” (Zahavi
2005, p. 46). The most basic sense of self in a phenomenological context is termed the
minimal-self which equals the Husserlian term “pure Ego”.

  11  
 “I take myself as the pure Ego insofar as I take myself purely as that which, in
perception, is directed to the perceived, in knowing to the known, in phantasizing
to the phantasized, in logical thinking to the thought,” (Husserl 1989, § 22, 103-
104).

In its simplicity, the minimal-self is rather elusive. It directs attention, exerts ownership
and bestows me’ness on all experiences that occur in the stream of consciousness, thus
ensuring unity to consciousness. It is quite different from the personal self that entails
character traits, dispositions and other changeable features (Husserl 1989, §24, 110).
The pure Ego has no hidden parts. It is a permanent and unchangeable feature of
wakeful consciousness (Ibid). Zahavi suggests that the minimal-self, which is an
experiential-self, could also be termed the “core self” (Zahavi 2005, 106). Whenever
there is self-awareness, there is also a form of selfhood involved (Zahavi 2000, 69).

The problem that we encounter if we do not define self-awareness as an intrinsic part of

experiences can also be defined as a lack of identity, i.e., how will the reflecting ray of
consciousness (which has no self-awareness) identify the immanent experience it takes
as its object as belonging to itself? “After all, self-awareness is precisely supposed to
acquaint us with our own subjectivity; it is not supposed merely to acquaint us with yet
another object of experience” (Zahavi 2004, 54). It might be claimed that when the
child is able to identify itself in the mirror, the child has acquired a self. This might be
right, but it is a higher order account of a self than self-awareness. The child (or the
intentional ray of consciousness) was necessarily already self-aware, how else would
the child identify the reflection in the mirror as being itself, and not just another object.
There is general consensus among phenomenologists that the experiential dimension is
necessarily self-aware “for in such a case my consciousness reveals itself to me”
(Zahavi 2004, 55).

Hume is taken to have stated that it is not possible to find a self in consciousness when
scrutinising consciousness, and he was quite right: the self is not in consciousness as an
object to be found. What Hume might have missed is pre-reflective self-awareness, i.e.,
himself as the experiential scrutiniser (Zahavi 2005, 101). The minimal-self is lived in
pre-reflective consciousness and is not an object of intentional consciousness. To claim
that a self only emerges in an additional reflection is counterintuitive.2 If one argues that
there is no self-awareness while practising meditation, one overlooks the fact that it is
possible to account for what it was like to meditate, thus at least the minimal-self is
present. I know myself as a subject because the minimal-self is present throughout
wakeful consciousness and in dreaming. I am not only pre-reflectively aware of the
minimal-self but also of aspects of subjectivity.

                                                                                                               
2
Phenomenology is in opposition to higher order theories of self-consciousness (Zahavi
2005, 17).

  12  
The Embodied-Self

Likewise, the lived-body is a permanent feature of pre-reflective consciousness, which

mean that the minimal-self is an embodied point of view (Zahavi 2005, p. 205; Husserl
1989, §41, 166).

Only by virtue of its experienced relation to the organism does consciousness

become real human or brute consciousness, and only thereby does it require a
place in the space belonging to Nature and the time belonging to Nature, (Husserl
1982, § 53, 125)

It is through the lived-body that orientation arises. I have the comprehension of where
up, down, left and right is, because consciousness is embodied, i.e., embodied
consciousness is the zero point of all orientation and perception. When I stand up, for
instance, I know what up and down is, because my feet press against the ground. “The
body is, in the first place, the medium of all perception; it is the organ of perception and
is necessarily involved in all perception” (Husserl 1989, § 18, 56). The subject is
basically in the world through the body, and the subject is able to act in the world
through the body. Zahavi writes that Husserl argues that spatial objects can only appear
for and be constituted by embodied subjects. “His thesis, however, is not that a
perspectival appearance presupposes the existence of the body, but that it presupposes
the self-givennes of the body” (Zahavi, 1999, 92).

We are constantly aware of the lived-body. I emphasise this because we are so familiar
with the lived-body. Just recall an episode when you had a numb limb (Zahavi 2011,
153), or when your mouth was sedated by the dentist, how strange it is not to have pre-
reflective awareness of the mouth. Eating with a numbed mouth makes it obvious how
much information one normally receives from the body.

I experience my own body as the power of adopting certain forms of behaviour

and a certain world, and I am given to myself merely as a certain hold upon the
world; now, it is precisely my body which perceives the body of another, and
discovers in that other body a miraculous prolongation of my own intentions, a
familiar way of dealing with the world. (Merleau-Ponty 2012, 412)

Time-consciousness

Now let’s turn to the possibility of getting acquainted with our self through reflection.
Husserl’s analysis of time-consciousness explains why, at all, it is possible to grab the
pre-reflectively lived experience reflectively, even though the main aim of the analysis
of time-consciousness is to understand how we are able to be conscious of temporal
objects, succession and change. If the now simply only entails the present now, we need
to account for the interconnection between these separate moments. Husserl’s solution
was to insist on the “width of presence” (Zahavi 2005, 56). The now has width because
an experience exists in consciousness in three different stages. An experience is first
anticipated (protention), then it is the primal impression, and last it recedes into the

  13  
background (retention) until it ceases to exist (Zahavi 2005, 56-58). Protention and
retention are not to be confused with the act of remembering or expecting, because in
these cases we are dealing with an intentional object. It is simply the structure of time-
consciousness that resembles the act of remembering and anticipating. This
understanding of consciousness means that the “now” entails both the past and the
future. Zahavi writes that Husserl did not take the present unit of temporality to be a
“knife-edge” presence, but instead a “duration-block” that contains the present, past and
future (Zahavi 2005, 56). It is not possible to reflect on the primal impression because it
is attention itself. “I cannot grasp my own functioning subjectivity because I am it”
(Zahavi 1999, 189; Zahavi 2005, 92). To reflect is to turn attention towards one’s own
mind, but it cannot be turned on its own functioning. In a reflection, we seize the
experience as it lingers on in pre-reflective consciousness while we live the functioning
intentional act that executes the reflection.

To speak phenomenologically of the temporality of consciousness is to speak of

the temporal givennes of consciousness … it should be realized that Husserl’s
investigation of inner time-consciousness is nothing apart from an investigation
into the temporality of prereflective self-awareness. (Zahavi 1999, 71)

The self-awareness phenomenology proposes is “a temporally stretched self-awareness”

(Zahavi 1999, 122).

“Anticipation” of an experience in time-consciousness can be explained in relation to

operative intentionality. As previously stated, we are already acquainted before we
actually see the world. I expect the world to be in a certain way. When I realise that I
have asked a dummy for directions and not a real person, I experience a short moment
of bewilderment until another set of expectations shapes my outlook, prompting that I
no longer expect an answer (Zahavi 2011, 123). If, on the other hand, I had no
expectations, there would be no cause for bewilderment, not even if the dummy walked
out of the shop. When I cut through an orange, I implicitly expect something specific to
be inside. Husserl’s favourite example is how music is perceived. Music would not be
possible if all we had was separate tones following each other (like beads on a string).
Tones must be interconnected to make a melody (Zahavi 2011, 121-123). While one
experience exists as a primal impression, another experience exists as retention, and a
third experience exists as protention. Time-consciousness also provides unity because
experiences occur simultaneously although not in the same mode. (Zahavi 2012, 152).
Experiences are not separate moments like beads on a string. If they were,
consciousness would be in need of a separate entity to ensure unity.

The Act-transcendent Self

It has become clear that consciousness entails minimal self-awareness, but we need to
account for a more permanent and superior self which Zahavi designates as the “act-

  14  
transcendent ego”3 (Zahavi 1999, 152). Since minimal self-awareness is an intrinsic part
of the experience itself, there must be a higher account of self that exists through the
multiplicities of “data” that constantly surface and fade in the stream of consciousness.
If minimal self-awareness were given this role, Husserl claims, the self would vanish
with the fading of experiences, and a new self would emerge as new experiences surface
in the stream (Zahavi 2000, 65-69). Zahavi points out that it is not a question of what
this higher order self is, but instead it is a question of the connection between the higher
order self and minimal-self awareness. Husserl identifies this higher order self as an
identity-pole shared by all experiences that arise in the same stream of consciousness
(Zahavi 2000, 65).

[Although] the ego must be distinguished from the experiences in which it lives
and functions, it cannot in any way exist independently of them. It is a
transcendence, but in Husserl’s famous phrase: a transcendence of immanence
(Zahavi 2000, 65).

This means that the act-transcendent self is to be thought of as being very closely tied to
minimal self-awareness, and if it were otherwise, it would be a problem to account for
the interconnection between the two. “[Yet] it is evident, in virtue of further reflections
at a higher level, that this and the other pure Ego are in truth one and the same”
(Husserl 1989, §23, 108). The only way to get acquainted with the act-transcendent self
is in reflection, fantasising and recollection (Zahavi 1999, 150).

“The essence of self-remembrance obviously includes the fact that the pure Ego
remembering itself, is conscious of itself as bygone, […] the fact that it grasps
itself as something temporally enduring from the past now to the actual flowing
now of the present.” (Husserl 1989, §23, 108)

The act-transcending self is a self that bridges the gap between experiences. Through
reflection, one becomes aware of the split between two selves, i.e., the reflecting self
and the self that is reflected upon. It is an awareness of the split between two selves that
is one and the same, only experienced at different times. In other words, the act-
transcendent self is an awareness of this fission in the self. Zahavi further points out that
it is important not to conceive of the act-transcendent self as only existing when the
reflection happens, but that it is a permanent feature of consciousness that becomes
aware in a reflection (Zahavi 1999, 150). “But the pure subject does not arise or vanish,
although in its own way it does “step forth” and once again “step back”” (Husserl 1989,
§23, 109).  

Reflection and Pure Reflection

Naturally, there is a difference between a lived experience and the same experience
when it is grasped by a reflection (Husserl 1989, §23, 107; Zahavi 1999, 190). Zahavi

                                                                                                               
3  The term “ego” was commonly used in the past, but it is here replaced with the more

modern term ”self”.  

  15  
discusses if the reflection radically changes the lived experience, and he reaches the
conclusion that it does not. The manner in which it is given to us is different, but the
content itself is not transformed “The aim of reflection is to remove the anonymity and
naiveté of prereflective experience, not to relive or reproduce it” (Zahavi 1999, 188). In
reflection, it is more a matter of difference in the level of implicit/explicit awareness of
the lived experience (Zahavi 1999, 186-187). We are “only able to grasp these
structures as they are reflectively articulated, and not as they are lived through” (Zahavi
1999, 188). When the experience is lived through, it is experienced as a unity. However,
in reflection we are able to grasp certain aspects of operative intentionality. Aspects of
lived subjectivity can be “grabbed” in a reflection; it becomes the object of intentional
consciousness and might thereby be grasped in a “cognitively valuable” manner (Zahavi
2005, 96).

Husserl speaks of reflection (and recollection) as a process that discloses,

disentangles, explicates, and articulates all those components and structures of
meaning which were contained implicitly in the prereflective experience. (Zahavi
1999, 186)

So far, I have accounted for the intentional act as an act that objectifies its object
through a bestowal of sense. Zahavi suggests that self-awareness attained through a
reflection does not have to be understood as an act of objectification and ratification but
simply as a “constitution of identity” (Zahavi 1999, 185). This form of reflection is
termed “pure reflection” and can be understood as an accentuation and grasping of the
primary experience. It might also be understood as a “higher form of wakefulness” or as
an “articulate and intense form of self-awareness” (Zahavi 1999, 186). As the present
moment (primal impression) recedes into retention, accentuated awareness is possible.
“Only in the form of retention do we have a consciousness of the phase which has just
flowed away, or else in the form of a retrospective recollection” (Husserl 1982, § 44,
97).

The Personal-self

I now turn to the phenomenological idea that we are able to experience our self from a
third person perspective (Zahavi 2005, 94). We have already seen that through empathy
I am able to understand how the other judges me, i.e., if the other takes me to be an
equal, what the other thinks of my general appearance, if the other loves me or detests
me, finds that my skills are worth reckoning with or not, if the other finds me morally
flawed, etc. This founds a “social attitude” whereby I perceive myself from the other’s
perspective. It is not to be understood as an attitude that I can attain by a willed act. It is
through society’s apprehension of me that I come to apprehend myself as a social
object, and according to Husserl this is how the subject gains personhood. It is due to
intersubjective interaction that we cease to be solely experiential subjects and that the
personality structures develop (Zahavi 2005, 94). Through the social attitude I
apprehend or perceive myself from the perspective of society. The social attitude is
intentional because the object, my personal self or the other, is judged, which is not the
case in a pure reflection. Naturally, I am able to turn intentional attention towards

  16  
myself, but the intentional object is I as a person and not I as a subject. Zahavi suggests
that we should not understand subjectivity to be an object, and it follows that the pure
reflection is not directed towards an object but the subject (Zahavi 2005, 185).

The Phenomenological Attitude and the Epoché

Phenomenology deals with different attitudes, but first of all the “natural attitude”,
which is the attitude that I already have accounted for. In the natural attitude, we take
our self, the other and the world for granted, i.e., we are simply merged with a world
that is saturated with meaning that we do not question. The natural attitude includes the
content that shapes the social perspective, but the social attitude is a specific attitude,
i.e., it is different from an ordinary reflection that is executed in the natural attitude.

We tend to approach subjectivity in the same manner that we approach worldly objects,
i.e., from the natural attitude, but we will not gain access to our own subjectivity by this
approach. This requires the phenomenological attitude (Zahavi 2007, 23; Heidegger
1962, §5). Zahavi further adds that phenomenology can be described as a battle against
this self-forgetful levelling that is an outcome of the natural attitude. Husserl was well
aware of the great potential of the phenomenal attitude in relation to its impact at the
personal level, even though it is not the aim of the epoché within phenomenology.

Perhaps it will even become manifest that the total phenomenological attitude and
the epoché belonging to it are destined in essence to effect, at first, a complete
personal transformation, comparable in the beginning to a religious conversion,
which then, however, over and above this, bears within itself the significance of
the greatest existential transformation which is assigned as a task to mankind as
such. (Husserl 1970, 137)

The phenomenological attitude is acquired by executing the epoché. For most people
this requires a meditative effort. The epoché is executed by bracketing or setting aside
the meaning or propositions of the natural attitude. In the epoché, what was before a
vague and unthematic presupposition becomes thematic. By acknowledging our
propositions, we are able to put them out of action, i.e., the proposition is no longer
taken for granted. In Husserlian terminology propositions are converted into a
”parenthesized positing” (Husserl 1983, § 31-32). Nothing disappears; it is still there,
but we are able to refrain from executing the positing.

With regard to any positing we can quite freely exercise this peculiar (epoché), a
certain refraining from judgement which is compatible with the unshaken
conviction of truth, even with the unshaken conviction of evident truth. (Husserl
1982, §31, 59-60)

In the natural attitude, the perceived object is bestowed and shaped by sense; in a sense,
we already know what we perceive. In the phenomenological attitude, the veil (of
taking the perceived for granted) is at least partially lifted, enabling us to see afresh. It is
an acceptance of what is and a refraining from judging.

  17  
2. Chapter: Schizophrenia  

Introduction to Schizophrenia

The main proposition in phenomenological psychiatry is that schizophrenia is a specific

disorder of the self. This idea dates back to Kraepelin (1856-1926), Bleuler (1857-
1930), Minkowski (1885-1972), Schneider (1887-1967) and Jaspers (1883-1969) (Sass
and Parnas, 2003; Henriksen and Parnas 2013). Unfortunately, this proposition has not
been implemented into mainstream psychiatry, but its importance is now being
revitalized within contemporary phenomenological psychiatry in the works of Sass,
Skodlar, Parnas, Fuchs, Zahavi and Henriksen among others. I mainly adhere to these
authors in this chapter.

According to Parnas, Schizophrenia is the most severe mental illness from a communal
perspective, because, at least in Denmark, half of the over-night admitted psychiatric
patients are patients with schizophrenia. In Denmark and generally, one percent of the
population have the illness. There is no reason to suggest that the illness has increased
in frequency, but the severity of the course of the illness may be in recession.
Schizophrenia is found in all countries and has definitely existed since the Middle Ages
(Hemmingsen 2000, 281). Parnas describes schizophrenia as a psychotic condition that
features disrupted contact and communication with the world, and he writes that
schizophrenia is mysterious in the sense that the patient might express extremely odd
ideas, but at the same time the patient proves that the intellect is intact (Hemmingsen
2000, 281). Schizophrenia is also remarkable in terms of its diversity of symptoms.
Symptoms that are characteristic of other disorders are also found in schizophrenia,
such as anxiety, anorexia, compulsive disorder and other symptoms similar to neurosis.
The course of the illness also varies significantly from individual to individual. Parnas
recommends, especially in relation to young people admitted for an evaluating
interview, that schizophrenia is a differential diagnostic possibility (Hemmingsen 2000,
282).

In this chapter, I expose the phenomenological take on schizophrenia, according to

which schizophrenia is a self-disorder that contains two main features: a diminished
sense of self, or rather a diminished self-affection, and hyperreflexivity. The self-
disorder causes operative intentionality to function inadequately, which means that the
natural attitude is not fully executed, thus the bestowal of sense in relation to the self,
others and the world is limited. Hyperreflexivity may be an attempt to compensate for
the diminished sense of self, and it contains two components: an access of operative
reflexivity and an access of reflection. Hyperreflexivity, however, creates a distorted
sense of self, and it also turns attention towards the inner mental states creating a
solipsistic attitude. Following the exposition of the self-disorder, I account for the main
symptoms that are subtyped into the basic, negative, positive, and disorganisation
syndromes. These relate back to the self-disorder. Furthermore, I describe how the
solipsistic attitude becomes an integrated part of the self and that this may explain why
many patients are reluctant to comply with treatment.

  18  
The Ipseity-disorder

From a phenomenological perspective, the whole spectrum of schizophrenic disorders

can be accounted for as having its origin in a self-disorder. I portray this self-disorder
based on the so-called “Sass and Parnas ipseity-disturbance model of schizophrenia”.
According to this model, the ipseity-disorder entails two interrelated components: a
diminished sense of ipseity and hyperreflexivity. The meaning of “ipse” is “self” or
“itself” (Sass and Parnas 2003, 428). Ipseity equals the minimal-self, and in a
phenomenological context it is defined as “[the] experiential sense of being a vital self-
identical subject of experiences or first person perspective on the world” (Sass and
Parnas 2003, 429), or simply as the most basic sense of selfhood. When ipseity is
disturbed, the experiential framework in general becomes affected and altered.
Ordinarily, ipseity is a stable presence for the subject as it is lived through in pre-
reflective consciousness. When the pre-reflectively lived ipseity is disrupted, it also
means that operative intentionality cannot function properly.

The most prominent feature of altered presence in the pre-onset stages of

schizophrenia is disturbed ipseity, disturbance in which the sense of the self no
longer saturates the experience. (Parnas and Handest 2003, 125)

The distorted sense of ipseity can also, according to Fuchs, be articulated as a given
lack of experiential awareness; the person with schizophrenia has a “blind spot” in
experiential self-awareness (Fuchs 2007, 424).

Of special importance will be to gain a different approach to the problem of the

unconscious, which I regard not as an inner compartment of the psyche in the
traditional psychoanalytic sense, but as a certain way of living without full
awareness—a blind spot in lived space, so to speak. (Fuchs 2007, 424)

The blind spot in ipseity, or the disrupted ipseity, and the concomitant feature of
“hyperreflexivity” are the main features of the self-disorder in schizophrenia (Sass and
Parnas 2003, 428). The term “hyperreflexivity” is coined by Sass (1992). With a
functioning ipseity, there is no need for reflection because the subject is already self-
aware. “The term “reflexive” refers to situations or processes whereby an agent or self
takes itself, or some aspect of itself, as its own object of awareness” (Sass 2003, 156).
In Sass’s approach to schizophrenia, hyperreflexivity entails both an excess of
reflexivity and an excess of intentional or intellectual reflection, and it is the reflexive
kind that is the core in hyperreflexivity.

In this case, however, the hyperreflexivity would be of an operative rather than a

reflective kind -affecting what Blankenburg (following Husserl) calls the
‘fundamental receptivity’ of the automatic or ‘passive syntheses’ that structure the
basic act of consciousness and constitutes a person’s most immediate and
fundamental relationship to self and world. (Sass, 2003, 167).

Most basic to schizophrenia is a kind of “operative” hyperreflexivity that occurs

in an automatic fashion. … [At] its core, [it is not] an intellectual, volitional, or
“reflective” kind of self-consciousness; nor is it merely an intensified awareness

  19  
 of something that would normally be taken as an object (e.g., in the case of an
adolescent’s self-consciousness about his or her appearance). (Sass, Parnas and
Zahavi 2011, 7)

In the chapter on phenomenology, we saw that Zahavi distinguished between an

intentional reflection and the pure reflection. A commonality between the operative
kind of hyperreflexivity and the pure reflection is that they cannot be executed by a
willed action. If we use Zahavi’s (or rather Husserl’s) terminology, we might say that
the core of hyperreflexivity is pure reflection, i.e., that the kind of awareness that we are
dealing with in hyperreflexivity is at its core an accentuated self-awareness and not an
intentional objectification of subjectivity. According to phenomenology, the content of
the pure reflection is that of subjectivity, i.e., the implicit self-awareness that would
normally be lived and experienced pre-reflectively to facilitate intentional attention. The
analogy might not be fully viable because Sass states in the above quote that “reflexive”
denotes a manner in which the subject takes an aspect of itself as an object of awareness
(Sass 2003, 156), and the pure reflection is not an objectification but rather an
accentuated pre-reflective awareness.

The fact is that hyperreflexivity entails both an access of intentional reflection and an
access of operative reflexivity. In schizophrenia, a diminished sense of presence or
existence is often encountered. The person with schizophrenia might attempt to replace
the diminished sense of presence by an access of reflection. "Descartes' cogito ergo
sum' (I think therefore I am) may still be superficially cogitated but it is no longer a
valid experience'' (Jaspers, General Psychopathology, 1997, 122). The implicit
background is often turned into objects by an excess of intentional reflection, but since
the reflection is not properly grounded in operative intentionality, these objects are
experienced as alien and strange as they pop up as an attentional matter, and they
disrupt the ordinary flow of consciousness (Sass, Parnas and Zahavi 2011, 7 and 12).
This might lead to an excess of intellectual reflection, I return to the topic later. For
now, I attend to the disrupted ipseity and the excess of operative reflexivity that I equate
with that of pure reflection.

The blind spot in ipseity is not replaced by hyperreflexive self-awareness, and the main
feature of schizophrenia is articulate as a diminished self-affection; “Self-affection
refers to subjectivity affecting itself” (Sass and Parnas 2003, 428). In the exposition of
phenomenology, we have seen that a precondition for intentional consciousness is that
the subject is pre-reflectively self-aware or that subjectivity affects itself. When self-
affection is disrupted, the subject reveals distorted acts of awareness (Sass and Parnas
2003, 428) in relation to self, others and the world. The person with schizophrenia is
only partially merged with operative intentionality, and the formation of meaning that is
supposed to bestow the encountered objects with sense does not function properly,
which can come to mean that the self, others and world no longer make much sense.

A tacit or subsidiary awareness of kinaesthetic and proprioceptive sensations

serves as the medium of prereflective selfhood, ipseity, or self-awareness, which,
in turn, is the medium through which all intentional activity is realised. Any
disturbance of this tacit-focal structure, or of the ipseity it implies, is likely to

  20  
 have subtle but broadly reverberating effects that upset the balance and shake the
foundations of both the self and world. (Sass and Parnas 2003, 430)

The diminished self-affection in the schizophrenia spectrum disorders means that the
primary manner of being self-aware for the person with schizophrenia is through an
excess of operative reflexivity (pure reflection). This manner of being self-aware entails
a distance or disjunction. As we have seen in the exposition of phenomenology, the self-
awareness gained from pure reflection entails fission because it is a relating of the core
self upon the self that has just been lived, i.e., as the present moment recedes into
retention. It is attended to by the present self, so that the person with schizophrenia may
have a feeling of having a self rather than being a self (Sass, Parnas and Zahavi 2011,
11), and at this level it is not as such an objectification but rather a self-relating that
creates the fission. This might, as we will see, be further enhanced by an access of
reflection.

The disturbed sense of ipseity causes a diminished sense of presence that pre-reflective
minimal-self awareness ordinarily provides. The person with schizophrenia might not
only have a diminished sense of being present as the zero point of orientation, but due
to the excess of pure reflection, there might also be a sense of being outside or beside
oneself. It can also be framed in terms of a disembodied mind (Stanghellini 2004). The
lived-body facilitates the subject’s experiential sense of being in the world as an
embodied mind. In schizophrenia, however, the body might not simply be “lived
through” due to the diminished self-affection, and the mind of the person with
schizophrenia might be somewhat disembodied (Fuchs 2005, 102).

Different people with schizophrenia have expressed the following statements:

“I don’t feel myself” or “I am not myself” to “I am losing contact with myself,” “I

am turning inhuman,” or “I am becoming a monster.” The patient may sense a
sort of “inner void” or “a lack of inner nucleus,” […] The patient does not feel
being fully awake or conscious: “I have no consciousness,” “My consciousness is
not as whole as it should be,” “I am simply unconscious,” “I am half awake,” “I
have no self-consciousness,” “My I-feeling is diminished,” “My I is disappearing
for me,” “My feeling of consciousness is fragmented,” “It is a continuous
universal blocking” […] This alteration of self-consciousness is frequently
associated with diminished affectability or reactivity of the self. (Parnas and
Handest 2003, 125)

The above statements illustrate some of the probably most basic features of experiences
in schizophrenia. They reflect a diminished sense of self. The statements below are also
basic features and are related to fissure created by pure reflection that becomes
manifested as a sense of not being in line with focal attention.

Many patients exhibit a subtler spatialization of inner experience. They describe

their thoughts or experiences in physical terms, as if possessing object-like spatial
quality (“dense and encapsulated thoughts”) or locate them spatially (“my
thoughts feel mainly in the right side of the brain”; “ it feels as if my thoughts
were slightly behind my skull”). One patient reported an experience as if she

  21  
 looked at the world somehow much “far from behind”; her “point of perspective”
was felt “as if displaced some centimeters behind.” (Parnas and Handest 2003,
128)

It is important to keep in mind that schizophrenia is never a fixed state of being. The
symptoms change according to context and other factors, and from person to person the
symptoms are not homogeneous. Also the severity of the illness varies in the individual
and from person to person.

The Negative, Basic, Positive and Disorganisation Syndromes

In mainstream psychiatry, the major symptoms are subtyped in syndromes, such as the
negative syndrome, the positive syndrome and the syndrome of disorganization (Kay,
Fiszbein and Opler 1987). Mainstream psychiatry may understand these syndromes to
derive from different deficits, such as cognitive defects, false belief ascription and from
defects in more volitional mental processes. They are also thought to designate separate
aspects of schizophrenia. However, from a phenomenological perspective, these diverse
syndromes may be conceived as originating in the specific ipseity-disorder that is
explicated above (Sass and Parnas 2003). Even though the phenomenological literature
on schizophrenia not necessarily agrees with the sharp division and conceptualization of
these syndromes, I will in the following view the symptoms associated with
schizophrenia as they are subtyped by mainstream psychiatry since this is a common
approach also in the phenomenological literature on schizophrenia (Sass 2003, 154).

Negative and Basic Syndromes

The negative symptoms are basically associated with a withdrawal both from self,
others and the world. They designate the absence of something that is normally there.
Both from the observer’s and from an experiential perspective, these negative
symptoms are described as a “poverty of speech, affective flattening, avolition, apathy,
anhedonia, and a general inattentiveness to the social or practical world” (Sass and
Parnas 2003, 433). It was assumed that the observed subject’s own experience matched
the observer’s impression. This has turned out to be right in relation to depressions but
not in relation to schizophrenia. From an observational perspective, it is not possible to
tell the difference between depression and schizophrenia, whereas subjective reports
clearly reveal a differentiated picture. The depressive person tends to report a decline in
initiative and experiential activity, but in schizophrenia there is no correlation between
the observed lack and the subject’s own account, which not only describes a decline in
some areas but also an altered experiential activity (Sass and Parnas 2003, 433).
Interviews with patients with schizophrenia who display negative symptoms reveal that
there need not be a diminishment of thought pressure and experiential activity, “a claim
corroborated by electrodermal measurements showing higher reactivity than for normal
subjects” (Sass and Parnas 2003, 433). The negative symptoms have simply been
thought to entail a loss, but in schizophrenia that loss is present along with experiential

  22  
activity.

The basic-symptom research demonstrates that even the most clearly negative
symptoms, such as apathy or avolition, are accompanied by a panoply of positive
experiential disturbances in the domains of cognition, perception, bodily
experience, action, and emotion. (Sass and Parnas 2003, 434)

Those basic experiential disturbances (that might be present along with the negative
symptoms) depict another syndrome termed “basic-symptoms”, and “they occur in
virtually identical form both before and after the development of productive positive
symptoms” (Sass and Parnas 2003, 435).

Other "basic symptoms" involve abnormalities of the core sense of the self as a
thinking, feeling, or willing being. To think clearly may begin to seem difficult;
thoughts seem to disappear, come to a halt, or appear as objects of introspective
awareness. Emotions can seem unnatural, absent, unsatisfying, or somehow
inappropriate or out of kilter. (Sass and Parnas 2003, 435)

Sass and Parnas write that detailed first person reports of the basic symptoms are rare
and that the poet Antonin Artuad has been described as the only person with
schizophrenia who has described this realm in real detail (Sass and Parnas 2003, 435).
The lack of detailed descriptions probably relates to a linguistic shortage, i.e., our
ordinary vocabulary is simply not tailored to describe these alienated phenomena
(Parnas and Handest 2003, 124).

Artaud writes of "the limbo of a nightmare of bone and muscles, with the
sensation of stomach functions snapping like a flag in the phosphorescences of the
storm" and "images of bloody old cottons pulled out in the shape of arms and legs,
images of distant and dislocated members. (Sass and Parnas 2003, 435)

The above citation is an example of an abnormal objectification of the functioning

subjectivity that is normally experienced in a tacit manner. These basic symptoms also
entail sensations of being pushed from the inside or the outside, or a pressure on the
body from the inside or the outside, the body or parts of the body are enlarged or
diminished, and an exaggerated sense of heat or cold (Sass and Parnas 2003, 434). The
stream of consciousness that is ordinarily experienced pre-reflectively is not only a
realm related to self-awareness and the lived-body, it also contains a variety of
potentiality like needs, cravings, longings, thoughts, images, phantasies, pains,
emotions, moods, the sense of agency, and other dispositions. Ordinarily, if any of these
potential objects were turned into actual objects, they would make some kind of sense,
but in schizophrenia they might appear as distorted and alienated objects.

According to Blankenburg, the most basic loss in schizophrenia is a “loss of natural

self-evidence” (Sass and Parnas 2003, 434). One of his patients, “Anna,” describes that
she is unable to stop thinking, however the loss of natural self-evidence inhibits her
ability to understand which again leads to perplexity (Sass and Parnas 2003, 434).

What is it that I am missing? It is something so small, but strange, it is something

  23  
 so important. It is impossible to live without it. I find that I no longer have footing
in the world. I have lost a hold in regard to the simplest, everyday things. It seems
that I lack a natural understanding for what is matter of course and obvious to
others. (Blankenburg 2001, 307)

The loss of natural self-evidence equals a loss of operative intentionality. The person
with schizophrenia is not fully able to take the reality of the self, others and the world
for granted. When the common sense of the natural attitude is inhibited, the world no
longer appears as obvious. The person with schizophrenia might become enclosed in a
“solipsistic attitude” because the intentionality of the natural attitude no longer directs
him/her towards the world. The solipsistic attitude can be further magnified because
motor intentionality is also inhibited and replaced by hyperreflexivity, i.e., the everyday
tasks that are normally executed in an automatic fashion no longer functions efficiently,
and the person with schizophrenia must pay special attention to perform these tasks
(Sass and Parnas 2003, 434). Simple tasks like opening a door is not preformed
automatically, and instead it becomes an attentive accomplishment to bestow sense to
and to execute actions. A chair might not appear as a place to sit, or framed differently,
the chair does not afford sitting. Getting dressed, walking, and talking; all these tasks
require a mental effort to be accomplished. “This hyperawareness precludes spontaneity
and may help to account for the loss of the esprit de finesse common in schizophrenia,
as well as for a diminished sense of vitality [and] motivation” (Sass and Parnas 2003,
434).

Hyperreflexivity might be considered a compensation for the loss of natural self-

evidence and the lack of automatic motor intentionality. However, we should be aware,
as Fuchs writes, that the “overload of details” is a consequence of the loss of natural
self-evidence that manifests itself as “an impaired capacity to recognize familiar
patterns or gestalten which in turn leads to an overload of details” (Fuchs 2005, 102).
With the loss of natural self-evidence, and along with that common sense, subjectivity
simply becomes fragmented, and what is ordinarily in the background becomes visible
in the foreground in a strange and self-alienating manner. This means that the person
with schizophrenia is not present as a unified perspective, which also affects perception
so that for example familiar faces may be perceived as alien and distorted (Fuchs 2005,
102). From this perspective, hyperreflexivity could also be seen as an attempt to make
sense out of the chaotic overload, but as Sass writes, “I prefer to see hyperreflexivity
and diminished self-affection (the two aspects of the disturbed ipseity), and their
various manifestations, as aspects of a single whole” (Sass 2003, 156).

From a phenomenological perspective, the negative symptoms, such as poverty of

speech, apathy, and also passivity in relation to others and the world, derive from an
overload of the basic symptoms that again derives from the ipseity disorder. In the
following, we will see that it makes much sense to view the positive symptoms as a
further magnification of the basic symptoms.

  24  
Positive Symptoms

As schizophrenia progresses, the basic symptoms change into positive symptoms that
are associated with delusions and hallucinations. Mental processes and the self become
more estranged, e.g., one’s own voice seems to come from the outside, or it seems to
belong to somebody else, or one’s own thoughts are spoken aloud so that others are
thought to hear them, or a voice might be commenting on whatever one is doing or
thinking (Sass and Parnas 2003, 432). In this manner, the border between self and
others disappears, and more volitional forms of hyperreflexivity further fuel this
progress. In the prodromal phases, we saw a mild form of estrangement in relation to
the self that derived from an automatic kind of hyperreflexivity and the lack of self-
affection. Whereas in the advanced stages of schizophrenia, a more extreme form of
self-estrangement occurs, such as the first rank symptoms that may be related to a
further lack of self-affection (Sass and Parnas 2003, 432). In relation to schizophrenia,
the distinction between negative and positive symptoms is from a phenomenological
perspective not as obvious as it is usually cashed out to be. The positive symptoms do
not add anything new. It is simply the ordinary experiential background that becomes
further objectified and distorted, and the positive symptoms still relate back to the
diminished self-affection and hyperreflexivity (Sass and Parnas 2003, 433).

Mental processes and inner speech no longer exist at what Husserl (1989, sect. 41)
called the "zero point" of orientation: they are no longer permeated with the sense
of selfhood but have become more like introspected objects, with increasingly
reified, spatialized, and externalized qualities. (Sass and Parnas 2003, 433)

Pre-reflectively lived inner speech is an ordinary property of the stream of

consciousness, i.e. it is common that we have an inner dialogue. Even when talking to
other people we have trains of thoughts in the back of the head. It is also common
behaviour to continue or repeat a conversation that one previously had with another
person, or to tell the other person in one’s head what one feels should have been said,
and it is not that rare that one cannot stop those thoughts even when one wants to. In
normal circumstances, the content of the social attitude that is attained unwillingly, can
be experienced as a vocal commenting or judging of one’s character, and the content of
the social attitude might also be experienced as a formation of bodily sensations or as
formations of muscular contractions that carries a certain meaning, such as a wish to
disappear, or a feeling of being the master of the universe, or simply to blush. These
ordinarily lived elements and other more or less explicit elements of the stream of
consciousness become objectified and distorted to such an extreme that they appear
foreign and strange. Functioning subjectivity is naturally individuated and determines
how one is in the world. If, for instance, a person has experienced lack of love and care
in his/her childhood, this person probably has a soothing fantasy of being loved and
cared for that occurs in specific encounters. Such a phantasy is usually played out so far
back in the stream of consciousness that it never becomes an actual object of intentional
consciousness. This does, however, not mean that it is unconscious. It has the potential
of being objectified, and the person is implicitly aware of the phantasy as it is being
lived. It is also this kind of material that ordinarily passes by unnoticed that is
objectified in hyperreflexivity, and that can be experienced as if it was expressed by

  25  
somebody else, i.e., as a foreign voice spoken out aloud inside one’s own head. This
kind of material fuels hallucinations.

These hallucinations appear, in some sense, to represent the perfectly normal

phenomena of ordinary human experience—which, however, are radically
transformed because of being lived in the abnormal condition of hyperreflexive
awareness and diminished self-affection. (Sass and Parnas 2003, 433)

In the same way, the body is prone to distortions that range from experiencing the body
in an objectified sense to the extreme where the body is no longer experienced as one’s
own, i.e., the body becomes detached and separated and is no longer experienced as an
aspect of the self (Sass and Parnas 2003, 432). The whole body might come to be
experienced as if it was somebody else’s body. But this can also occur in relation to
body parts, such as one’s arms and legs or one’s face might feel as if they were
possessed by an alien being.

A young man was frequently confused in a conversation, being unable to

distinguish between himself and his interlocutor. He tended to lose the sense of
whose thoughts originated in whom, and felt “as if” his interlocutor somehow
“invaded him,” an experience that shattered his identity and was intensely anxiety
provoking. When walking on the street, he scrupulously avoided glancing at his
mirror image in the windowpanes of the shops, because he felt uncertain on which
side he actually was. He used to wear a wide and tight belt in order to feel “ more
whole and demarcated.” He was very much attracted by the philosophy of
Merleau-Ponty, whom he considered as the only philosopher who truly had
grasped the fundamental subject-object reversibility. (Parnas and Handest 2003,
129-130).

This might also be expressed as a sense of not being fully human or of not really
existing, and it might also be expressed as if one was an automaton.

Disorganisation

In disorganisation, the person with schizophrenia still has a feeling of myness towards
experiences, and that feeling stems from the first person giveness of the experience. As
Zahavi states: “To believe that a thought which occurs in my mind is somebody else’s
thought can be compared to a situation where I acknowledge that my arm went up while
denying that I raised it” (Zahavi 1999, 155). It can also be framed in terms of ownership
and agency (Gallagher 2000, 16). In the above case, the person will acknowledge
ownership (the thought appeared to me from a first person perspective) but not agency
(I did not initiate the thought). Disorders where depersonalization happens, as in the
case of schizophrenia, are no threat to Shoemakers thesis, which states that the first-
person perspective is immune to the error of misidentification (Zahavi 1999, 153).

In the above, we have already seen that the disorganisation particular to schizophrenia
relates to the perplexity caused by the ipseity disorder and the basic symptoms. When

  26  
background becomes foreground, it disrupts attentive awareness, and the disturbed
ipseity disables the unity of the first person perspective and fractures operative
consciousness.

[The result is a] fundamental failure to stay anchored within a single frame of

reference, perspective, or orientation. … Often this involves a shift among
conceptual levels, including hyperabstract as well as hyperconcrete (or
hyperliteral) perspectives. (Sass and Parnas 2003, 435)

This is not a failure to stay focused on a single topic (as it is in the manic disorder). It is
rather that the subject interpenetrates concepts with each other indicating a general lack
of reference (Sass and Parnas 2003, 435). According to Artaud, his thinking is
experienced as a "violent flow" and as a "prolific and above all unstable and shifting
juxtaposition" (Sass and Parnas 2003, 436). Ordinarily, we are more or less wilfully
able to attain different perspectives on a given issue. In schizophrenia, however,
perspectives shift in an automatic fashion where one perspective automatically replaces
another (Sass and Parnas 2003, 435). And further, these drifting perspectives do not
necessarily have their reference in the natural attitude but might be grounded in a
solipsistic attitude. The natural attitude provides us with a common ground so that a
valid argument or reasons cannot be based on contradictions and must adhere to
common sense, whereas a solipsistic attitude is an individuated frame of reference that
is only accessible for others through communication (Henriksen and Parnas 2013, 3).
The person with schizophrenia can come across as if speaking in codes that make little
sense to the listener. It is the solipsistic attitude and the drifting perspectives that can
make the person with schizophrenia appear incomprehensible.

We saw earlier that the solipsistic attitude derives from diminished self-affection and
hyperreflexivity. Because the basic symptoms occupy attention, the person is directed
inwardly, and the solipsistic attitude naturally also arises because the natural word-
directedness of the natural attitude is not functioning properly, i.e., the world is not
pregiven in pre-reflective consciousness. The solipsistic attitude or perspective “usually
culminates in psychosis as a profound and rigid alteration of the sense of reality and
existence” (Henriksen and Parnas 2013, 3). Disorganisation is not a constant state of the
schizophrenic’s mind. It varies in relation to context and motivation, and it might even
disappear if there is a strong motivation in relation to practical activity (Sass, Parnas
and Zahavi 2011, 14).

Coexistence of the Natural and the Solipsistic Attitude

The person with schizophrenia is often aware of being different from other people, but
it may not be an awareness that relates to an illness as such. It is rather related to a sense
of having a unique access to deeper layers of reality that others do not have (Parnas and
Handest 2003, 130-131).

Unconstrained by these certitudes [from the natural attitude], the world may
appear as only apparent or staged, ontologically mind-dependent, prone to
noncausal relations, and the patient may experience a unique access to deeper

  27  
 layers of reality, which are inaccessible to others. Often, these experiences evoke
a specific sense of grandiosity, leaving others to be seen as oblivious to the true
nature of reality and only concerned with everyday trivialities. (Henriksen and
Parnas 2013, 3)

In the pre-onset stages of schizophrenia, interviews have revealed that the symptoms of
anomalous self-experience have been present for as long as the patient can remember
and are not experienced as anomalous by the patient. The symptoms are integrated into
the patients’ mode of being. This means that the patient do not necessarily differentiate
between an ordinary experience (silent thoughts) and a delusion of having foreign
thoughts inserted into the mind, at least not as a distinction between normal and
abnormal which is “perhaps irrelevant to the patient” (Henriksen and Parnas 2013, 5).
According to Henriksen and Parnas, patients might be surprised and suspicious when
they are told by the clinician that most people never hear thoughts spoken out aloud
internally. Henriksen and Parnas also write that, in their view, this is characteristic of
many self-disorders (Henriksen and Parnas 2013, 5). Even though patients are unaware
that their experiential manner of being present differs from that of other people, they
might still feel different from other people in the sense that they possess a unique access
to deeper layers of reality.

The sense of having a unique access to deeper layers may be fuelled by delusional
experiences that appear from within the solipsistic attitude. These experiences are
usually not correctable by common sense arguments.

[D]elusional beliefs in schizophrenia do typically not belong to the public sphere

but rather to a solipsistic ontological attitude, facilitated and antedated by self-
disorders, and these beliefs are rarely modifiable by counterarguments.
(Henriksen and Parnas 2013, 4)

A common feature in young pre-onset patients is an excessive preoccupation “with

philosophical, supernatural, and metaphysical themes” (Parnas and Handest 2003, 130).
“Many young, preonset patients try to account for their sense of “Anderssein” by
fantasies of being time-travelers, extraterrestrials, etc.” (Henriksen and Parnas 2013, 5).
The following citations are cases that describe the sense of having access to deeper
layers of reality.

Thomas, 22 years old and a highly gifted and successful student of mathematics,
hospitalized with a pre-psychotic panic, reported that he felt to be quite different
from other people since his very early childhood. He never had intimate friends,
yet was very popular in the primary school because of a gift for inventing
imaginary games. At the interview he mentioned that he always believed in the
existence of a “world-soul.” All humans were, metaphorically speaking, like
water drops fallen on earth, and so irreversibly separated from this soul. He,
however, still felt in touch with the “world-soul,” like a droplet yet hanging in a
tiny manner to its original source. Asked about magical abilities, he responded
that “ability” was a wrong word to use; rather, he felt “as if” he somehow
contained the entire universe within his own consciousness. He was perfectly
aware of the impossibility of its being true in the ordinary causal sense. He felt

  28  
 superior to others and was always amazed by a profound banality of ordinary
human strivings and interests. (Parnas and Handest 2003, 131).

A former physician, when working in the emergency room of a provincial

hospital, experienced, during fleeting moments, a feeling that he was the only true
doctor in the entire world and the fate of humanity was in his hands. He quickly
suppressed such feelings as entirely nonsensical. (Parnas and Handest 2003, 130).

The citations also reveal that the ability to differentiate between beliefs that are founded
in the natural attitude and beliefs that adhere to the solipsistic attitude are not
completely excluded.

The quest for metaphysical meaning is naturally not solely a feature of schizophrenia; it
is a basic human feature. The main point is that the person with schizophrenia is
founded in the natural as well as in the solipsistic attitude, and both are experienced as
part of the self. This topic also relates to what Bleuler designated as “double
bookkeeping” (Henriksen and Parnas 2013, 3). The main difference is that the
solipsistic attitude relates to a psychotic world (it is not merely a sense of having a
unique access to reality). Double bookkeeping designates a manner in which the person
with schizophrenia is able to live simultaneously in both the natural attitude and in a
psychotic world (Henriksen and Parnas 2013, 3). Bleuler mentions a patient that
hallucinates being threatened by a sword; she is afraid and cries out for the sword to be
driven away, only she does not seek cover but begs for a piece of chocolate (Henriksen
and Parnas 2013, 4). The following quote reveals that the person with schizophrenia is
well aware of both the shared social world and the psychotic world.

Rather than confusing his psychotic experiences with those of real objects,
Schreber seems for the most part to have been able to differentiate the two
“worlds”: “I could even say with Jesus Christ: ‘My Kingdom is not of this world’;
my so-called delusions are concerned solely with God and the beyond… The
certainty of my knowledge of God and divine matters is so great and unshakeable
that it is completely immaterial to me what other people think of the truth or
probability of my ideas. (Henriksen and Parnas 2013, 3)

The experiential sense of panic engulfs the whole body when one awakens from a
nightmare. A nightmare does, however, loosen its grip completely, and the conflict that
caused the nightmare retreats into pre-reflective consciousness. In schizophrenia, the
grip caused by delusions is not completely loosened. Instead the delusional episodes are
integrated and shape that person’s being. “[The] original delusional (or hallucinatory)
experience is an essentially lived, pathic (felt) event within the patient’s own
subjectivity, thus presenting a quality of an irrefutable subjective (egological) reality”
(Henriksen and Parnas 2013, 4). A patient of Henriksen and Parnas was asked, years
after her psychosis had remitted due to antipsychotic depot medication, why at the onset
of the illness her telephone had been tapped. She replied:

“This question I continue to ask my self to this day!” Here, the original feeling of
having been tapped retained, in the patient’s memory, a status of the experience’s
irrefutable subjective reality. In other words, she could doubt the objective reality

  29  
 of her fully formed delusions but not her original feeling of “being listened to.”
(Henriksen and Parnas 2013, 4)

The above exposition relates to the topic of “poor insight.” People with schizophrenia
display “poor insight into their illness” (Henriksen and Parnas 2013, 4), and many
patients with schizophrenia are unwilling to comply with treatment. Cognitive
neuroscience relates poor insight to a failure of metacognition which is a deficit in the
ability to accurately reflect on the mental content and/or a bias in relation to the mental
content (Henriksen and Parnas 2013, 2). The psychoanalytical tradition, on the other
hand, suggests that poor insight is a coping strategy or defense mechanism (a denial of
being ill) (Henriksen and Parnas 2013, 2). From a phenomenological perspective,
however, it is obvious that it is not a question of missing insight or a denial of illness.
The patient has insight, he/she is able to and does reflect on the illness, only the patient
does not consider the alleged illness to be an illness because the symptoms are an
experiential and integrated part of the self. This may explain why many patients with
schizophrenia are unwilling to comply with treatment.

  30  
3. Chapter: Gestalt-therapy

The Gestalt Prayer:

I do my thing, and you do your thing.
I am not in this world to live up to your expectations
And you are not in this world to live up to mine.
You are you and I am I,
And if by chance we find each other, it’s beautiful.
If not, it can’t be helped. (Perls 1969, 4)

Introduction to Gestalt-therapy  

Gestalt-therapy emerged in the 1950ies. The front figure was the psychiatrist and
psychoanalyst Fritz Perls (1893-1970), who wrote his first book Ego, Hunger and
Aggression in 1941-42 (Clarkson and Mackewn 1993, 16). His wife, Laura Perls, was
one among others who also had a great impact on the development and establishment of
gestalt-therapy (Clarkson and Mackewn 1993, 18-19). Perls was influenced by a variety
of ideas, such as those of Wilhelm Reich (body-armour), Jan Smuts (holism), Kurt
Lewin (field-psychology), Jacob Moreno (psychodrama), Martin Buber, eastern
philosophy, psychoanalysis, phenomenology, existentialism, etc.

Perls has his own style of writing and only sporadically mentions the theories that have
inspired him. His books on gestalt-therapy contain only very basic theoretical
explanations, but they also contain a large number of experiments for the reader to
explore in order to facilitate the reader with an experiential understanding of gestalt-
therapy. His manner of approaching the topic makes it hard to clarify specifically what
underlying theories he adheres to at a given moment. In Perls’ writings there is no
reference to Husserl or phenomenology. Laura Perls studied Husserlian
phenomenology, and she is probably the source of inspiration (Clarkson and Mackewn
1993, 6, 8). Anyhow, it is widely accepted that the therapeutic method is based on
Husserlian phenomenology and that the metaphysical foundation is existential (Hostrup
2004, 87, 37; Clarkson and Mackewn 1993). Perls refers to very few authors in general,
and none of his books contain a bibliography; in his autobiography even the page
numbers are missing. I will, however, mainly present gestalt-therapy from Perls’
perspective because I do not want to discuss what the founding theories may be; I only
want to discuss his perspective’s relation to phenomenology.

Perls does not claim that gestalt-therapy is a new theory; he has organised a variety of
existing theories that provides a new approach to psychotherapy. Referring to gestalt-
psychology (Gestalt School, Perls 1973, 3), he writes about perception: it is not the
perceived parts that shape a meaningful gestalt; the shape of a meaningful gestalt
depends on how the individual parts are organized, and the organization of parts is
determined by interest (Perls 1973, 2). “A gestalt is a pattern, a configuration, the
particular form of organization of the individual parts that go into its make up” (Perls
1973, 3).

  31  
Gestalt-therapy is designed to alleviate neurosis, and Perls’ idea was that gestalt-therapy
can be applied on any mental disorder. It is widely accepted within the community of
gestalt-therapy that the gestalt-therapist, who for example wishes to treat patients with
schizophrenia, must have a sound understanding of that particular disorder. I account
for how gestalt-therapy conceptualises neurosis, but be aware that the way the neurotic
character is framed applies to mental disorders in general.

This chapter starts with a description of how the neurotic character develops, which
happens when society impinges to heavily upon the subject. This elicits a fixation of
defence mechanisms instigating a diminished self-awareness that somewhat refrains the
person with neurosis from organizing meaningful gestalts. The self is revealed in its
manner of contacting the world, but to accomplish contact the self must be able to
distinguish between self and other; without this ability the self is in a chronic state of
confusion. I describe the defence mechanisms that instigate the diminished self-
awareness and muscular contractions. Following that, I describe the phenomenological
method that founds the therapeutic encounter. Finally, I describe some of the techniques
and experiments that are used in the therapeutic encounter to facilitate a re-experiencing
process that enhances experiential self-awareness.
 

Neurosis and Self-awareness

According to gestalt-therapy, neurosis develops due to a problem of identification;

neurosis entails an insufficient differentiation between self and other. “Indeed, this
confusion of identification is in fact neurosis … its hallmark is disintegration of the
personality and lack of coordination in thought and action” (Perls, 1973, 43).

The neurotic is, by accepted definition, a person whose difficulties make his
present life unsuccessful. In addition, by our definition, he is a person who
chronically engages in in self-interruption, who has an inadequate sense of
identity (and thus cannot distinguish properly between himself and the rest of the
world), who has inadequate means of self-support, whose psychological
homeostasis is out of order, and whose behaviour arises from misguided efforts in
the direction of achieved balance. (Perls, 1973, 63)

The problem of identification is caused by “introjects”. According to gestalt-therapy an

introject is: “Concepts, facts, standards of behaviour, morality, and ethical, esthetical or
political values–all these come to us originally from the outside world” (Perls 1973, 33).
The healthy4 self either assimilates or rejects the introjected object, and it thereby ceases
to be an introject. The neurotic character, on the other hand, develops as a sort of
psychological survival mechanism. As a means to survive, the introjected object is,
figuratively speaking, swallowed whole, and since it is not assimilated or rejected, the
introject resides in the organism as a foreign object causing confusion in the
individual’s self-relation. An unassimilated introject might also be referred to as an
unfinished situation or an incomplete gestalt (Perls 1969a, 42). Just as food must be

                                                                                                               
4  The term ”healthy” is used by Perls.    

  32  
chewed to facilitate growth in the organism, introjects must be assimilated or rejected to
foster growth in the person (Perls 1973, 32). The confusion of identification arises
because introjects lead to a diminished self-awareness which again elicits a state of
disorganization. “Confusion is a matter of inadequate orientation, and unacknowledged
confusion is one of the characteristics of neurosis” (Perls 1973, 50). Diminished self-
awareness is also likely to arise if a need is not met over an extended period of time. A
blind spot develops in relation to that particular need, which is termed a “fixed gestalt”
(Clarkson and Mackewn 1993, 69).

Introjects most likely create an “as if” character (Perls 1969, 143) as if the person is the
introjects, which means that the person is both an “I and not I, [or] self and self-image, a
personality so confused that it has become incapable of distinguishing one from the
other” (Perls, 1973, p. 42). The subject is an organism that interacts with its
environment (Perls, 1973, 26; 1969a, 5), and in this sense the self is an organismic-self
or rather an individual-self, but the self is also able to attain or to express a social-self in
a given context. “Our approach, which sees the human being as simultaneous and by
nature both an individual and a member of the group” (Perls 1973, 52). The healthy
person is able to differentiate between the individual-self and the social-self and is in a
given context aware if his/her behaviour is an expression of the individual-self or the
social-self, and further, she can choose to express either one or the other. People with
neurosis identify with, and conflate, the individual and the social-self, i.e., in a sense
they take both selves to be the individual-self and therefore behave in an automatic
fashion. Often they have no clear choice because they are usually unable to differentiate
between the two. “Without awareness, there is no cognition of choice” (Perls 1973, 65).
The healthy person is able to maintain an equilibrium or homeostasis between the two,
whereas the person with neurosis has a tendency to either withdraw from society or to
become engulfed by society (Perls 1973, 26).

The individual-self is based on self-awareness and that which is assimilated from the
social world. When the social world clashes with the individual-self, and the clash is
experienced as life threatening, the person is likely to introject the world (especially
children may experience the threat of not being loved and accepted as threatening their
survival). If I, as a survival mechanism, have come to identify myself with a submissive
and kind character (because I have swallowed an introject), I need to stop expressing
any inclination to the contrary. This is achieved through the execution of different
defence mechanisms. Originally, there is awareness of the execution of defence
mechanisms, but with time they may become fixated and awareness will diminish. Due
to the diminished awareness, the behaviour that is a consequence of the defence
mechanisms will come to be experienced as an expression of my own character, i.e., I
identify with the expectations of the other and thus have developed an “as if”
personality. Although these mechanisms or functions are often termed defence
mechanisms, they are in fact ordinary mechanisms that facilitate how we want to
engage with the world. They may, however, become crippling, because when the
mechanisms are executed without awareness, their manifestation in behaviour is
identified as part of one’s personality. When awareness of the defence mechanisms is
regained through psychotherapy, it is possible to abstain from executing the defence
mechanisms and to reintegrate the parts of the self disassociated through the automatic

  33  
execution of the defence mechanisms. Later I attend to the different defence
mechanisms; but for now turn to an investigation of awareness.

“Our emphasis is on self-awareness … because it is where most of us are handicapped”

(Perls, Hefferline and Goodman 1998, 76). “Repressions mean the avoidance of
awareness” (Perls 1969, 66). To Perls, self-awareness is “that subjective state of
primary feeling that one exists, as well as the feel of how one exists” … “being aware of
one’s being and doing” … “the feel of yourself” (Perls 1969, 255). As far as I can tell,
Perls does not differentiate between self-awareness and awareness, i.e., awareness is
always both of the self and its response to its environment. Perls writes that
“[awareness] is more diffuse than attention–it implies a relaxed rather than tense
perception by the whole person” (Perls 1973, 10). I suggest that Perls here intends to
say that awareness is an implicit awareness of subjectivity. In the following quote, Perls
differentiates between awareness and introspection. Awareness is a spontaneous sensing
of what is at play in the self, whereas introspection is a deliberate and evaluating
attending to a specific part of the self which may prevent awareness.

Awareness is the spontaneous sensing of what arise in you–of what you are doing,
feeling, planning; introspection, in contrast, is a deliberate turning of attention to
these activities in an evaluating, correcting, controlling, inferring way, which
often, by the very attention paid them, modifies or prevents their appearance in
awareness. […] Awareness is like the glow of a coal which comes from its own
combustion; what is given in introspection is like the light reflected from an
object when a flashlight is turned on it. In awareness a process is taking place in
the coal (the total organism); in introspection the process occurs in the director of
the flashlight (a split-off and highly opinionated part of the organism which we
shall call the deliberate ego). (Perls, Hefferline and Goodman 1998, 75)

According to Perls, awareness is something in addition to the conscious (Perls 1973,

64). He writes that the conscious is the mental; in attentional consciousness an
experience is sifted through the mind and words, whereas awareness is an experience
that simply is. There is no evaluating taking place in self-awareness. Self-awareness
provides a sense of one’s capacity, abilities, sensoric, motor and intellectual equipment
(Perls 1973, 64-65). “Awareness is a process engaging the whole organism” (Clarkson
and Mackewn 1993, 44-45). Perls talks about the pleasure of self-awareness and of
satisfaction and “peace of mind” which one does not encounter in self-consciousness
(Perls 1969, 255). What Perls more precisely means by self-consciousness seems to be
the state of being explicitly self-conscious, which prevents one from fully attending to
the world. Perls does state that self-consciousness arises from a wish to be admired or
from “ungratified narcissistic wishes” (Perls 1969, 256), and that a similar self-
consciousness is the sense of being watched (Perls 1969, 256). Self-consciousness is a
retroflection where attention is directed towards the self instead of towards the object of
irritation or interest. It is “consciousness of one’s own condemned or despised features
or behaviour” (Perls 1969, 254). No retroflection takes place in self-awareness, and it is
important not to conflate self-awareness and self-consciousness (Perls 1969, 255). In
the process of regaining self-awareness, the client is helped to form a gestalt of her

  34  
interests,5 and it follows that instead of being self-conscious she will attend to the object
of interest; “one way to cure self-consciousness is to change it into object-
consciousness” (Perls 1969, 256). When the self in this self-conscious manner is the
foreground figure, it entails a “lack of concentration, confusion and a general
discomfiture” (Perls 1969, 256).

So far, we have seen that the most basic self in gestalt-therapy is conceptualised as an
organismic and spontaneous self (Perls 1969, 229). We only come into contact with the
self through self-awareness. Another self is the “deliberate ego” (Perls, Hefferline and
Goodman 1998, 75) which is a self that is encountered through introspection and in
self-consciousness (Perls 1969, 256). It is a self that partially derives from (false)
identification, and it is also a self that is created from what one imagines that one is, and
what one decides and chooses to be. Consequently the deliberate-self it is not
necessarily founded on what actually is, i.e., self-awareness. “The basic barrier to full,
healthy experiencing is the tendency to accept as one’s own only what one does
deliberately–that is, “on purpose”” (Perls, Hefferline and Goodman 1998, 75). This
means that the deliberate-ego is able to disown the organismic-self even if there is
awareness, but also that the deliberate-ego of the healthy person is founded on the
organismic-self or self-awareness.

The neurotic symptom is always a sign that the biological self wants attention. It
indicates that you have lost the intuition (in the sense of Bergson)–the contrast
between your deliberate and spontaneous self. (Perls 1969, 229)

Contact and Contact Boundary

Many topics in gestalt-therapy are related to an understanding of contact and contact

boundary because contacting the environment is a precondition for both organismic and
personal growth. ““Be yourself,” is misleading, for the self can be felt only as a
potentiality; anything more definite must emerge in actual behaviour” (Perls 1989, 375).
The individual is not self-sufficient but exists at any given moment in an environmental
field. Language splits the unity “I” and “see” and “tree” but in experience they are one
(Perls 1973, 17). Behaviour is an expression of the individual’s relationship with the
environment. The contact boundary is not to be understood as a separation of the two,
but where the relationship takes place (Perls, Hefferline and Goodman 1998, 229). “The
concept that sensing is a passive, mechanistic phenomenon has to be replaced by the
insight that we are active and selective in our sensing” (Perls 1948; Stevens 1975, 50).
The phenomenological concept of “life-world” (Lebenswelt) corresponds with Lewin’s
“field-psychology” (Fuchs 2007, 425) that gestalt-therapy adheres to. Clues as to how a
particular person functions is gained from attending to how that person contacts the
environment and the person’s lack of contact.

                                                                                                               
5
The term ”gestalt” is used in the sense of figure-background formation adhering to
gestalt-psychology.

  35  
 The study of the way the human being functions in his environment is the study of
what goes on at the contact boundary between the individual and his environment.
It is at this contact boundary that the psychological events take place. Our
thoughts, our actions, our behaviour, and our emotions are our way of
experiencing and meeting these boundary events. (Perls 1973, 16)

The neurotic configurations consist in “various inhibitions of the process of contacting

the present” (Perls, Hefferline and Goodman 1998, 371). A precondition for contact is
awareness, and since awareness only occurs in the present moment, gestalt-therapy
attends to the “here and now.” “Awareness, contact and presence are merely different
aspects of one and the same process–self-realization” (Perls 1973, 65). Contact can only
take place in the present now, and a necessary condition for contact is the ability to
distinguish the self from the other. In this sense, contact can only occur between two
separate entities.

Intellectualism might become a fixed defence mechanism that prevents one from being
aware of the present moment. If, say, one intellectualises or is occupied with the past or
the future to an extreme extent, one may be more or less unaware of how one functions
in the present moment. “There is no other reality than the present. […] Predilection for
either historical or futuristic thinking always destroys contact with reality” (Perls 1969,
92). “It [intellectualism] is an attitude designed to avoid being deeply moved” (Perls
1969, 67).

A premise in gestalt-therapy is that all life and all behaviour are governed by
homeostasis (Perls 1973, 4), a process of self-regulation. When the organism detects an
imbalance, it will attempt to restore balance, and if the organism is in a state of
disequilibrium for too long, it becomes sick (ibid). The human organism has a variety of
needs, both physiological and psychological, and to meet these needs the organism must
contact and interact with the environment. The first step is for the subject to become
aware of a need, say a hunger. If everything goes well, the person will contact the
environment and eat (contact). After having eaten, the person will withdraw from
contact, and the equilibrium of the organism is restored, which leads to growth. This,
however, requires a clear gestalt; the need must step out of the background and into the
foreground for the subject to become aware of the need, which in accordance will
organize the perceived environment so that the need can be fulfilled. “The need (or
interest) organises the field” (Clarkson and Mackewn 1993, 43). Since the human
organism at times has a myriad of needs, the subject must be able to prioritise its needs.

When the figure is dull, confused, graceless, lacking in energy (a weak gestalt),
we may be sure that there is a lack of contact, something in the environment is
blocked out, some vital organic need is not being expressed; the person is not “all
there,” that is, his whole field cannot lend its urgency and resources to the
completion of the figure. (Perls, Hefferline and Goodman 1998, 232)

Perls refers to the ego boundary and writes that it is “the differentiation between the self
and the otherness” (Perls 1969a, 7); he further writes, the “self means nothing but this
thing as it is defined by otherness” (Perls 1969a, 8), i.e., the self is defined by
identification and alienation. “The self is the contact-boundary at work; its activity is

  36  
forming figures and ground” (Perls, Hefferline and Goodman 1998, 235). This ability is
somewhat diminished in the neurotic character.

He no longer has a clear sense of the order of his needs–he tends to give them all
equal value. He is like the young man Stephen Leacock once spoke about who got
on his horse and galloped off madly in all directions. (Perls 1969, 66)

The result of the diminished self-awareness is an inability to differentiate between self

and other, which means that parts of the other or the social world are identified as part
of the self and that parts of the self are disassociated. When the ego boundary is fuzzy in
this manner, it is experienced as a state of confusion. The inability to differentiate
between self and other causes confusion in differentiating between one’s own needs (or
interests) and the needs of the other, i.e., the other’s needs and interests and one’s own
conflate. The state of confusion affects the ability to form clear gestalts and to prioritise
between the vague gestalts, which to some extent obstruct contact, since contact
requires acknowledgement of difference.

Defence mechanisms

I have already introduced introjection as a defence mechanism; in this function, the self
identifies with or takes responsibility for something that really belongs to the
environment. Introjection is a function where we identify with “standards, attitudes,
ways of acting and thinking, which is not truly ours” (Perls 1973, 35). When those
unassimilated introjects collide with assimilated beliefs, wishes, desires or impulses, a
function called projection can be executed to stop them from colliding.

Projection
A projection is a function whereby the self rids itself of aspects that it finds difficult,
offensive or unattractive, such as beliefs, wishes or desires. It is usually introjects that
leads to the feeling of self-contempt and self-alienation that again leads to projections
(Perls 1973, 37). In projection, the environment is made responsible for something that
originally originated in the self. We must be careful and distinguish between
assumptions and projections. When we assume what the other’s intention is, then we are
aware that it is an assumption. On the other hand a projection is experienced as real in
the sense that there is no awareness that the projected “object” in fact originated in the
self (Perls 1973, 35). Perls further writes that paranoia (a highly organized system of
delusions) is an extreme case of projection; the person with paranoia hides his
aggression, but really wants to persecute somebody (Perls 1973, 35). A projection can
also be executed on a part of the body, for example when one’s bladder is objectified
(becomes an introject) and is not experienced as part of the self. The person feels
victimised by the bladder and might exclaim, “It really is a nuisance” (Perls 1973, 36-
37). “When the projector says “it” or “they” he usually means “I”” (Perls 1973, 37).
Introjects make the self a battleground for unassimilated ideas, whereas projections
make the world the battleground (Perls 1973, 37-38). If introjection and projection
become chronic (without awareness), they will to some extent affect the ability to
distinguish between the self and the environment.

  37  
Retroflection
Retroflection is a function whereby the self turns impulses against itself instead of
directing the impulses towards the environment. In retroflection, a boundary is drawn
right through the self splitting the self into an “I” and “myself” (Perls 1973, 40). Instead
of directing energy or behaviour towards the environment to have one’s needs met,
impulses are directed towards the self; the self becomes a substitute for the
environment. Naturally, it is good to refrain from executing one’s destructive impulses;
it is, however, a different matter to turn the destructive impulses towards the self.
Retroflection prevents one from confronting an offender or the person that might fulfil
one’s need. Instead “I” confront “myself” (Perls 1973, 40-42).

Confluence
Confluence is a function where one identifies with a group of people or another person,
i.e., the experience is devoid of any sense of boundary. It is not a problem if the state of
confluence entails awareness, i.e., for example if it is recognised as an exaltation to
rejoice with the group (Perls 1973, 38). However, when confluence becomes chronic,
the person often demands sameness and refutes any difference (Perls 1969, 39). In
pathological confluence, it is not possible to determine if the “we” is expressed as an “I”
or “everybody” (Perls 1973, 40).6

The introjector does as others would like him to do, the projector does unto others
what he accuses them of doing to him, the man in pathological confluence doesn’t
know who is doing what to whom, and the retroflector does to himself what he
would like to do to others. (Perls 1973, 40-41)

Perls has described other defence mechanisms than the above, such as egotism and
desensitization (Clarkson and Mackewn 1993, 134). All defence mechanisms relates to
gestalt formation. It is somewhere in the attempt to finish the gestalt (to fulfil a need)
that the disruption of the gestalt occurs. When a gestalt is disrupted by a defence
mechanism, gestalt-therapy talks of an “unfinished gestalt.” These unfinished gestalts
add to the state of confusion because until gestalts are completed, they are part of the
ground from which new gestalts emerge. Since needs and impulses cannot be
completely repressed but only its expressivity, the unexpressed needs add to the
confusion. The unfinished gestalts engage resources that should have been involved in
the creation of new gestalts (Perls, Hefferline and Goodman 1998, 430). One aim of
gestalt-therapy is for the client to finish those unfinished gestalts. To achieve this, the
client must first become aware of how he interrupts himself. Defence mechanisms are,
however, not restricted to the mental; also muscular contractions can interrupt the
gestalt formation from being completed.

                                                                                                               
6  Perls writes that the infant is in a symbiotic fusion with its mother and that the initial

state of the infant is a confluence; “they have no sense of any distinction between inside
or outside, between the self and the other” (Perls 1973, p. 38). This is, however,
questionable (Zahavi 2005, 198).
 

  38  
The Body-armour

If a particular behaviour is not accepted, we have different means to stop impulses from
being expressed. One option is a willed contraction of a given formation of muscles. An
impulse to cry is held back by contracting the diaphragm. This not only holds back the
cry; it also inhibits respiration (Perls 1969, 39).

Perls was a client of Wilhelm Reich’s and was especially inspired by Reich’s
understanding of the “body-armour” and of resistance being inhibition of respiration.
“Reich’s bringing down to earth the psychology of resistance” (Perls 1969, 5). “We
repress vital functions (vegetative energy, as Reich calls their sum) by muscular
contraction” (Perls 1969, 229).

The character armours turned out to be functionally identical with muscular

hypertonic. The new concept “functionally identical”, which I had to enforce, just
says, that muscular and character positions in the mental apparatus have the same
function, they can replace each other and mutually affect each other. In fact they
cannot be separated, their function is identical. (Reich 1971, 260)

If a person for an extended period of time is in a social environment that disapproves of

crying, expressing anger or any other behaviour, and it is felt as a matter of either
survival or a striving for recognition (naturally the child is vulnerable), a certain
muscular formation can develop into a body-armour or a multiplicity of armours that
restricts unwanted behaviour. The body-armour might also develop from the impact of a
traumatic experience. Awareness of the body-armour is limited or even absent like other
functions that have turned into a defence mechanism. The body-armour is caused by a
retroflection (Perls 1969, 229).

The motoric system has to a great extent lost its function as a working, active,
world-bound system and, by retroflection, has become the jailer rather than the
assistant of important biological needs. (Perls 1969, 229)

Perls also writes of confluence between the wish to cry and respiration, which entail the
loss of both the ability to breathe freely and the ability to cry, thus causing
psychosomatic illness (Perls 1973, 39). In psychotherapy, both the wish not to cry and
the body armour must be recognised and dealt with. The gestalt is completed, in this
particular case, when the client is able to cry in a fully sobbing manner. This is what
Reich means by identical function; a mental function has its identical function in the
body.

The Phenomenological Method

Perls only scarcely presents the method that the gestalt therapist is supposed to practice.
To my knowledge, Perls does not mention the phenomenological epoché as the method
of gestalt-therapy. He writes about a “phenomenological basis” (Perls 1973, p. 64),
which refers to the present now. Gestalt-therapy not only attends to the here and now, in

  39  
the sense that you are not meant to talk about the past or the future. Gestalt-therapy also
describes rather than analyses the phenomenon that arises in the encounter. I elaborate
further on this topic below in the section Practising Gestalt-therapy and Techniques. I
do, however, think that the following quotes from Perls are indicative of the need to
effectuate something like the epoché in the therapeutic encounter, and that is probably
why contemporary takes on gestalt-therapy agree that gestalt-therapy is based on
Husserlian phenomenology (Hostrup 2004, 87).

Ideally, the therapist would act in compliance with the Eastern sages: make
yourself empty so that you can be filled, or with Freud’s rephrasing of the concept
in the demand that the therapist’s attention be free-floating and he himself free
from complexes. (Perls 1973, 103)

And the acute therapist can find plenty of material right under his nose; he need
only to look. Unfortunately, even this is not easy, for to look and to see requires
that the therapist be completely empty and unbiased. (Perls 1973, 75)

Perls, however, writes that the therapist is naturally not able to become fully free of
himself, and further that fixed abstractions and theoretical assumptions prevent the
therapist from fully seeing the other (Perls 1973, 103). This does not mean that the
therapist should not be well founded theoretically, only that the therapist must, to some
extent, be able to bracket those assumptions while practising gestalt-therapy.

Since contact always occurs on the surface, it is the surface that the therapist must
see. But make no mistake about it, that surface is much broader and more
significant than the orthodox therapist will admit. First of all, their preconvictions
prevent them from seeing much of it. And second of all, they tend to take it for
granted, to talk about it contemptuously as ”obvious.” (Perls 1973, 75)

Perls believed that the expressivity of the body has an authentic language (Clarkson and
Mackewn 1993, 40). “[Everything] the patient does, obvious or concealed, is an
expression of the self” (Perls 1973, 75). The biggest mistake for a gestalt-therapist is to
take the surface for granted and to dismiss it as obvious, because this leaves the
therapist without the tools to facilitate the therapeutic process (ibid). The tools appear in
the here and now, such as a clenched fist or a twisting foot, a pitched voice, avoiding
eye contact, inhibited breathing and so on.

[The] therapist should be sensitive to the surface the patient presents so that the
therapist’s broader awareness can become the means by which the patient is
enabled to increase his own. (Perls 1973, 64)

When Perls writes that the therapist must see the surface, I do not think he refers to the
mechanical-body (Körper) but rather to the lived-body (Leib) and to expressivity.

According to Clarkson and Mackewn, the phenomenological method applied in gestalt-

therapy entails three interrelated steps: bracketing, describing and equalizing.

  40  
 1) Bracket assumptions and biases
2) Describe impressions rather than explain or interpret
3) Equalize all aspect of the field and assume no hierarchy of importance
(Clarkson and Mackewn 1993, 46)
 
In the phenomenological attitude, the therapist is supposed to be a non-judgemental
observer of the whole field. The basic idea is that gestalts that could be obscured by
propositions are likely to emerge in this attitude. We must “rupture our familiarity with
it [the world], and this rupture can teach us nothing except the unmotivated springing
forth of the world” (Merleau-Ponty 2012, xxvii). The phenomenological attitude is in a
sense an “experiential attitude.”

Practising Gestalt-therapy and Techniques

Perls was founded in the psychoanalytic tradition, and he often refers to Freud mainly to
explain how his own theory and general approach to psychotherapy differs from
Freud’s. In psychoanalysis, the client is lying on a couch, and the therapist is placed in a
way that avoids direct contact between the two. This is to avoid transference and
resistance, i.e., to avoid that the therapist is used as a projection screen by the client.
The client is asked to freely associate (talk about whatever enters the mind). The
therapist is silent until sufficient material is collected to provide the client with an
analysis or interpretation of the client’s problems or, for example, the meaning of a
dream. In gestalt-therapy, the therapist knows that the valuable material takes place
between the client and the therapist including transference and resistance. Since the
foundation of gestalt-therapy is existential, the only interesting meaning or truth comes
from the client. The aim of gestalt-therapy is for the client to become so well founded in
his own existence that he is able to lead a meaningful life, naturally on his own accord,
and is able to accept the existential pain as a condition of life. Gestalt-therapy does not
analyse or reinterpret past events because that does not resolve the client’s problems
(Perls 1973, 52-53), and the gestalt-therapist does not encourage the client to understand
but to become aware.  

The following quote from Kierkegaard expresses the idea that peace of mind is gained
by submitting to what one is and not by avoiding pain.

Ja, dersom Du nogensinde, optugtet ved Lidelser, har underkastet Dig i

fuldkommen, i ubetinget Lydighed: da har Du ogsaa fornummet det Evige
nærværende i Dig, fundet det eviges Ro og Hvile. Thi hvor det Evige er, der er der
Ro; men der er Uro, hvor det Evige ikke er. Der er Uro i verden, men fremfor Alt er
der Uro i et Menneskes Sjel, naar det Evige ikke er i den, og han kun ”mættes med
Uro”. Men vil Adspredelser, under Skin af at forjage denne Uro, forøge den: saa vil
Lidelser, under Skin af at forøge den, forjage den. (Kierkegaard 2010, 356)

Perls writes that therapy “consists in rectifying false identifications” (Perls, 1973, p.
43), and also that the therapist must help the client experience himself, and not tell the

  41  
client what his problems are. The whole session with the client is more or less devoted
to experiential experiments in order to increase awareness.

What is essential is not that the therapist learn something about the patient and
then teach it to him, but that the therapist teach the patient how to learn about
himself. This involves his becoming directly aware of how, as a living organism,
he does indeed function. This comes about on the basis of experiences which are
in themselves non-verbal.7 (Perls, Hefferline and Goodman 1998, 15-16)

“[The] patient must come to his “senses.” He must learn to see what is there, and not
what he imagines to be there” (Perls 1973, 102). The person with neurosis mainly
identifies with the mind, and that is what Perls means by the slogan “lose your mind and
come to your senses” (Clarkson and Mackewn 1993, 145). If one mainly identifies with
whatever goes on in the mind, it becomes almost impossible to make sense of one’s life;
thus one must strive to identify with the whole organism. “Man transcends himself only
via his true nature, not through ambitions and artificial goals“ (Perls 1973, 49). To
become self-aware requires an acceptance of what is and an unconcern with
understanding (Perls 1973, 97). If the client becomes aware of being angry, and she
switches her attention towards understanding why she is angry, the awareness of the
anger is radically reduced or eliminated. Instead of asking why, the client is encouraged
to describe what it is like being angry, to embrace the anger. Change, or rather personal
growth, does not come about through a rational decision to change. Awareness evokes
the “paradox of change” which means that the gained awareness elicits a different
functioning. With awareness the functions are no longer automatic; the functioning is
willed.

“Routine and habits are established functions, and any need to change them requires
that they should be brought into the focus of awareness afresh” (Perls 1973, 65). The
practising of gestalt-therapy is founded on some basic awareness experiments, and their
spirit carries the therapeutic session (Perls 1973, 64). The experiment starts by
repeatedly exercising the sentence ““now” or “at this moment” or “here and now””
(Perls, Hefferline and Goodman 1998, 31). For example, “now I am aware” and “now I
need” and “now I want” and “now I feel.” The therapist can also ask the client to focus
attention solely on bodily sensations: “At this moment I am aware of a muscular tension
in the lower back, and now I am aware that I hardly breathe, and now I am aware that
my feet are cold” and so on. The body experiment is a variant of yoga. The main
difference between the two is that gestalt-therapy has no intention of relaxing the
conflicts or tensions in the organism (but if relaxation comes spontaneous it is not
meant to be prevented).

Forced relaxation is as unsound as forced concentration. The muscular tensions

which prevent relaxation constitute important parts of the very resistances that we
want to attend to, so we must not drive them out of the picture to begin with.
(Perls, Hefferline and Goodman 1998, 76)

The basic aim is to enter the present moment and possibly become aware of a function
                                                                                                               
7
Grammatical errors are not corrected in the quote.

  42  
or of resistance. If the client resists engaging in an experiment, it provides a fine
opportunity to examine how (and not why)8 he holds himself back. “His behaviour here
and now is a microscopic cross section of his total behaviour. If he sees how he
structures his behaviour in therapy, he will see how he structures it in every-day life”
(Perls 1973, 101). The experiment can be executed anywhere (while walking, shopping,
eating) and also given as homework. In the therapeutic setting and at home, the client
will be comfortably seated or lying down on a not too soft surface.9

I have already stated that the metaphysical foundation of gestalt-therapy is existential.

During the session, it is expressed by the way the therapist asks the client to become
responsible for himself. “The “I” is used as an antidote to the “it” and develops the
patient’s sense of responsibility for his own feelings, thoughts and symptoms.” … The
“am” is his existential symbol” (Perls, 1973, 64). And the “aware” provides a sense of
his capacities. The statement: ”he is annoying” often indicates that it is out of the
client’s hands to change how he feels, whereas “I let him annoy me” or “I am annoyed”
indicates taking responsibility, and it provides the client with a choice. The therapist
asks the client to change for example “one must” to “I want” to enhance the client’s
self-expressivity by being specific.

The gestalt-therapist will look for unfinished situations, how the client holds herself
back or interrupts herself (Perls 1973, 103). When the client clenches her fist, grinds her
teeth, holds her breath, swings her foot or folds her arms across her chest, it is an
indication that subjectivity wants to express something, and it is always a good
opportunity for the therapist to investigate. Usually, the client will have no awareness of
what she does before the therapist points her attention towards it. A very efficient tool is
to ask the client to exaggerate the movement or expression; this might prompt the
repressed to surface, and it might provide an opportunity to finish the disrupted gestalt.

The client’s past experiences are interesting in relation to how they interfere with the
client’s ability to lead a fulfilling life (Perls 1973, p. 70). In gestalt-therapy it is,
however, insufficient to recall past incidents. Instead the therapist uses psychodrama to
bring the past into the present (Perls 1973, 65). When the client talks about an incident,
it often lacks awareness of what it felt like to live through the event (Perls 1969, 228-
229). Instead of letting the client talk about an incident from childhood, an option is to
ask the client to again become the child and tell the story from the child’s perspective:
“I am hiding behind the sofa, my mother opens the door” and so on. The therapist will
ask the client to be aware of and to describe bodily sensations and emotions during the
experiment. The psychodrama will often prompt the client to re-experience what it felt
like. The aim is to direct the client’s attention away from her thoughts and towards her
body. It is very different to talk about a past event and to re-experience it. Getting in
touch with the organismic or experiential-self is easier when it is explicitly felt. These
experiments can be overwhelming for the client, and the therapist must be supportive.
Often, the experiences may be unexpected and new to the client, such as fear, sadness or
a profound loneliness, even though the client later may state that she in a sense knew all
                                                                                                               
8
Generally, the gestalt-therapist never asks questions starting with “why” because it
calls for an explanation.
9
The book Gestalt Therapy (1998) provides a variety of such experiments.

  43  
along. The same kind of experiment is also applied on dreams. Perls believed that
dreams carry an existential message (Stevens 1975, 6).

When events are re-experienced psycho-dramatically, introjects, projections or other

material will surface and can be placed in the “empty chair.” In fact, everything can be
placed in the chair, but the empty chair is never used in a therapeutic session without
explicit consent from the client. If the client talks about another person, the therapist
will ask the client to imagine the other person. This imaginary person is invited to sit in
the empty chair. The client will then talk to the person and not about the person. The
client is also involved in placing the chairs (the therapist will encourage the client to
express whether a given distance between her and the empty chair feels right), and she
can change the position of her own or the empty chair during the experiment. After
having observed the client’s manner of interacting with the person in the empty chair,
the therapist can provide sentences for the client to say out loud; the sentences are
merely suggestions, and it is up to the client to decide if a given sentence feels right.
The main aim here is that a sentence can be repeated or even shouted to the imaginary
person in the chair if it feels right and is explicit (not avoiding responsibility). If the
client has difficulty expressing anger, the therapist can suggest that the client beats the
imaginary person in the chair with a soft bat. This exercise helps loosen the body-
armour. In these instances, it is important not to let the client beat an aspect of the self
that is placed in the chair. The aim of re-experiencing and of placing a problematic
something in the empty chair is first to gain awareness and then either to reject,
assimilate or finish an unfinished gestalt.

As I wrote earlier, a gestalt emerges as a need or an interest, but the gestalt can also be
an unassimilated introject that is to be either assimilated or rejected. When that is done,
the gestalt is finished (or closed), it will vanish, and a new gestalt can emerge.10 The
finishing of the gestalt may, however, be interrupted by the subject. Within gestalt-
therapy, it is also referred to as an unfinished situation. If the client becomes aware of a
need to tell her mother that she wants her mother to stop putting or letting her down, the
empty chair is an opportunity for her to investigate how she prevents herself from doing
just that. Confronted with her mother in the chair, the client might become aware that
she is literally terrified and that her mother is furious and never wants to talk to her
again, or she might become aware of how she strangles herself by muscular contractions
so that she is unable to speak. In this case, the main aim is not to finish the gestalt, i.e.,
that the client tells her mother whatever she needs to say. On the contrary, the main aim
is for the client to become aware of, and possibly describe, how she holds herself back
because the client will most likely use the same means of interrupting herself in similar
situations. With the heightened self-awareness, the client will most likely be able to
confront the person in real life, because the client may realise that the fear experienced
in therapy is no longer valid, or that she is able to cope with the fear. The need to avoid
the experiential reality is no longer present. If an introject (such as a moral norm) is

                                                                                                               
10
Gestalt-therapy is based on gestalt-psychology, and its understanding of perception
corresponds with the phenomenological understanding of perception. It is the subjective
meaning formation that makes a figure stand out from the background. Inner perception
functions in the same manner.

  44  
placed in the empty chair, the client is helped to either assimilate or reject the introject
through an interaction with the introject in the chair.

The therapist should also pay attention to the client’s “as if” character, which is
expressed through “role play.”11 The client might act as if being helpless, victimized,
funny, flirtatious or another kind of role that hides the organismic-self (Stevens 1975, 4-
5). The client brings with him these clever ways of manipulating the environment, but
the client who enters therapy “feels that he is in an existential crisis” (Perls 1973, 44)
because his means of manipulation have become insufficient in the sense that they no
longer help him fulfil his needs. The client identifies with these roles; they are simply
taken for granted in a way that the client lacks awareness of what she is doing. The
different roles must be brought into full awareness (Perls 1973, 44-46).

The neurotic cannot conceive of himself as a self-supportive person, able to

mobilise his potential in order to cope with the world. He looks for environmental
support through direction, help, explanation, and answers. He mobilizes not his
own resources, but his means of manipulating the environment. (Perls 1967;
Stevens 1975, 11)

The main aim of gestalt-therapy is for the client to gain self-support. Thus it is vital that
the therapist does not provide more support than necessary. “Maturation cannot be
achieved for him; he has to go through the painful process of growing up by himself”
(Perls 1967; Stevens 1975, 12). The therapist must help the client to support himself,
and naturally this approach will frustrate the client. Perls writes that the ideal therapist
is an “empathist” (Perls 1973, 104). In empathy, the therapist is excluded from the field,
and the therapist’s interest is focused exclusively around the client and the client’s
reactions (Perls 1973, 104). “There can be no true contact in empathy” (Perls 1973,
106). If the foundational state is that of sympathy, the client is likely not to gain the
strived for self-support. “In sympathy, as in all forms of confluence, the contact
boundary is absent” (Perls 1973, 106). Consequently, the therapeutic foundation should
be that of empathy. From this position, the therapist will determine whether to provide
support or to encourage the client to take responsibility. Frustration should never be
achieved from forms of sadism, for instance when the therapist presents a poker face to
the client (Perls 1973, 108).

In dealing with psychotics, we are very careful not to use the tool of frustration
too much. We are careful, too, to let them and their behaviour–rather than our
fantasies and theories about psychosis–guide us. (Perls 1973, 107)

“We touch each other by honestly being what we are, not by intentionally making
contact” (Perls 1969a, 65). The therapist cannot insist on contact, but it might occur if
he is what he is.

The aim of this paper is to investigate if gestalt-therapy is a relevant therapeutic

treatment for schizophrenia, but it is also relevant to ask what to expect from treatment.
                                                                                                               
11
Perls also referred to the adopted roles as “mental torture” and “phoney behaviour”
(Clarkson and Mackewn 1993, 38).

  45  
If a cure is expected, in order for the patient with schizophrenia to become a productive
and integrated member of the community (according to the expectations of a given
state), then gestalt-therapy is not a relevant treatment. Gestalt-therapy does not provide
a normalisation process. Its aim is not to shape individuals who adhere to a given codex
of normal behaviour; rather its aim is for the individual to be able to make sense of his
own behaviour. This is expressed in the gestalt prayer in the beginning of this chapter.
If gestalt-therapy is successful, it will, however, probably open the possibility for the
individual to interact in a more fruitful manner with his/her community. When the
patient with schizophrenia acquires a self-relation founded on the experiential-self that
entails recognition and acceptance, then he is also likely to be in a state of mind that
enables him to engage with the world but naturally on his own accord.
   

  46  
4. Chapter: Discussion

Introduction

In this chapter, I underscore why gestalt-therapy is a relevant psychotherapeutic

treatment for schizophrenia. To do that, I briefly present the perspective of cognitive-
behavioral therapy, as it is critically portrayed by Skodlar et al. in Cognitive-Behavioral
Therapy for Schizophrenia. Their focus is on what they term the second wave of
cognitive-behavioral therapy. Today, the first choice of psychotherapeutic treatment for
schizophrenia (and psychiatric disorders in general) in mainstream psychiatry is
cognitive-behavioral therapy (Skodlar et al. 2013, 249), but the phenomenological
understanding of schizophrenia is not in line with the understanding of schizophrenia
found in cognitive-behavioral therapy (Skodlar et al. 2013). In relation to schizophrenia,
the self is not mentioned in the main classificatory systems DSM-IV and ICD-10 (Sass
and Parnas 2003, 427; Parnas and Handest 2003, 122). This is problematic since it is not
possible from a behaviouristic perspective to detect the early symptoms with sufficient
accuracy, because the prodromal behaviourally defined features of schizophrenia are too
common in the general population (Sass and Parnas 2003, 428). The phenomenological
perspective on schizophrenia increases the possibility of detecting the pre-onset
symptoms of schizophrenia. An early detection of distorted acts of awareness is vital,
because the sooner the prodromal features are detected the better the prospects are in
relation to limiting the severity the course of the illness will take (Sass and Parnas 2003,
428). I argue that from the perspective of gestalt-therapy, the approach of cognitive-
behavioral therapy might in fact increase the distress of the patient with schizophrenia
rather than weakening the distress.

I further question Barnaby Nelson’s assumption that borderline personality disorder

(and possibly neurosis) adheres to the narrative-self, and not the experiential-self as it is
presented in this thesis. Finally, I suggest the importance of implementing the
phenomenological perspective of both the phenomenological attitude and empathy into
gestalt-therapy to assist the therapeutic process.

The Vitality of Recognising the Experiential-self

Both phenomenology and gestalt-therapy understand the self-relation as a relation

between the experiential-self (organismic-self) and what is often termed the narrative-
self (deliberate ego). The perspective of cognitive-behavioral therapy understands the
self solely in terms of the narrative-self or as a purely mental phenomena. To be more
precise, the subject builds a kind of “rational theory” through reflective capacities that
incorporates beliefs, motives, goals and the intersubjective world. This rational theory
founds the subject and underpins the experiential life (Skodlar et al 2013, 251). This
means that behaviour, emotions, sensations and moods are secondary, i.e., they are
generated by the theory and are not the target in treatment. Even though affective
disturbances, such as low self-esteem and anxiety, are discussed, their significance is
unclear apart from being the result of the dysfunctional theory (Skodlar et al 2013, 258).

  47  
According to cognitive-behavioral therapy, schizophrenia adheres to a failure in the
rational theory, and the aim of cognitive-behavioral therapy is to rectify the
dysfunctional theory by encouraging alternative beliefs (Skodlar et al 2013, 252).

The role of the cognitive-behavioral therapist is thus to identify the elements in

patients’ personal ‘theory’ causing the distress and to help them become aware of
these ‘dysfunctional’ elements and replace them with more ‘functional’ ones, e.g.
beliefs or goals that do not cause distress. (Skodlar et al 2013, 251)

It is not only cognitive-behavioral therapy that understands schizophrenia and delusions

as a phenomenon caused by false or dysfunctional beliefs or goals that have distorted
the process of rational reasoning, so does mainstream Anglophone psychiatry (Skodlar
et al 2013, 257). Furthermore, cognitive-behavioral therapy is in accordance with the
DSM-IV and ICD-10 (Skodlar et al 2013, 259).

From both the perspective of phenomenology and gestalt-therapy, the perspective of

cognitive-behavioral therapy fails to acknowledge the complexity of the human psyche.
Skodlar et al agree that beliefs play a role in the configuration of experiential life, but
not that the role of the belief is central in the symptom formation of schizophrenia
(Skodlar et al 2013, 257). Cognitive-behavioral therapy especially fails to see that the
inner “affective nucleus” (the core self) is sentient being. It is only when the
individual’s sentient nucleus is out of kilter that rationality takes over and attempts to
figure out what one wants and feels. Without going into any details, I want to suggest
the fragility of the nucleus. For example, at a family gathering a child is placed on the
lap of an old man, the child reacts with fear, everybody laughs, and ignores the child’s
nucleus (the child’s experiential understanding of the situation). Then with time, the
child might likewise ignore his/her own nucleus. If others do not recognise or see us for
what we are, we might not be able to be ourselves. According to phenomenology, the
self is an intersubjective accomplishment, and from a psychological perspective this line
of thought can be found in Reich (1975), very explicitly in Alice Miller (2001), and we
find a similar understanding in Berit Bae’s relational models, which state that children
need to be seen and not judged.

I propose that the dysfunctional theory is caused by a default in the nucleus that
experientially informs of what it is like being in the world. If the world is believed to be
frightening, that belief derives from a dysfunction in the nucleus. In that sense, a belief
is not false. It is in fact real to that particular person, and if the psychotherapist fails to
acknowledge the client’s sense of reality, it is possible that the intervention may further
damage the client’s nucleus.

[If] a schizophrenia spectrum patient states that she feels profoundly different
from other people, we cannot just conceive her statement as a belief that causes
anxiety as well as other affects. Such a statement frequently expresses a pervasive
and immediate sense of altered self-presence (e.g. a sense of not really existing)
and uneasiness when engaging with others (Skodlar et al 2013, 252).

The symptoms of schizophrenia are created by the subject. Without a sense of agency
towards delusions or other symptoms, the client is in a sense the victim of the

  48  
symptoms. It is the aim of gestalt-therapy to help the client attain a sense of mineness
towards the symptoms by attending to the experiential realm. The experiential reality
that the patient with schizophrenia seeks to avoid is very distressful to endure, thus
gestalt-therapy supports the client in staying with and in taking responsibility for the
experiential realm. By attending to the experiential realm, which is naturally embedded
in a given world, the meaningful unity is likely to be at least somewhat revealed. From
this perspective delusions are seen as an escape from experiential reality. Psychotherapy
must refrain from correcting errors of judgement (belief) and instead attend to the
patient’s vulnerability and see ”their psychotic experiences as potentially relevant
sources of meaning for the patient” (Henriksen and Parnas 2013, 5). A patient that
recalled “his persecutory delusions, defined them as ‘attempts to explain a very deep
restlessness’, as ‘an attempt to seek rescue in a story in which you eventually get lost’”
(Skodlar et al 2013, 254). “Contrary to the majority of CBT [cognitive-behavioral
therapy] theories, which often conceive anxiety as a consequence of delusions, patients
frequently report that they found relief in their delusional grasp of their stressful,
anomalous experiences” (Skodlar et al 2013, 258). Therefore, “emotions and moods are
neither considered evaluative judgments nor accompanying ‘subjective’ phenomena that
color our otherwise ‘objective’ experiences” (Skodlar et al 2013, 253).

The description of the ipseity disturbance has shown that part of the disturbance entails
an accentuation of reflection, and the therapeutic approach should reconsider
encouraging reflection and understanding. “It suggests the potential danger in
overemphasizing certain forms of confrontation and self-reflection in the therapeutic
process” (Sass, Parnas and Zahavi 2011, 14). This might be especially appropriate to
take into account when approaching symptoms such as “thought pressure”. The
phenomenon of thought pressure is described in the EASE manual (Parnas et al. 2005).

A sense of many thoughts (or images) with different, unrelated or remotely related
meaning/content that pop up and disappear in quick sequences without the patient
being able to suppress or guide this appearance/disappearance of (ever new)
contents of consciousness. Alternatively, all these thoughts seem to the patient to
occur at the same time (simultaneously). This symptom involves a lack of control,
many changing thoughts, but also a lack of a common theme and hence a loss of
coherence or meaning for the patient. The semantic content of the thoughts may
be distressing but also neutral or even trivial, without any special personal
significance. (Parnas et al 2005, 240)

If the patient is encouraged to attend, in a reflective manner, to an already

hyperreflective mind, it is very likely that this action will further add to the thought
pressure. By contrast, in gestalt-therapy the patient is encouraged to attend to her body
or to what it is like in the here and now to interact with the therapist. This may help the
patient experience how she can leave the thought pressure unattended to; she may
experience a great relief because the thought pressure will be less distracting.

In the chapter on schizophrenia, I have already described how the lived-body in

schizophrenia might not simply be lived through, and that this elicits an experiential
sense as if the mind is somewhat disembodied. The EASE manual (Parnas et al, 252-
254) describes how bodily experiences are distorted. The following description is only

  49  
one of many differentiated experiences.

The body feels as if not really fitting, as either too small, too big, or otherwise
uncomfortable or somehow changed. This is usually, but not always, associated
with a feeling that mind and body do not fit or belong together, as if they were
somehow disconnected, or independent of each other. (Parnas et al, 253)

It seems likely that the approach of gestalt-therapy might lead to a re-integration of the
givenness of the body in pre-reflective consciousness, since this is also one of the aims
in relation to neurosis, even though the givenness of the body in the neurotic character
often is associated with a profound lack of body-awareness.

The symptoms in the disorder of schizophrenia and the symptoms in neurosis are
distinctively different, but according to gestalt-therapy, in both cases the symptoms
derive from the experiential-self that entails blind spots of awareness. This, however,
does not mean that the disorders of the experiential-self in schizophrenia and in neurosis
are not distinctively different. The disorder of schizophrenia is thought to be a disorder
of the minimal-self, i.e., an ipseity disturbance. In the article Is basic self-disturbance in
ultra-high risk for psychosis (‘prodromal’) patients associated with borderline
personality pathology? (Nelson 2013) Barnaby Nelson et al argue that the pathology of
borderline patients is associated with a disturbance of the narrative-self and not the
minimal-self. “In BPD [borderline personality disorder], the narrative self, that is, social
identity, is disturbed and the more basic pre-reflective experiential self may remain
intact” (Nelson 2013, 311). According to gestalt-therapy, the disturbed social identity is
founded on or derives from the experiential-self, but I agree that it is not the minimal-
self. The experiential-self of gestalt-therapy that is portrayed in this thesis not only
entails the minimal-self but also the experiential-nucleus. The neurotic character
develops because the experiential reality of the nucleus is unbearable.

In the previous chapters, I see no indication to assume that the approach of gestalt-
therapy is not an adequate treatment for schizophrenia as well as it is for neurosis.
However, the gestalt therapist must naturally be well acquainted with the specific self-
disorder of schizophrenia.

Empathy and the Phenomenological Attitude

Fuchs writes in Psychotherapy of the lived space that psychotherapy founded on

phenomenology opens up an experiential field in the here and now where the client
dares to experiment with the relational patterns that become visible by interacting with
the therapist (Fuchs 2007).

Their pre-existing phenomenal worlds interact, even merge in part, resulting in a

new, emerging dyadic world that is harboured by the “therapeutic niche” and
creates a new horizon of possibilities. At the same time the blind spots or gaps in
the patient’s lived space may become visible by the illumination of the interactive
field. (Fuchs 2007, 433)

  50  
Even though I have mainly focused on specific experiments in the exposition of how to
apply gestalt-therapy, it is naturally the interactive process or contact between the client
and the therapist that provides the foundation of treatment in gestalt-therapy. I suggest
that the phenomenological attitude is a pre-condition for opening an experiential field.
The natural attitude, as Zahavi writes, entails a self-forgetful levelling (Zahavi 2007,
23) that does not open an experiential field. In the natural attitude, the therapist judges
rather than sees the client. It is the being seen, the therapist’s ability to see the client that
facilitates the process of illuminating the blind spots in awareness. From this
perspective, gestalt-therapy is a meeting between equal beings and as such not a
diagnostic tool.

Many schools of contemporary gestalt-therapy are based on the conception that

empathy is a projection.12 This means that all the therapist knows about the mental
states of the client derives from the therapist, i.e., the therapist projects her own mind
onto the client. From this perspective, contact is founded on assumptions and is not an
immediate and actual contact with the other. In a review of the book Aggression, Time,
and Understanding: Contributions to the Evolution of Gestalt Therapy by Frank
Staemmler (2009), Des Kennedy (2012) writes that “[this] reviewer is puzzled how so
many eminent Gestalt therapists can so fulsomely endorse a work, which in its
theoretical stance on perception, strikes at the very heart of Gestalt therapy” (Kennedy
2012, 110). Kennedy asks, when “we speak of “Contact” is that immediate, actual
contact with my client? Or am I just in contact with a projection, an interpretation of my
client?” (Kennedy 2012, 110). Even though Perls does not explicitly state that his
understanding of empathy adheres to the phenomenological understanding of empathy
that I have exposed in the chapter on phenomenology, I do not think his writings
indicate anything to the contrary. Since Perls in the following quote writes that the
client intuitively feels the therapist’s mental states, he seems to acknowledge that we do
have actual access to the other’s mental state, i.e., empathy is not solely based on
assumptions that are projections onto the other.

If the therapist disapproves of resistance, he might as well give up. It does not
matter whether he expresses it openly or not; the patient’s intuition is seldom so
dull that he does not feel it. (Perls 1973, 48)

Staemmler does, however, not question if gestalt-therapy is founded on

phenomenology, but “Staemmler speaks as if all phenomenologists share his view of
perception” (Kennedy 2012, 110). The problem is that Staemmler argues that the
phenomenological conception of empathy is based on non-conscious cognitive
processes that are inferential in nature, but as I have written in section on “Empathy,”
the phenomenological conception of empathy is opposed to any theory that is inferential
in nature (Gallagher and Zahavi 2008, 183).

Staemmler’s conception of empathy has vital implications for gestalt-therapy. If the

therapist does not bracket the assumption that empathy is a projection, the execution of
the epoché is inhibited, and the actual perception of the client is likely not to be taken
seriously, i.e., the therapist will assume that the perceived mental states of the other are
                                                                                                               
12  In gestalt-therapy the content of a projection belongs to the projector.  

  51  
in fact her own assumptions. According to Perls the therapeutic process is facilitated by
precisely what the therapist sees of the client’s surface (Perls 1973, 64, 75), as written in
the chapter on gestalt-therapy under the section The Phenomenological Method. If
empathy is a projection, it is a paradox how the therapist can help the client become
aware of a self that the therapist does not actually perceive or experience. One central
reason why the gestalt therapist must undergo years of training is for the therapist to
become aware of her own functioning and manner of being in the world, i.e., to remove
blind spots in her own awareness. The therapist must be able to refrain from conflating
her own functioning with that of the client, i.e., she must be able to clearly distinguish
herself from the client, to avoid having projects on behalf of the client. However, if
empathy is a projection, the therapist is in a sense both self and client.

To ensure that gestalt-therapy is a relevant psychotherapeutic treatment in relation to

mental disorders, I suggest that gestalt-therapy should be based more explicitly on
phenomenology. Especially, its conception of the phenomenological attitude and
empathy is important, because it affects the therapist’s manner of relating and the
practising of gestalt-therapy in general.
   

  52  
Conclusion

According to phenomenology, the self, intersubjectivity and the world constitute a

meaningful world. This formation of meaning founds the natural attitude, which means
that the self is already familiar with the world before the world is thematised by
intentional consciousness or by accentuated awareness. When perceiving another
person, that person is judged based on the formation of meaning. From the
phenomenological perspective, the symptoms of schizophrenia occur because the core-
self is disrupted, and consequently the self is not fully merged in a meaningful world.
The core-self is the foundation of the experiential-self, and it is the experiential-self
(subjectivity) that gestalt-therapy attends to. The phenomenological conception of
empathy and the phenomenological attitude (acquired by the epoché) open a therapeutic
field in which the patient and the therapist interact on an experiential level. In the
phenomenological attitude, the natural attitude is bracketed which enables the therapist
to refrain from judging or analysing. Instead, the therapist shares whatever appears in
the present moment of the encounter with the patient, which helps the patient become
aware of his/hers pre-reflective functioning.

   

  53  
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